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To Cry or Not to Cry

Ben_3Ben Bryner -- I've been thinking about breaking bad news a lot lately, and an interesting article in the New York Times addressed that topic. Briefly, the author presents both sides of the issue of whether crying when delivering bad news is appropriate.

My scant experience with this kind of discussion (limited both in number of cases as well as limited by my student-level role and knowledge) has been that there's wide variability in these discussions, and therefore variability in the appropriate response. While the article tends to pigeonhole individual doctors as criers or non-criers, as Dr. Lerner concludes, it depends mostly on the individual patient. I'm sure all the people in the article do tailor their approach to each individual patient. And it's absolutely true that doctors can convey deep empathy without crying.

But the article takes the study by Dr. Anthony Sung (archived here, scroll down to page 5) a little out of context -- his survey found that a majority of third-year medical students and interns (69% and 74% respectively) had cried in a medical setting, but that "the most common reported cause for both students and interns was burnout," not from discussing bad news with a patient. Also, the abrupt shift in the article from talking about attendings to talking about students and interns is not a trivial difference; the role of an attending is very different than that of a trainee in this kind of situation.

Hopefully the following example will help explain what I mean by that.

I witnessed a very good example of breaking bad news on my neurology rotation. I had gotten to know a patient in his mid-50s with glioblastoma during clinic visits at the beginning of the rotation. At those visits he was talking about going back to work, but over the next couple of weeks his condition deteriorated. It became clear that the several experimental chemotherapy regimens he tried had failed, and that the chance of another regimen slowing down his disease progress was basically zero. He was admitted, and when his neurooncologist stopped by his room to tell him the results of the latest scan, I went with him.

The news was no real surprise to the patient and his wife, but it was still devastating when he heard that the scan was discouraging, the chemotherapy was not working, and that it was almost definitely not worth pursuing more chemotherapy. Importantly, the oncologist still left the option of chemotherapy out there for him to take if he liked, but included his recommendation against it. As the message set in, the patient and his wife began to cry, and so did the oncologist. It was a very appropriate display of emotion from the oncologist, I thought, and the patient later told me how much it meant to him. But I didn't feel like crying, and didn't feel like I needed to. It was fine that I was there, but our brief student-patient relationship was not enough to allow for my crying in that situation. If I had cried too it would have cheapened the experience for them, which was the last thing I would have wanted.

A doctor's emotional display also depends on the type of visit. In the above example, there was plenty of time to talk, the setting was quiet, and nothing needed to be done immediately. (Hospice care was arranged over the next couple of days). But in some of these discussions, especially in the ICU setting, practicalities dominate the conversation and the emphasis needs to be on helping the patient and family through difficult decisions. In these discussions, I can't remember the attendings ever crying, although they were compassionate, helpful, and empathetic towards patients without exception. And for all patients who have strong emotional relationships with their loved ones, those are far more beneficial than the most empathetic doctor's tears could ever be.

Another doctor is quoted in the article as saying it's not a doctor's job to cry with patients. I agree that that's not what a doctor's essential role is. The physician's role is to help the patient through difficult medical decisions (and perform procedures as necessary). Working with the patient, forming a team with him or her, carefully assessing what the patient knows and what he or she still needs to learn, and then making careful recommendations (sometimes very strong recommendations) are the true elements of compassion and empathy in the doctor-patient relationship. Whether the doctor cries or not while delivering bad news is only an outward manifestation of that relationship.

Which brings the topic back around to one of Dr. Lerner's original points, that medical school doesn't teach a lot of these things. Too often, we're taught about things on the superficial level -- what words to use, how close to sit to the patient, whether to cry or not. And while that's a good place to start, medical education has much further to go toward comprehensively preparing new doctors to develop empathic relationships with their patients.

April 25, 2008 in Ben Bryner | Permalink

Comments

Hey med. community...
Self healing and faith does exist ..Evidence based medicine doesnt recognize this because the word "Faith" itself is not measurable..you just need to beleive in it.....It is working for millions of exceptional, rare cancer patients and other clinical "remissions" . Wonder why alternative medicine is gearing fast attention by patients???
On this account i would suggest book by Dr Bernie Siegel (former surgeon at Yale): Love, Medicine and miracles..is a MUST read for "everyone" (docs and patients).It would change your outlook about life.

Posted by: Dr.Ammara ayub | May 1, 2008 9:08:07 AM

i am a medical student too, doing my first clinical year and finally having exposure to real patients and at times to real situations, rather than being engrossed with a thick textbook of clinical medicine!

Unfortunately two days ago it was the first time ever i experienced a consultation between a highly reputed consultant, the patient and his wife. The patient who had been completely asymptomatic was found to have severe cancer and his chances of survival were very low. I am an emotional person and i can say with certainty that i would cry or start welling up and in this situation I did! I tried to keep it together and I found myself constantly staring at the floor in order to avoid looking directly into the patients eyes. If I had cried it would have been highly inappropriate for me because in this case, i barely knew the patient. Being a medical student we are taught how to deal with these situations in theory but unfortunately the reality is somewhat different!!
The reason for me to be so emotional was unfortunately a family member of mine had the same illness as this patient, so on that level I could actually feel genuine compassion but even then I tried not to cry in front of them.
The cry or not to cry situation is definately not a clear cut area. If you cry; yes some patients feel that okay this doctor is going beyond their role of diagnosing, investigating and finally treating the patient. Infact the doctors come across as humans with real emotions. However on the flip side of the coin, patients who feel very perplexed about the news they have just received may perhaps look to the doctor hoping that they may be able to provide some strength and some optimism, despite the situation. In essence, you can hardly ever forsee your emotional reactions and although you could read so many books on how to deliver bad news; it is very difficult to control your emotions. This could be due to a variety of reasons. 1)young doctor who has not had alot of experience in delivering bad news, 2) the patient had the same illness as your friend/relative had, 3) it already had been an emotionally challenging day for the dr, so much that he/she perhaps breaked down in front of the patient or perhaps 4) the dr-patient relationship had developed so well, and there was alot of compassion and concern between the two, so that when it came to delivering bad news- it would be alot harder than expected.


In summary, each individual is different so it is difficult to say who you will cry to and who you wont : /

Posted by: medstudent | May 1, 2008 10:55:27 AM

When I had a surgery last week, my doctor acted like a father figure. He spoke softly, held my hand, and smiled. Although these were very simple things (and my case wasn't a big deal), his treatment showed that he cared very much for me, which led me to trust him. Crying is another display of emotions that some patients (in desperate situations) might consider as a display of courage and sympathy. Great article.

Posted by: Alkawi | May 1, 2008 1:33:24 PM

I am one of those med students that have cried. After attempting to ressus an elderly lady that I had gotten to know well. Unfortunately it was unsuccessful. However on my way out of her room, her son came up and gave me a hug and told me it was ok, and that she was old. This may have seemed inappropraite to some, and it was a shock to myself as well. However it was hugely comforting to both myself and her son. It was only a brief encounter, but one that I will never forget. I think it is important to cry if it is what you feel. Helps with the process of grieveing, we are after all human.
Fantastic article. I applaud you for bringing it to light.

Posted by: Jc129670 | May 1, 2008 2:51:37 PM

Very interesting article.
I agree with everyone who believes that crying infront of their patients is acceptable. I liked Val's comment in response to the comment that "crying is not professional". I do however think that every situation and every person is different and people should be themselves and showing empathy toward others during difficult times in their lives is important.

I am an RN and I have cried with and hugged my patients during hard times because some people need that support. There are other times when I will not show my emotion on that level. It depends on the individual and the relationship I have with them.

Recently a doctor that I work with had delivered bad news to a patient very quickly without any empathy and feeling in his delivery. I don't think that it would be necessary for the doctor to cry in this situation, but I do know that his lack of empathy upset the patient and his family during a very hard time in their lives.

Posted by: Shelly | May 2, 2008 12:13:50 AM

I wanted to add to my earlier post, that although I am an emotional person and have spent considerable time with folks who are ill, suffering, and dying, and their families, I think that I have not felt compelled to cry so much because I focused on a quality of life goal for my patients which is always something to strive for, regardless how long life is or what the obstacles are. Life experience lends to this. Someone in their 20's or 30's who has seldom or never experienced death may have a different outlook than someone older who has seen death more closely through medical practice or through their own family members.

Accepting death is an individual process. I have learned to accept death as a part of life--it is suffering that upsets me, but it makes me angry more than it makes me sad, and channeling the fight against suffering as something realistic to work towards helps to avoid tears. I've seen this with my own family members coping with the death of a loved one on a different level--keeping busy and having healthy outlets for emotion keeps emotion from building up too much, although tears will come from time to time in the swing of the grief process. By focusing on the needs of the dying as I did with my own father when he was dying of cancer, it gave me strength.

I think that once a genuine emotion starts to flow it can be almost impossible to mask, so the key to managing emotion as a caregiver is to focus away from one's own experience and focus on the patient and the patient's family, and what comfort one can give.

Doctors often focus on saving life at all costs, and that can be frustrating both for a physician and for a family that already has trouble coping with an inevitable end, as in many advanced cancers. In fact statistically physicians often put patients through too much for too long before finally agreeing to hospice care (which can offer a great deal of comfort to both the patient and the family in terms of pain management and coping).

Each family will have different cultural practices, different religions, and it is integral to be aware of the differences in cultural traditions relating to death and grief.

Death and dying is something often bypassed in psychology courses and avoided in medical focus which seeks to promote life whenever possible. Some doctors scare elderly patients into giving up DNR's by focusing on the dire threat of death. On the other hand other doctors (and hospice nurses, particularly) can be very pushy in persuading patients who may not quite be ready to face their own mortality into doing a DNR. There's a very delicate art to guiding people through death and dying. As a whole I think that nurses are more comfortable with the death process than doctors are, and it may be in part due to the more holistic focus of nursing education and the longer time spent with patients and families. No one would ever criticize a nurse for crying with a family.

Posted by: btaylor | May 2, 2008 7:31:28 AM

BE LIKE YOURSELF.NOT LIKE ANOTHER.IF YOU WANT TO CRY DONT HOLD YOURSELF....

Posted by: | May 3, 2008 9:11:12 AM

After reading your commentary, it made me wonder about the patients that I have had that unfortunately did not respond to treatment. It made me sad to think about how many deaths that I have witnessed; it made me sad to think about how the families sat and cried and their doctor was no where in sight. As I nurse, there have been a number of times that I have held a patients hand while they are taking their last breath or comforted their spouse while they cried in my arms. It often makes me think how one could "not" cry. I have probably cried more tears than needed but you don't cry for the patient, you cry for their family and the feelings that they are forced to feel. Anyone who has ever had a loss, would know that the feeling is one of the worst you can have. Doctors need to have some compassion when talking with their patients and communicating bad news. If I had to trade my nursing position for a doctor's position and had been given the ultimatum to not "feel", I would be left with no choice but decline the position of being unhuman.

Posted by: Kelly O. | May 3, 2008 12:51:04 PM

Nobody would actually tell you if crying in front of the patient is good or bad, i believe that in caring for a patient sincerity play a major role, if you are treating your patient based on monetary reason, the patient will feel it, same thing when you treat your patient with sincerity, the patient fill feel it too. the way you deliver the bad news is very important, you can be straight forward without being arrogant or rude, you can tell it without crying but the sincerity should come from the heart. i have delivered several bad news to a patient during my intership, i didn't cry though, but my heart was breaking, i know they felt how sad i was when i break the news, what am i driving at here, simply be yourself, if your not the type of person who don't want to cry in front of the patient so be it, stop pretending just to be yourself, the real you.

Posted by: | May 3, 2008 4:43:43 PM

Hi,
I'm a medical student of 1st year in our local medical school.Each month we a bond to a patient & for me personally its a wonderful experience to learn & understand the student-patient relationship.It depends on the type of sitution the patient is in.In some cases words are easily let out with relieve by the specialist while on the other hand emotions arise with disappointing end.After all we are all human with emotion &in the medical field crying is part of our job

Posted by: varanaisi talai | May 3, 2008 7:12:13 PM

Awesome post Ben

Even doctor cry, what about med student? They're also cry during the study week to facing their clinical examination. Now is my second year in medical course. Not all of the time I'm starting feeling stress. Lots of clinical cases needed to understand, an assignment for diagnosing cases and also my horrorble terrorfying fobia to speak infront of the public to present a topic not to forget 6 medical book need to read per week. My brain can't stop to think. In medical research, cry is good to improve your sight eye-seeing, but also bad which can cause blind if your are type of always cry person. So cry or not to cry?

Posted by: Hafidz Lee | May 5, 2008 10:24:56 PM

I don't think that seeing a medical professional cry decreases the patient's respect for him or her. If anything, it does the opposite.

I had just turned 16 years old, and I had just had a root canal on a back molar. I needed a crown preparation. I had met the new dentist at the consultation a week earlier.

Dr. Rogers had graduated from dental school just a few months before, and at 26 years old, she was very young. However, her professionalism and natural talent were far beyond her years. She was also very warm hearted, and her sparkling personality and great sense of humor endeared her to me immediately. At the consultation, she told me that a crown prep usually takes about 45 minutes.

Two hours into the crown prep, we were getting nowhere. We discovered that the endodontist who did my root canal had left almost no tooth left for the dentist to restore. She was struggling to keep my mouth dry, and the far distal location of the tooth made it nearly impossible for her to work on it. An hour later, with three hours elapsed and almost nothing accomplished, she set down her tools and burst into tears.

I think many people who suffer from dental phobia have this problem because they don't like to sacrifice their power, and when he/she is completely in control of your mouth, using terms and procedures you don't understand. But to see Dr. Rogers express her emotions so plainly, I felt as if she was bringing herself to an approachable human level. It was as if she was saying, "Look, I'm frustrated and tired and I feel like a failure right now. And I'm not above tears; I'm human just like you."

Seeing her cry made me respect her exponentially more, because she was able to humble herself and admit that she was at the end of her rope, rather than putting both of us through more hell and leaving me to wonder if I was the only one feeling the way I did.

She was able to collect herself after a few minutes, and with the help of the senior dentist, she finished the procedure after another hour and a half.

So, my point is this: crying in front of patients doesn't-- or shouldn't-- lower the patient's opinion of the doctor. Seeing the doctor as human is beneficial to patients.

Posted by: Anna | Aug 12, 2008 12:05:04 PM

very excellent topic to discuss...
doctor 'to cry or not to cry'.....
situations that we're facing everyday in our doctor's life, very subjective, its up to individual judgment.
u can be a sympathy or empathy...two different things but closed with each other...sympathy is u cry together with the patients, and empathy is u are not crying with the patients but u show that u are sincerely sad (sympathy) with the news....:) the best way to be a doctor is be an empathy man not the sympathy. not because u are not concern about your patient but to make a protection between doctor n patient. you doesn't have a single patient, u have to remember that...you have to be strong to encourage your patient to be strong to face the situation...
the critical situation not only effect the patient but the doctors too...we have our part to playoff...

Posted by: shu | Aug 24, 2008 7:36:01 PM

hello, I love your post, I like the part that talks about mourn, it is very interesting, thanks for sharing the information!

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