Clinical and Health Affairs
To Cry or Not to Cry: Physicians and Emotions at the Bedside
By Navneet S. Majhail, M.D., M.S., and Erica D. Warlick, M.D.
Abstract
Whether it is appropriate for physicians to display their emotions in front of a patient is a question that has no easy answer. Some physicians may consider it an expression of empathy, while others caution against doing so. This article describes the findings of a survey of blood and marrow transplant physicians who were asked whether it is OK to cry in front of patients.
She appeared calm and peaceful, oblivious to the tubes and lines that violated her body. The silence in the room was disrupted by the sound of a ventilator pushing air down her endotracheal tube and the beeps from monitors tracking her cardiac and respiratory activity. We walked past her bed to the end of the room where her husband and mother waited anxiously. They watched us expectantly, waiting for a glimmer of hope, as we shook hands and settled down across from them to start the family conference.
She was just 36 years old and was two years out from an umbilical cord blood transplant for a highly aggressive acute myeloid leukemia. Her first few months after transplant had been complicated by acute graft-versus-host disease (GVHD) and multiple infections. She subsequently developed severe treatment-refractory chronic GVHD; after failing many drug therapies, her GVHD was finally controlled with a regimen of cyclosporine and high doses of corticosteroids. During the following year, however, she had been admitted to the hospital many times—for a subdural hematoma that needed surgical evacuation, renal failure, and numerous bacterial and fungal pulmonary and sinus infections. Each time, she would recover and go home.
But this time was different. She had recently recovered from Pseudomonas aeruginosa otitis externa and bacteremia. Two weeks later, she was readmitted with high-grade fevers and hypoxia. Over the next two days, she rapidly deteriorated and developed acute respiratory distress syndrome, septic shock, and multi-organ failure. Workup revealed a multi-drug-resistant Pseudomonas in her lungs and blood.
She had been hospitalized for almost six months during the two years following the transplant. She had been seen frequently in the outpatient clinic as well, often several times a week. Although multiple providers were involved, the majority of her care had been coordinated by her primary blood and marrow transplant (BMT) physician. With her refractory chronic GVHD and penchant for frequent infectious complications, her BMT physician had had multiple conversations with her and her family about her advance directive for health care. She was determined to “make it” but was also very clear about not wanting to be a “vegetable.”
Her primary BMT physician and the BMT physician on inpatient service that day led the family conference. A medical student, hematology-oncology fellow, and nurse practitioner also participated. The BMT physicians summarized her clinical course since the transplant and since her most recent hospitalization. They noted that she was going to require dialysis soon and emphasized the almost negligible likelihood of her leaving the hospital alive. They recounted her resilience and the many times she had beaten the odds. Her mother and husband remembered her as a good daughter, wife, and mother and mentioned that she knew she would not beat the odds this time. All agreed that she would not want to continue with aggressive measures and allowing her to die peacefully would be in her best interest. At an emotionally intense moment, her primary BMT physician’s eyes began to water, and she shed a few tears prior to regaining composure and continuing the conversation.
As the team left the room, the medical student asked, “Is it OK to cry in front of a patient?”
What Physicians Say:
The following is a sampling of blood and marrow transplant physicians' responses to the question "Is it OK to cry in front of patients?"
Emotions at the Bedside
The physician-patient relationship is the quintessence of clinical medicine. It is a complex construct that demands mutual respect, support, and participation, especially in the context of cancer and other life-threatening chronic diseases.1,2 According to Wade, “These relationships do not develop instantaneously; rather, they are cultivated over time and are usually strengthened by shared experiences.”2
The role and appropriateness of physician emotions has not been well-described. Some physicians may consider expressing emotion a sign of empathy while others caution against doing so in front of patients.3 In a survey of 301 trainees, 69% of third-year medical students and 74% of interns reported crying for reasons related to medicine, with twice as many women as men reporting to have cried.4 Several factors may determine the nature of physicians’ emotional responses including the personality of both the physician and the patient; the length of their acquaintance; the intimacy, frequency, duration, and intensity of their interactions; as well as the clinical setting in which a discussion that precipitates an emotional response takes place.
The relationship between patients undergoing BMT and the doctors who treat them is unique. Because of the high risk of associated morbidity and mortality, BMT is reserved for patients with a high probability of death without the intervention. Consequently, patients trust that their physicians will provide them with information and assist them with decision making. The initial transplant course itself can be quite intense. It is not uncommon for patients to develop long-term complications such as chronic GVHD. In addition, there is always the looming risk of relapse of underlying disease.
As patients move down the transplant path, they are frequently accompanied by their transplant physician and many other members of the transplant team, who may follow them closely for an extended period of time. Transplant physicians are often there for the joyful moments documenting remission or cure, for the hospitalizations for transplant-related complications, and to help the patient integrate their new reality into their life. If the patient has serious complications or disease relapse, they frequently have to lead end-of-life discussions. The initial patient-physician bond can grow stronger as patients deal with such challenges, and as physicians feel a sense of responsibility and sometimes guilt over the complications ensuing from a treatment they recommended. This dynamic can intensify conversations that are already emotional such as those dealing with end-of-life care.
A Minnesota Perspective
To explore what BMT physicians think about expressing emotions in front of patients, we presented the case of the 36-year-old woman to 15 BMT physicians at our institution and electronically surveyed them about whether it is appropriate to show emotions and cry in front of patients. Eleven respondents were male; five were pediatricians. The median year of medical school graduation was 1990 (range, 1975 to 2000). All generally agreed that it is acceptable to convey emotions; however, opinions varied about the extent and means of emotional expression in the presence of patients (see “What Physicians Say,” p. 41). One respondent suggested that emotionally intense conversations with patients be held in the presence of a team so that providers could support one another and have an opportunity to debrief later on.
Although these comments were specific to physicians who care for BMT recipients, physicians who care for cancer patients and patients with other life-threatening chronic diseases likely have similar perspectives. However, considerable variation can be expected based on the physician’s personality, the patient population served (adults versus children), and cultural norms.
Conclusion
During end-of-life discussions with a long-time patient, it is not uncommon for a physician to shed tears. Doing so allows them to express their sadness for the patient’s and family’s current and future losses. Being able to express such emotion can provide relief for physicians and convey empathy to the patient and family. The challenge for physicians is being able to express how they feel while still being an objective advocate for the patient. MM
Navneet Majhail and Erica Warlick are assistant professors in the Blood and Marrow Transplant Program, Division of Hematology, Oncology, and Transplantation, at the University of Minnesota.
References
1. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992;267(16):2221-6.
2. Wade JC. The patient/physician relationship: one doctor’s view. Health Affairs (Millwood). 1995;14:209-12.
3. Lerner BH. At bedside, stay stoic or display emotions? New York Times. April 22, 2008. Available at: www.nytimes.com/2008/04/22/health/views/22essa.html?_r=2. Accessed November 1, 2010.
4. Sung AD, Collins ME, Smith AK, et al. Crying: experiences and attitudes of third-year medical students and interns. Teach Learn Med. 2009;21(3):180-7.