Have you cried at work? Do you show the depth of your emotions when faced with tragic clinical circumstances? I have never cried, and it is unusual for clinical situations to even moisten my eyes. Although I have been tempted to hug patients when they appear emotionally broken, I am far too inhibited to break through that force-field of unfamiliarity. A gentle hand on the shoulder or leg is about as intimate as it gets really.
This is not true for all doctors – some are much more comfortable with displays of sympathy or warmth…but we are all different. How do we describe doctors who admit to being moved to tears? Sentimental? A sentimental person is predisposed to be moved or swayed by emotions; it is a normal characteristic, but one that is repressed to a greater or lesser extent in most working lives. The empathetic doctor on the other hand will feel sadness and grief when they see their patients cursed by nature’s caprice, and will allow this to inform their own understanding. The sentimental doctor will reflect and display those emotions, and be visibly affected. If we accept that a continuum exists which encompasses these two characteristics, knowing where, or how, to draw the line is a huge challenge. Particular circumstances may pull individual doctors over that line now and again. When that happens, we cry. This tendency must be balanced with cool professionalism, for if sentimentality reigns there may be a deficiency of dispassionate thought.
So what lies at the other end of that continuum? How do we describe those who appear to feel no emotion at all? Does their stony facade hide inner turmoil? Are they likely to suffer from a build up unresolved mini-traumas? Or can they function indefinitely without releasing those emotions? Well, perhaps the key word here is ‘appear’. We can only know as much as we can see, and the profundity of their feeling may well be hidden from us.
In ‘To Cry or Not to Cry: Physicians and Emotions at the Bedside’ by Navneet Majhail and Erica Warlick, an account is given of a bone marrow transplant physician who cried when a young patient whom she knew well discussed the likelihood of death.
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?”
In response to this an informal survey of other physicians’ attitudes to the display of emotion was undertaken. The selection of responses is fascinating, and very measured. For instance:
“I think that it is totally fine not to cry … If that is not in your nature … a physician should express some genuine sympathy/empathy for a grieving family, but it can be done with words or mannerisms.”
“I think it is a problem if the emotional moment is primarily about the physician’s feelings … But if the context is about the patient or the family’s feelings then I think it is good to show empathy. … If the “primary gain” is to make the family or patient feel better … then it is OK … whereas if the primary gain is to make the physician feel better … then that is not OK.”
“I think it is acceptable to break down the austerity of the medical relationship at times … when families and patients need someone they trust the most (eg, endof- life crisis), the emotion we show only helps bridge the divide that we’ve built within medicine.”
And this one reflected my own thoughts very closely:
“There can be a fine line between being compassionate and empathetic versus allowing emotions to adversely cloud recommendations for patient care.”
A 2008 New York Times article by Barron H. Lerner explored the question ‘At Bedside, Stay Stoic or Display Emotions?’. He (and the fact that he is a ‘he’ becomes relevant) contrasts the behaviour of two physicians. There is Dr Benita Burke, who was in the habit of,
‘…skipping lunch to spend extra time with her cancer patients. They dubbed this time ‘mental health rounds,’ during which they could address issues that were not strictly medical. Many times, Dr. Burke would wind up in tears or giving an embrace.’
I find that behaviour remarkable – in fact I find it uncomfortably eccentric. In contrast, according to the article, Dr. Hiram S. Cody (acting chief of the breast cancer service at Memorial Sloan-Kettering Cancer Center) adjures his staff,
‘to understand, to sympathise, to empathize and to reassure…not to be emotional and/or cry with my patients.’ The writer of the article then comments, ‘whether because of my personality or my being a man, I, too, have never cried in front of a patient.’ (Phew. I am not the only unfeeling man out there!)
In 2006 I wrote an article called ‘The Absence of Sadness: Darker Reflections on the Doctor-Patient Relationship’, which began with a paradox – recognition that I felt sadder when patients whom I barely knew died, rather than those I had watched suffering for days or weeks on the ward. I was moved (moist eyes, nothing more) by the love shown to a dying man by his family:
In this case my sadness derived not from torn attachment, but the juxtaposition of familial devotion with death. The brief sketch of his life, drawn during our first interaction in casualty, contained only positive images. My appreciation of him as a person was unchallenged, our relationship unsullied by the more complicated emotions that can accumulate on the ward.
Then, having described various threats to the patient-physician relationship, I conclude,
The tensions created by sudden, severe or incurable illness settle on the most vulnerable aspect of our experience with patients; not our medical proficiency, not our energy, not our commitment to advocacy…but our sense of attachment.
So, if emotion cannot be explored (by some of us) at work, where can it be resolved? I have read some very emotional medical accounts recently. One example is Elin Lowri’s beautiful blog post about the importance of love in the inevitable progress of death. A number of commentators have admitted that they were moved tears. I certainly felt emotional, and that is saying a lot, for me! I asked myself how it is that someone like me can be moved by such well-written words at home, while being in little danger of sniffing back tears in the workplace. Then I was reminded of the Onion Cellar.
In The Tin Drum, by Gunter Grass, people who have been deprived of the opportunity to display emotion pay good money to meet in an onion cellar.
“…It was this drought, this tearlessness that brought those who could afford it to Schmuh’s Onion Cellar, where the host handed them a little cutting board – pig or fish – a pairing knife for eighty pfennigs, and for twelve marks an ordinary, field-, garden-, and kitchen-variety onion, and induced them to cut their onions smaller and smaller until the juice – what did the onion juice do? It did what the world and the sorrows of the world could not do: it brought forth a round, human tear. It made them cry. At last they were able to cry again. To cry properly, without restraint, to cry like mad. The tears flowed and washed everything away.”
I wondered, thinking about the right place and the right time for displays of emotion, whether a sentimental reaction to accounts of patients and their illnesses, read outside the workplace and in relation to people that we have never seen, may provide that access of emotion that we cannot readily, or safely, tap into on the awards. Perhaps there is a place for vicarious emotions, whereby the feelings that we probably should be feeling on the wards, as normal, feeling men and women, can be experienced in abstract, at a distance, through the words of others. So please keep those blog posts and articles coming…they are healthy!
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