Appropriate bedside manner

8

Category : Medical Rants

Today’s NY Times has an interesting piece about physicians crying at the bedside. As I consider my career, I do not remember crying at the bedside. Does that make me cold? Which behavior is more appropriate?

At Bedside, Stay Stoic or Display Emotions?

These days, all medical schools have some type of education in topics like the physician-patient relationship and breaking bad news. But knowing how to respond to a personal wave of stress or sadness remains a major challenge. Is crying O.K.? How about hugging a patient who starts to cry?

One physician who cautions against excess emotions is Dr. Hiram S. Cody III, acting chief of the breast cancer service at Memorial Sloan-Kettering Cancer Center. Although Dr. Cody emphasizes the need for doctors “to understand, to sympathize, to empathize and to reassure,” he says his job “is not to be emotional and/or cry with my patients.”

There are two reasons for this stance, Dr. Cody tells young physicians on rounds: It is not therapeutic for the patient, and it will cause “emotional burnout” in the doctor.

These beliefs are shared by many other physicians, but some new data suggest that crying in a medical setting is common among young doctors. At a recent meeting of the Society of General Internal Medicine, Dr. Anthony D. Sung of Harvard Medical School and colleagues reported that 69 percent of medical students and 74 percent of interns said they had cried at least once. As might be expected, more than twice as many women cried as men.

So what should I teach?  How should I act as a role model?

As I consider my job, I often have to deliver “bad news.”  Now bad news is not an absolute concept, rather “bad news” has shades of grey.

I believe that my patients’ deserve my empathy, and also careful explanation.  When I tell someone they have cancer, I then spend a significant amount of time explaining what it means.  I then explain it again the next day, because patients often do not grasp all of my words after I say the C word.

My students and residents have told me that I do a good job of this necessary and painful task.  I take the time to sit down and explore the patient’s understanding and help the patient develop a “game plan.”  If I let me emotions take over, then I believe my effectiveness will diminish.

Delivering bad news is painful.  Before each session I prepare myself using a self visualization technique.  I have learned over the years the art of these conversations.  Each one drains me both because I empathize and I care.  However, crying would detract from my ability to do the complete job of helping the patient.

Perhaps men, and men of my generation are better at compartmentalizing.  Perhaps our maturation process included not openly crying.

I think about my patients.  I do care.  Displaying raw emotion does not work for me.

I wonder if we are doing a good job of teaching our learners about breaking bad news.  Even with the worst news I try to provide hope and support.  We can always do something to help the patient.  Our toolbox includes palliation and emotional support.

I discuss these issues on rounds.  As an attending I consider it my responsibility to be a useful role model.  This includes debriefing every such discussion, focusing on technique, wording, and body language.

As I broke bad news to a patient with a new diagnosis of esophageal cancer last week, I spend a long time each day explaining all the options, what tests we were doing, why we were doing them, and then reporting the implications of the results.  The nursing case manager overheard our discussion, and made a point of remarking how unusual it was to spend enough time making certain that the patient understands the plan, and the process.

I once had a colleague who stressed the importance of maintaining composure when everything seems to be failing.  Patients deserve composure, empathy and a well developed plan.  Maybe they also deserve my crying with them, but I really do not think so.

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Comments (8)

Warm and Fuzzy Or Cold and Technical?

Crying in front of a patient seems pretty irresponsible. As you alluded to: if you’re losing control, how do you expect the patient to handle things?

First of all I think if I had just been given some BAD medical news it would be hard enough to deal with but if the DOCTOR started crying I would freak….
I mean if the DOCTOR is crying there must be no hope… I might as well get in the coffin now. I think that would scare me to ….well you know….
I just asked one of my female residents if she had ever cried over a patient, she said “NO” She felt it would make the patient think the doctor was weak…..

Second, and this is NOT meant to be a sexist statement but just a statement of fact the article says 69% of med students and 74% of interns said they had cried. The article further states that most of these were women. I believe statistics will show that more women now enter medical school. Maybe this has increased the percentages???

Lastly the article doesn’t say if those percentages who cried were in front of a patient and their family or if it was later at home or in the call room. I think that would be a big difference.

Just My,
Twocents

The most absurd thing I read in your post is that somehow crying will lead to burnout. In my experience, it is that consistent, sustained attempt to stifle any emotional response that has been most linked to burnout. Crying with a patient is not a decision, it is not voluntary: It is an escape when whatever is going on is just too damn sad.

I cried once with a patient when she was telling me about the final moments with her dying child. The story was tragic; as a parent, it felt so real that I could not help but imagine myself in her shoes. The tears came and it was therapeutic for both of us. I would not plan or want to repeat a moment like this, but to have tried to remain stoic during this history would have been false and certainly would not have helped either of us.

It’s funny, breaking bad news, which I do a lot (and I feel I do well) does not bring me close to tears. I am able to be very clinical and for lack of a better word, professional when I am in that role. But when patients relate history that is especially touching, I do not back away from gettting a little misty. It is natural, it is a release, and I have never had a patient “freak” when they notice me dabbing at my eyes a bit.

We do ourselves and our patients a disservice by trying explicitly to remain automatons. People will seek out caregivers with whom they connect. Expressing some emotion as you feel it, within reason, is part of that connection.

Fergie said it best – Big Girls Don’t Cry. That goes for boys too. One can express compassion and empathy without crying. Jeff, the situations you describe are totally different in so far as you are not in the role of treating physician when you cried with the patients. I think Fergie would see that as acceptable.

One of my vivid memories from the birth of my first child was the midwife in the back of the room crying when the OB came in to get my consent forms signed for the C-section. I’d been pushing for four hours (big, posterior baby). I don’t know if those tears helped or hurt in the long run. They did make me feel like there was at least one person there who understood how disappointed I was at the outcome.

This may be simplistic, but to me, nothing says “I’m truly and completely screwed” like my doctor bawling at my bedside…

There’s a line between showing appropriate emotion, and outright crying. I’ve seen a doctor cry when sharing information about a serious medical error with a patient’s family, and I think it helped the family accept the information without feeling animosity toward those involved (it was not the doctor’s error). However, in most other situations I don’t feel it’s appropriate. The focus should be on the patient, and what the patient needs from the interaction, not the doctor’s feelings, or his/her need to vent about the situation. There are some patients it might help, but on the whole, patients seem to be a little shocked and put off whenever their doctor expresses any kind of strong emotion.

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