To Cry or Not to Cry

Considering the tragedies that occur daily in the hospital, there are plenty of reasons to stop and cry, but should you? After talking with colleagues about this and being in many difficult conversations, the simplest answer is that if crying fits for you and for the situation, it can be positive in its ability to strengthen existing bonds. If tearing up in public is not your thing, don't go there.

As a palliative medicine physician, I encounter many sad, difficult, and trying situations that test my emotional stamina daily. In fact for some physicians, it may be that visceral connection to another human that attracts us to medicine. I was surprised in residency when I first discovered that ''breaking bad news'' and ''compassionate honesty'' led to praise and gratitude from patients and families who would cry, be angry, and eventually come to a certain peaceful but sad acceptance of dying. Using my medical knowledge to guide patients and families through this was personally rewarding and occasionally emotionally difficult, but I never cried in these meetings. But then, I also am firmly planted in the second half of the answer above: I don't cry in public.

Of course once you begin telling stories with your peers, most quickly realize this dilemma goes beyond whether to cry with a patient or family. For example, it's important to consider the intensity of the emotion you show compared with the emotion you feel. Many times, I have felt completely torn up inside as disastrous news played out in front of me. As the family looked to me and the team, it was clear that we were all affected by the scene. I am sure you all recognize the ''nearly crying'' face. Well, that is about as far as I get in the room with a patient or family. Outside the room in my private moments, if that sadness is still there I let it out.

How I maintain my emotional stamina is by becoming a chameleon. By adapting to the situation in front of me, my emotions can be sincere but protected from my core by what I call a ''professional mask.'' It is much like a 2-way mirror. Stimulus comes through the mask in both directions; I am able to show genuine compassion and concern at the level needed without compromising my emotional integrity. But when someone turns the lights on the other side of the 2-way mirror, the emotions of the meeting can come through that ''mask'' as well to affect me. Some may think having a professional mask is faking it or just acting, but I know I am sincere in the concern and compassion I display for my patients. How do I know? At the end of some days, I can tell my wife "I don't feel much like talking," and she understands. I am drained. To figure out how much emotional stamina you have, it may help to think about how opaque your ''professional mask'' is today.

It has been an honor watching other doctors and nurses who respond with a much more open display of emotions in similar difficult situations. And you know what? The professionals did fine, and the patients and families genuinely responded to the grief in the room. No one seemed hurt or bothered by their demonstrativeness, and in fact some of the connections were much stronger because of the shared experience.

Gone too Far?

When there is potential for bonding, crying openly can work positively, but whenever you open your true feelings it comes with some risk. For example, I recall a time in my training when the intern identified too closely with the patient as he reminded her of her brother who died at an early age. The intern was smart to identify this association to the rest of the team but also felt it would be good for her to keep that patient on her service. Unfortunately one day when the patient crashed, she also took it pretty hard. The patient's decline was no one's fault, yet her tight connection to the narrative shifted the focus when she and the family cried together. The family came up to our senior resident and expressed genuine concern about the intern.

What a professional should not do is allow the crying to change the focus from the family or patient to the physician. A good built-in boundary check is if the family members are more concerned about you than about themselves, you may have gone too far. Some doctors might also use their emotions to make a quick connection to the patient or family. In the guise of ''I lost my (insert relationship here) too,'' the doctor skips the natural trust building that comes from caring for a patient and jumps right for the emotional connection. This strategy also turns the focus away from the patient and family and to the provider. Building trust quickly is important in medicine when you sometimes go from "0 to death and dying" in 5 minutes but not at the expense of shifting the focus away the patient or family.

Burnout

For some doctors, crying at the bedside of a patient is acknowledgment of grief, impending loss, and the connection that has been built. Crying can be worthwhile if it restores some emotional stamina by releasing pent-up negative feelings. If crying at the bedside starts to become something you do more often than not, or it starts to feel as though you should cry, then you might need to look at other ways to replenish yourself and see if your team notices any signs of compassion fatigue/burnout.

Emotions, boundaries, and self-care are important areas to recognize to avoid burnout and depression. Depression and burnout are underrecognized in medical trainees and later in your professional career, so do not underestimate these 2 powerful influencers on the control of one's emotion in professional settings. In our palliative medicine fellowship, we "stress" self-care activities for fellows, and we let faculty know if fellows are pushing themselves too far. In training, it is actually a good sign if you can recognize when this happens, so don't be afraid to identify it in yourself. The work of a physician is emotionally taxing, which is why we must look out for ourselves and for each other.

Christian Sinclair is Editor of Pallimed, a hospice and palliative medicine blog at www.pallimed.org.

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