In front of patients or colleagues, or hidden in the toilets, is it appropriate—or maybe even a good thing—for medics to shed a tear on the job? Fran Robinson investigates Many doctors admit to crying at work, whether openly empathising with a patient or on their own behind closed doors. Common reasons for crying are compassion for a dying patient, identifying with a patient’s situation, or feeling overwhelmed by stress and emotion. Probably still more doctors have done so but been unwilling to admit it for fear that it could be considered unprofessional—a sign of weakness, lack of control, or incompetence. However, it’s increasingly recognised as unhealthy for doctors to bottle up their emotions. Unexpected tragic events Psychiatry is a specialty in which doctors might view crying as acceptable, says Annabel Price, visiting researcher at the Department of Psychiatry, University of Cambridge, and a consultant in liaison psychiatry for older adults. Having discussed the issue with colleagues before being interviewed for this article, she says that none of them would think less of a colleague for crying at work: “There are very few doctors who haven’t felt like crying at work now and again.” A situation that may move psychiatrists to tears is finding that a patient they’ve been closely involved with has died by suicide. “This is often an unexpected tragic event: it’s very human to become upset, and sometimes it’s hard not to cry when you hear difficult news,” says Price. She adds that the possibility of losing control and crying in front of a patient is something medical students often tell her that they feel anxious about. She responds by telling them about the occasions when she’s cried at work, how she managed at the time and afterwards, and that it’s possible to do this and still be a good doctor. She recalls an occasion when a well respected colleague cried in front of an entire medical school year during a teaching session: “A patient he had worked with for a long time had died the night before, and while he was talking about a separate medical case it brought home to him how sad he felt about the death. He was very open about feeling sad. “Medical students looked up to this doctor, and this allowed them to see that it doesn’t matter how experienced and revered you are—sometimes a patient dies, and you feel sad about it.” Therapeutic for doctor and patient Caroline Walker, a psychiatrist and psychotherapist specialising in doctors’ wellbeing and founder of Joyful Doctor (https://www.joyfuldoctor.com/), an organisation that supports struggling doctors, says that the various reasons for crying are all very common, natural, and acceptable. “There’s something meaningful and appropriate about shedding a tear with patients when something really awful is happening to them,” she says. “When the doctor shows some vulnerability it can be incredibly powerful and a therapeutic tool that makes the patient feel more understood or cared for. “Crying with the patient is a bit like self disclosure1: it’s fine if it’s in the patient’s interest and doesn’t take the consultation away from them. It’s about being with them in that moment, being real and honest.” Women are known to cry more than men, but Walker says that she’s seen male doctors cry at work. She recalls, as a trainee, observing an emergency medicine team attending an accident where a 9 year old girl had fallen from a building. The girl survived the helicopter ride but died when the team reached the hospital. During the call-out the team members did everything they could for the patient. But at the end of the shift they gathered outside the emergency department, and the lead physician sat down on the pavement and sobbed. “The entire team felt compassion,” says Walker. “It was a shared emotional response at the overwhelming tragedy of watching a child die and not being able to save her.” The “stress” sob Walker warns, however, about different types of crying at work. Many doctors will have experienced the stress of having been pushed to their limit, causing them to cry privately in the toilets or in a cupboard because they feel unable to cope. “A lot of doctors functioning at this level do not realise that they might be ill. If this is happening frequently the doctor should seek professional support,” she suggests. Doctors can also find support in safe spaces such as Balint groups, Schwartz rounds, or reflective practice groups, which bring doctors and other healthcare professionals together to discuss the emotional and social aspects arising from patient care. “The happiest doctors I’ve come across are those with an informal peer group that meet regularly to chat and share,” says Walker. Chantal Meystre, a palliative care consultant and psychotherapist, set up Schwartz rounds at the Heart of England NHS Foundation Trust to enable doctors to talk about their experiences. She says that a lot of doctors don’t allow themselves to feel emotional, and they bury their feelings. Schwartz rounds give them an opportunity to talk about these feelings and listen to each other. Don’t kid yourself that you can get through a medical career without responding emotionally “Doctors do cry at work and may feel confused and guilty about it,” says Meystre. “My view is they should have access to psychological supervision so that they can learn to express their emotion, understand that they will be OK afterwards, and that if you cry it’s not the end of the world. “Don’t kid yourself that you can get through a medical career without responding emotionally, because when it happens it often takes you by surprise: a patient might look like your old girlfriend, or a child may have the same birthday as yours, so suddenly this dying child becomes your child in your head. Doctors sometimes forget that they’re human.” Inappropriate moments Hannah Barham-Brown—GP trainee, blogger, and member of the BMA Council and Junior Doctors Committee—says that in some situations it’s not appropriate to cry. She recollects the first time when, as a foundation year doctor, she had to confirm the death of a young man who had died unexpectedly. “I turned up on the ward where there were a number of family members. One started yelling at me about how the hospital killed his brother,” she remembers. “It felt very close to home, as I have lost two younger brothers in NHS hospitals and this young man was the same age as one of them. Part of me really wanted to burst into tears, but it wouldn’t have been appropriate because they were angry and didn’t know me from Adam. “As far as they were concerned I was just another person wearing scrubs and a stethoscope who hadn’t managed to save their brother. After I’d done what I needed to do, I took five minutes, made a cup of tea, and had a quiet sob in the corner before going back to work.” Barham-Brown says that she’s a big fan of a therapeutic sob. “If you hold on to emotion it becomes a much longer term problem,” she says. “We need to stop trying to see ourselves as superhuman, because it’s a damaging concept.” Emotional intelligence Surgeons may be seen as the medics least likely to cry at work. But this is no longer the case, says Scarlett McNally, consultant orthopaedic surgeon and Royal College of Surgeons council member. The college now recognises that, as in other specialties, surgeons become involved in intense situations that can affect them emotionally. In June 2018 the Royal College of Surgeons held a workshop on surgery and emotions, and an ongoing project at the University of Roehampton is exploring the emotional landscape of surgery. McNally says, “We are now aware that well trained, emotionally intelligent surgeons commit to a standard of good, safe care for patients and better teamworking. This makes them better surgeons and team members.” Ane Haaland, a social scientist at the University of Oslo who teaches emotional intelligence, says that doctors should feel able to cry at work but should be able to control it. “I call it crying with awareness,” she says. “This is about the focus being on helping the patient, not getting the patient to help you—there’s a huge difference, and doctors need to understand this.” Haaland has developed a model of reflective learning, in collaboration with health professionals in nine countries, that has been used in the Wales Deanery to train postgraduate doctors in self awareness and emotional intelligence. The programme teaches doctors to recognise and manage (rather than ignore) their feelings, to set healthy boundaries, and to see vulnerability as a resource rather than as a sign of weakness. Doctors learn how to recognise their emotions and to take a step back so that they can make a choice on how to react. This enables them to connect more effectively with the patient as both a doctor and a human being. It takes five to 10 minutes of practice a day. Haaland says, “The main benefit of becoming aware of your emotions is that you can then recognise when you’re in danger of burning out and can take action to prevent it. There’s a huge need for a culture change, and many people are now talking about it.” Doctors learn how to recognise their emotions and to take a step back so that they can make a choice on how to react Thomas Kitchen, an anaesthetic registrar in Wales who both practises and has taught the Haaland model, says that he has cried at work but not, so far, in front of a patient. “If I end up crying I will not be thinking straight and therefore will not able to help my patients to the degree that I’d like to,” says Kitchen. “Recognising that there are different types of crying, there are few professional situations where I think that it would be the best thing to do with a patient. But I believe that, as doctors, we must still be able to show empathy and emotion and reflect this back to patients.” He concludes, “We work in an environment full of emotion, and developing the skills to help us demonstrate our care, vulnerability, and humanity in a sustainable and healthy way is essential—yet it’s so rarely taught. “Developing emotional intelligence skills has enabled me to find enjoyment and positivity at work while protecting myself from the more extreme emotional challenges.” The patient’s experience of a doctor’s tears Cherry Jackson from Hertfordshire, whose 21 year old daughter died by suicide, says that she was touched when a GP shed a tear with her during a consultation. A few weeks after her daughter’s death she had gone to see the GP about a health problem. The GP raised the issue and told her that she had a daughter the same age. “This helped me to open up, something I usually find hard to do. I could see by her face that she was struggling,” Jackson recalls. “The doctor then told me that she had recently lost her baby niece, and she became emotional. “She got a tissue for me and one for herself. She didn’t cry a lot, it was just a few tears. She quickly composed herself and held my hand and reassured me that it was OK to feel like this. “It helped me a lot at a difficult time.” What the research says about doctors’ tears An Australian cross sectional study using self reported questionnaires found that crying was frequent in hospitals: 57% of doctors and 31% of medical students had cried at work at least once, and women cried considerably more often than men. Medical students reported the highest percentage of negative social consequences from their own crying (such as being ridiculed or screamed at). The main reason for all respondents’ crying was identification and bonding with suffering and dying patients or their families. A web based survey conducted in the United States found that crying was common among medical students (69%) and interns (74%), especially women. Many considered it unprofessional to cry in front of patients and colleagues. In both groups the most common cause was “burnout.” Most participants wanted to see more discussion of crying. Interviews with 182 medical students at Yale, Connecticut, found that 73.1% had cried because of an encounter with a patient, and 16.5% had nearly done so. Source
