Has the Bedside Become Messy? Crying with Patients in the Name of Intimacy
"A young doctor sat down with a terminal lung cancer patient and her husband to discuss the woman's gloomy prognosis. The patient began to cry. Then the doctor did, too. The scene was undoubtedly moving. But should physicians display this much emotion at the bedside?" This was the start of a thought-provoking essay in the New York Times by Barron H. Lerner, MD, a Columbia University Medical School and School of Public health faculty member, internist and renowned author. Lerner, in this article, addresses opinions about the issue of whether health care providers should stay stoic or show emotion in their communications, particularly regarding bad news to patients. Bloggers can access his essay: Excerpt from New York Times Article: At Bedside, Stay Stoic or Display Emotions? http://www.nytimes.com/2008/04/22/health/views/22essa.html
This article focused mainly on physicians' responses and relayed that at a recent meeting of the Society of General Internal Medicine at Harvard Medical School, colleagues reported that 69 percent of medical students and 74 percent of interns said they had cried at least once during their yearly trainings. (How wonderful to know that our doctors of tomorrow are human beings!)
As therapists, we are trained to work with our countertransference and to be clear on how we might use countertransference in an informed way within our sessions with patients and families. Recognizably the role of a doctor is considerably different than that of a therapist; however, the role of holding a space for a patient, especially during a time when traumatic information is being shared, seems vital. Granted, it is quite difficult to be the barer of horrible news, and yet, I wonder if, in crying, the doctor induces a feeling of trauma in the patient that in reality would take more time for the patient to digest, in order to arrive at such a point of emoting. Second, in watching the doctor cry, the patient may feel an unconscious (unreasonable, but existing nevertheless) sense of shame or guilt that s/he is failing the doctor in his mission to heal. Third, the patient, particularly if not well-adjusted, may be faced with having to worry about the doctor's emotional well-being. And so, I think it is inappropriate and on some level unprofessional and even selfish for a doctor to cry in front of a patient, especially in the face of having to relay traumatic material. Fine to stay with the patient; please, offer long listening, a shoulder, extra silence...but not with tears. In my opinion, the patient has enough to worry about, and needs a holding place - one who understands and who is present. I would love to hear your thoughts on this and most particularly if you are a doctor, nurse, social worker, OT, PT, clergy and of course, creative arts therapists... Patients too - what do you think? Cry or no cry?
Music Therapy: What not to do...
Once, while on vacation, I volunteered to work with a baby with an undiagnosed breathing disorder and her family.
The song I had offered to sing with their permission was the song the parents danced to at their wedding. My regular containing abilities were "on vacation" so when I began to sing, the mother picked up her daughter and held her (after not touching her for weeks because of the illness and her own exhaustion) and I felt my own tears start when the mother began to release and cry.
I ended up having to stop and re-start the song while apologized for emoting because I was embarrassed. That initial reaction of "embarrassment" was key in my knowing that something about what I did was off.
My role in working as a music therapist was to provide a safe musical space for the baby, her parents and sibling. It was inadequate and unprofessional that I emoted with them during their time in music. It was a valuable learning experience even if it makes be cringe at the choices I made to "help" that family.
Lessons from this experience:
1. NEVER work on vacation.
2. Crying makes an amazingly intimate connection between people
...and the lack of protection/boundaries...or whatever you want to call it... can enmesh feelings and people beyond a typically therapeutic, medical or professional relationship and compromise any and all work being done there.
3. Learn and continuously practice self-care.
"Dr. Sung’s study concludes with a call for senior doctors to acknowledge and discuss openly the apparent high rates of crying among medical trainees."
All clinicians in the field should probably have gatekeepers, peers for supervision and clinical supervisors to help nurture their professional lives. It's a tremendous responsibility to contain a space in music or silence for our clients. It takes much self-care and awareness to effectively 'hold' a person in their grief, new diagnoses or emotional or physical pain and etc. Perhaps teaching self-care to new professionals will help them learn how to find compassion, empathy and sympathy for their patients....not by crying with them.
4. Don't jump in head first
The first few years of any doctor, therapist, nurse and health care professional are tender. It can be easy to forget the steps and protocols we've learned and the fact that they are in place for a reason. It's important not to take advantage of people and their families when they are facing fragile psychological, medical or other issues/illnesses/traumas.
It's not about the medical professional's needs or ideals but about the patient/client.
5. Always Assess
This is why assessment is so crucial in all medical and therapeutic work as it helps to determine the 'if, 'when' and 'how' of whichever intervention being offered is actually appropriate or required.
> born, very ill, a
> social worker who was assigned to us came to my room and started
> to chat and then
> immediately started crying. My husband had her sent away. It was
> upsetting b/c I was
> feeling as though I had to help her. I needed someone who was
> strong who
> could make me believe I would get through this. And it felt
> like she hadn't
> encountered this kind of tragedy too much. And it also felt
> like the tears
> were about her - not about me. I didn't once feel that it was
> great that she
> was crying - b/c she had so much empathy.
>
> Now my ob walked in on me once, and I was crying - and he
> didn't expect to
> see that. You could see that he got tears in his eyes, which
> he tried to hide
> - and he was visibly upset for me but business- like but with
> compassion -
> and he left pretty quickly (think he was upset for me) but had
> a nurse come
> in. That was fine. I got that he cared but he wanted to be
> and was in
> control. That one is a good memory.
I think it's okay for doctors to be human beings. After all it is a human business.
Now I have no idea what attention this is given in the medical world at present. I assume these days more awareness IS built into educational medical programs about patient care, and self-care and self-awareness, hopefully this is not nearly my inner optimist.
Anyway, crying is often uncontrollable, and always has a personal element attached. I think that this is a wonderful thing to remember, and sometimes see, that doctors can have a personal reaction, as many I have met lately seem simply inhuman and often heartless.
On the other hand there should be a certain level of awareness of the tolerance of what they themselves can handle emotionally, in general and on a daily basis. This should often be monitered throughout all of our lives, doctors included, since it changes with personal traumas happening in one's life. If docotrs were taught this in school (which they may be), then there could be a great emphasis on self-awareness as well as the importance of assessing outside of work incidents with how they can and do effect work and how it can help or hinder responsibilites at work.
Overall, I do believe it is probably best for doctors to hold themselves together at the bedside, where we are right NOW in the evolutioon of awarenss. As we evolve, and doctors explore their inner processes and intuitions about the delicacy of situations, then crying may be at times appropriate if the emotional intelligence and intuitivenessis in tact, if I may. It is one of OUR primary jobs, as creative arts therapists to be fully aware of this process, it is not the primary job of the doctor (right now) to be aware of this.
Simply having patience for the evolving world and it's evolving awareness is all we can do. Sharing thoughts on this topic to spread awareness to any doctors and people in the medical field we may know in our lives as well is invaluable.