The Covert Rationing Blog

On Crying Doctors

April 23rd, 2008 by DrRich

The New York Times yesterday published an essay by Barron H. Lerner, MD, on the question of whether doctors ought to remain stoic at the bedside, or instead ought to openly display their emotions. Lerner himself seems neutral on this question, and offers arguments from both sides (i.e., the advantages on one hand of the physician graphically displaying the deep empathy he/she feels for the patient, vs, on the other hand, maintaining the professional distance necessary to convey a sense of control and hope).

As it happens, DrRich agrees with DB on this issue. DB stresses “the importance of maintaining composure when everything seems to be failing. Patients deserve composure, empathy and a well developed plan.” DrRich believes that this ought to be a doctor’s default position.

Certainly there are times when it may be entirely appropriate for a physician to cry at the patient’s bedside, for instance, when the emotional outburst is completely spontaneous and simply cannot be held back, or when a patient is relating a particularly affecting personal story, or in other circumstances no doubt too numerous to mention (or too painful to think about). But in general, DrRich is convinced that doctors should not make a habit of expressing their emotions too frequently or too luxuriously to their patients.

(That’s all well and good, some of you might be thinking, but we really don’t care what DrRich thinks about crying doctors. We do not come here for gratuitous opinions on touchy-feely stuff like this. We come here to read hard analysis tinged with sarcasm, and to get all riled up about covert rationing. What the heck do crying doctors have to do with covert rationing?

To which DrRich replies: Observe.)

It seems more and more likely that our medical schools, busily training America’s Doctors of Tomorrow, have reached or are about to reach the following epiphany: A particularly wonderful way to repair the failing doctor-patient relationship would be to indoctrinate young future physicians (most of whom these days are said to be women, not that there’s anything wrong with that) that crying at the bedside - indeed, openly displaying their every emotion at the bedside - is a marvelously therapeutic act. A display of the doctor’s true emotions conveys a powerful message to the patient.

But as it happens, crying doctors actually convey two powerful messages to their patients.

First Message: I recognize and empathize with your humanity. I feel your pain.

Second Message: Your position is so dire as to be beyond even my ken. You are well and truly screwed.

It is this latter message that, in the opinion of DrRich, DB and others, ought to make most doctors on most occasions relatively circumspect about crying in front of their patients.

It is also this latter message that offers to make crying doctors a tool for covert rationing.

For one thing, when the doctor is reduced to tears (thus graphically announcing to the patient that the game’s about up; that there’s pretty much nothing, really, that’s going to change this bleak outcome; and how very sad it all is) - well! Talk about reducing your patient’s expectations!

A chief tenet of covert rationing is that patients who can be made to expect little will be satisfied with little. In most cases this is accomplished by simply coercing doctors not to tell patients all of their options. (Since doctors have proven more resistant to such coercion than the feds and the insurers would like, docs are now being herded into P4P and 7.5-minute patient encounters to assure the same end.) But if they can be encouraged to cry when delivering bad news, doctors can destroy patients’ expectations in a much more dramatic (and thus more effective) fashion.

Furthermore, the traditional role of the doctor when a patient’s outlook is poor is to take charge of a very bad situation, and with great empathy, patience and fortitude attempt to guide the patient through that situation with as much skill and courage as possible, even if the final destination looks very bleak. If the doctor instead becomes just one of the people who are crying about it, then the patient immediately perceives themselves to be abandoned and alone, placed into a position irremediably desolate, with no sense of direction, and no sense of control over their own destiny. Patients fighting illness from such a position do more than merely lose their expectations; they will also die much sooner and in greater despair than necessary.

So obviously, a healthcare system founded on covert rationing will see immediate advantages to espousing crying doctors. In the name of advancing empathetic physicians and fixing a broken doctor-patient relationship, we could, more easily and more often, substitute emotional support for medical technology, and effect the patient’s end more quickly and more economically.

Certainly, now that medical schools are teaching forms of alternative medicine that in former years would have made real doctors blush, DrRich would not be at all surprised to learn that courses being taught on the doctor-patient relationship are already encouraging young doctors to “let their emotions free” as a way of bonding with their patients.

Young doctors should not be taken in by such ploys. They should empathize with their patients, but remain strong, and lead their patients gently and resolutely through their ordeal. They should try to avoid allowing a free display of their emotions to break their patient’s spirit. Their job, instead, is to use their expertise to fortify their patient’s spirit, even in the worst of times. And above all they should not allow themselves to become the trained tools of an ultimately cynical healthcare system, that uses every ploy at its disposal to covertly ration care.

Posted in General Rationing Issues

7 Responses to “On Crying Doctors”

1. AnnR wrote on 04/24/08 at 5:07 pm :

   I hadn’t thought about it that way, but I like your viewpoint.

2. Mike wrote on 04/26/08 at 12:21 pm :

   I would agree that providers need not burst into tears during the deliverance of bad news to a patient or when a patient’s prognosis appears bleak. Providers at all levels can demonstrate a level of empathy with patients and still be objective and offer a reasonable plan of care to suit the patient’s desires.

   What is lacking from today’s healthcare system though is a more humanistic approach to patients where quality of life and not quantity should be emphasized.

   Providers at all levels tend to distance themselves from patients and treat them very much like inanimate objects. Granted those of us in healthcare use distancing as a coping strategy much of the time; we need to be cognoscente that despite the fact that we may not know our patients well, they are real people with real problems, and they are looking to us for help and guidance.

   Providers need to practice a little closer to the edge of humanity and let patients and families see their genuine level of concern but not do this with a box of tissue in our hands. We as providers can certainly improve patient provider relations by showing genuine concern without the drama of emotions.

3. Dr. Val wrote on 04/26/08 at 6:52 pm :

   Crying happens for complex reasons and its appropriateness must be judged by the context in which it occurs. My misty-eyed moments in the hospital are more likely to occur from feeling moved/touched than from feeling sad about an unfortunate test result. When I witnessed a young patient survive the ICU (and a veritable death sentence) and make it to a General Medical floor where she was joined by her children on Mother’s Day… I did tear up.

   When a patient was mistreated and ignored by a whole series of physicians and consultants and yet I managed to fill in the gaps in communication and let her know what was planned, her husband turned to me and said, “I know you’re the most junior member of the team, but you’re the one who’s done the most for us tonight - thank you for being kind. Never let the bast*ds get you down.” That made me misty too.

   So the whole “to cry/not to cry” argument is missing the point I think. We’re not talking about bursting into tears over an elevated BUN/Cr, we’re talking about allowing ourselves to feel, to care, and to be moved.

   I do agree that we need to be strong for our patients in times of stress. They need us to tell them the truth, and express the facts with compassion and firmness. But if a little disabled kid hugs me after I fix his wheelchair, I’m not gonna sweat a tear drop.

4. DrRich wrote on 04/27/08 at 8:17 pm :

   Mike and Val,

   I’m actually not saying doctors shouldn’t express their emotions, or even cry, when circumstances warrant it. I know neither of you will believe this, macho-man that I obviously am, but even DrRich has teared up with patients on occasion.

   My argument, rather, is against actively encouraging doctors to adopt emotion-on-the-sleeve as the routine, default, preferred means of delivering bad news to patients.

   The situations Val describes, in particular, seem entirely appropriate by any standards (even mine) - because there is no chance of misinterpreting her empathy in such situations as “you are well and truly screwed.”

   THAT’S the message I think docs ought to try to avoid delivering in a display of emotions, whenever they can. And I think (for reasons I’ve outlined) that doctors should fight any suggestion that crying while delivering bad news ought to be taught and encouraged.

   Rich

5. James wrote on 05/2/08 at 3:12 am :

   Your honor, I object to this line of questioning - counsel has not shown relevancy!

   Everyone has an opinion on how doctor should behave. Doctors should act this way or that way. Nobody tells auto-mechanics or accountants how they should act on the job. My point is, whether or not it’s ok for a doctor to be emotional is completely subjective. I may want a doctor who cries, you may not. That’s totally fine, we can go to different doctors! Sometimes it’s as if there is some ideal doctor out there - ala Plato’s “form” of a doctor - that all doctors should aspire to be. Just be a good doctor; do your job well. If you cry, you cry - it’s not really anyone else’s business.

6. Zoe Brain wrote on 05/2/08 at 11:28 pm :

   An anecdote: the first time I saw my endo, and was feeling pretty hard done by by the Universe (and not without reason), he took a phonecall midway through the long consultation.

   When he returned to me, he had tears in his eyes. The test results for another patient were bad news, and the prognosis was about as bad as it could be.

   It was then that I realised I was in the care of a man who gave a damn. Now I already knew he was professionally competent, world-renowned in his field, but he was more than that.

   I spent most of my time giving him what sympathy I could. It was a wake-up call for me as a patient to have a sense of perspective too.

7. L. Longo wrote on 05/19/08 at 1:35 am :

   What the hell happens to you people in med school? Are you psychically lobotomized? There is a profound difference between genuine and humane empathy (might be accompanied by tears)and blubbering at the bed side. Just standing by and doing nothing but delivering the news shows an apalling lack of feeling.

   Any doctor who is so “professionally” removed from the human condition as regards the really “bad” news that he/she has to have a course on how to handle it, is a doc that has missed the boat and needs to find another profession…like dentistry.

   LL

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