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The Elephant in the Room

“I’m so sorry to tell you this, but we have found something abnormal with your mammogram results.”

I looked across the room towards the standardized patient and waited for her to respond. Dead silence.

“I know that this is quite upsetting for you, especially since you have been worried about your exam for several weeks.” I took a deep breath and continued hesitantly. I allowed the silence to settle as I racked my brain, trying to remember the SPIKES protocol (Setting/Listening Skills, Perception, Invitation, Knowledge, Emotions/Empathize, Strategy/Summary). We were learning how to deliver bad news to a patient with the assistance of standardized patients. I had dutifully read the assigned article and even memorized each component of the SPIKES acronym. As soon as I saw the standardized patient tearing up, however, I knew I was facing a bigger challenge.

I handed her a box of tissues and continued talking to her from my prepared dialogue despite a growing lump in my throat. When I began to ask her how she felt, I found myself blinking back tears. By the end of the interview, I had to grab some tissues as a few errant tears slid down my cheek. I slipped out of the door as quickly as possible, utterly humiliated at crying in front of a patient — a standardized patient, but a patient nonetheless.

I always knew that one of my biggest challenges throughout my medical education would be dealing with a patient’s emotions. I realized that early on when I found myself fighting back tears in the middle of morning rounds as I watched my resident tell a mother that her son had a brain tumor. I remember hiding behind the safety of a computer screen wiping away tears as I watched my attending embrace a weeping patient who was just diagnosed with ovarian cancer. I marveled at her ability to stay calm and yet sympathetic throughout the entire encounter and hoped that I, too, would be able to act similarly one day.

As physicians, we are often witness to intense emotional situations, yet crying in medicine is often equated with inadequacy, personal and emotional weakness, incompetence and unprofessionalism. Instead, physicians are expected to display detached concern towards patients to foster clinical objectivity and prevent burnout. In addition, such displays of emotion shift the focus away from the patient and can also be misrepresented with respect to the patient’s perspective.  “When I saw you tearing up, I felt guilty and embarrassed at crying in front of you,” confided my standardized patient as we reviewed our encounter. “I felt that it was inappropriate of me to cry.” In addition, crying could be misconstrued in ways opposite to the physician’s original intent. Little wonder then that crying is hardly discussed in the medical curriculum.

Even medical literature shares very little about crying in medicine. A PubMed search on statistics about physicians crying turned up few articles or essays. A survey on two medical schools, one in the Northeast and one in the Mid-Atlantic area, showed that 69 percent of third-year medical students and 74 percent of interns cried out of stress or sadness related to the practice of medicine. The survey also revealed that more than three-quarters of the respondents wanted more discussion of physicians’ experiences crying. So, then, why do our institutions avoid addressing this topic? Despite crying being commonplace in the practice of medicine, we fail to address it and discuss this issue with future physicians. Crying — as my standardized patient phrased it — was the elephant in the room.

My standardized patient was, however, determined to deal with the issue. “There’s nothing wrong with crying in front of a patient; the important thing is that you must address it with your patient.” Similarly, the attending physician who watched our recorded session echoed this sentiment during our debriefing session. “Experiencing emotions means that you’re human. However, you need to make your intentions clear to your patients. You could say that ‘this is difficult for me as it is for you.’ In that way, there is no miscommunication.

Hearing these words made me feel less inadequate. Although I still had difficulty reconciling the image of the competent, fully in-charge physician with one who cries with a patient, I realized that when our patients feel most vulnerable, showing compassion is the single best thing we can do for them. Displaying compassion comes in a multitude of forms, whether in the form of holding a hand, patting a shoulder or shedding a tear, our response rarely matters to a patient. What matters more is forging a connection, because, in the end, it is really not as physicians that we meet the sufferer but rather as persons meeting other persons who suffer.

If compassion is a quality that is highly desired in a physician, then there is no shame in grieving with our patients. All too often, the practice of medicine reveals to us the poignancy of human life and its entire spectrum of emotions. It is tempting to hide behind the sterile veneer of our white coats, but it is during our patients’ most vulnerable times that we need to relate with them on a human level.  Neurosurgeon and author Paul Kalinithi writes that this “openness to human relationality does not mean revealing grand truths from the apse; it means meeting patients where they are, in the narthex or nave, and bringing them as far as you can.” Early in our medical training, we are taught that we must validate our patients’ concerns and show our understanding of their emotions. Shedding a few tears with a crying patient is another way of telling the patient, “I can understand how this is distressing you.”

As we are taught to not ignore a patient’s tears, we too should not ignore the tears that we shed in the practice of medicine. As we are trained to remain supportive with our patients’ display of emotions, we too should support all forms of physician expression of grief and compassion. It is through these emotional encounters that we learn the true meaning of medicine and what it means to deal with the chaos, tragedy and grandeur that comprises human life. Patient emotions are often unpredictable. However, I rest comfort in the knowledge that when that day comes when I feel that telltale lump in my throat and the sting of tears in my eyes, I will have the courage to reach out to my patient and say, “I understand how you’re feeling. This is just as difficult for me as it is for you.”

Krishna Constantino Krishna Constantino (4 Posts)


University of Illinois at Chicago College of Medicine

Currently an M2 at University of Illinois at Chicago College of Medicine. Interests include global health, health disparities, and emergency medicine. Also enjoys photography, classical music, travel, and medical history. Will work for dessert.