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Monday May 06, 2019

Your Patient Is Crying. What Do You Do?

A few weeks ago, my patient cried twice in the same visit. She came in worried about dizziness and an enlarged lymph node on the back of her neck, both of which developed after a recent upper respiratory viral infection.

[physician comforting crying patient]

I examined her, felt the mobile, mildly tender lymph node and, with a smile, declared, "Oh! This is just a reactive lymph node. It'll probably improve in a few weeks. If not, we'll get an ultrasound, but I'm not worried."

Her body relaxed, her eyes welled up and tears flowed.

As I have done many times before, I rolled my chair over to the sink in the other corner of the room, where we keep a box of tissues. Sometimes in a dramatic flair of physical comedy, I exaggeratedly reach my arms out to pick up the box and sweetly scoot my chair back toward the patient, holding out the box as an offering of my empathy and understanding. It usually gets a chuckle from the patient, a brief moment of reprieve from distressing thoughts.

"Oh, my goodness," my patient said, wiping her eyes with a tissue. "A friend of mine just was diagnosed with cancer. I just didn't know what this lump meant."

After she recentered herself, I moved her through the motions of the Epley maneuver to see whether I could reproduce her post-viral dizziness. Displacing the little stones inside the inner ear to turn symptoms of vertigo on and off is like a party trick when it works. And in her case, it worked. I searched online for a picture of the inner ear and explained the pathophysiology of vertigo.

Within seconds her face eased. She was reassured, and again she began to cry.

"I'm so sorry," she said. "I don't even know why I'm crying."

I did.

An exam room is a sacred and safe space at the end of a ceremonial ritual. Patients check in, follow a medical assistant through the hallways, sit in a room, prepare by getting vital signs measured, and then wait until the mysterious doctor arrives. Our brains are primed for profound interactions in these spaces. It's no surprise, then, that within the safety of that space, people are able to receive compassion and those who wouldn't cry otherwise feel they can.

Sometimes I forget how remarkable it is to have this role, where patients -- even those I'm seeing for the first time -- are so open and vulnerable with me. Even more remarkably, it happens multiple times a day, with people from all walks of life. I've come to realize that it is not necessarily who I am but rather what I represent that allows these interactions to occur.

The best-case scenario is when patients cry because they feel heard, relieved or reassured, as in the case of my patient with vertigo. It means that I've addressed fears, clarified a confusing thought or made them feel safe in some way. These moments allow me to connect with my patients, to apply what I've learned about the human experience in the patient care setting. Giving compassion becomes cathartic for both the patient and me -- a positive outcome.

Most of the time, however, patients cry out of fear. Recently I had a conversation with the daughter of an 83-year-old man who was newly diagnosed with cancer. She teared up when I asked if she knew what her father would want if he couldn't make decisions for himself. In that moment, the fear of losing him was a lot for her to bear. I understand when patients cry at times like this. I'll get the tissues, but I insist on having this discussion. I've experienced moments in the hospital where family members are distraught and confused after a loved one is unable to speak or think. To me, that confusion is worse than the fear of loss. As uncomfortable as it is to address end-of-life decisions, I prefer to ensure that my patients are as prepared as possible for the worst-case scenarios.

At times, crying is not helpful. A few weeks ago, one of my patients, recovering from an eating disorder, cried with a desperate, twisted face -- fearful that being weighed would trigger behaviors she spent so long battling. Her crying, instead of being cathartic, actually exacerbated her anxiety loop. I've learned to ask, "How can I help you right now?" as a way to quickly refocus the patient. In this patient's case, I reminded her to stay in the present moment, and we reviewed the tools she had cultivated during the past year. She walked out of the room feeling empowered, which felt like a victory for both of us.

The most challenging situation is when patients cry and there is seemingly nothing I can do -- and the box of tissues feels like it's all I have to give. Like the patient who cried as he told me about his homelessness, or the patient who was separated from her child because of her mental health issues, or the patient who did not feel capable of leaving her abusive partner. I usually try to provide as many resources as possible and ask them to check in with me in a few weeks. Or I try to connect them to a mental health clinician at our practice. At the end of these visits, I still try to bring patients back to the present moment. I find it gives them some semblance of control. But it's always a challenge for me to move on to the next patient. The lack of a concrete plan makes the visit feel incomplete, even though technically I know that listening is itself an intervention.

I know I sound idealistically empathetic in each of these moments. I credit my approach and techniques in the patient care setting to remarkable educators in medical school and residency who modeled active listening and the power of narrative. However, my ability to be present is largely dependent on what else I'm preoccupied with that day, how many patients are waiting, or whether I've eaten, exercised or slept well. Frankly, sometimes I need to cry after having difficult conversations or simply because I'm overwhelmed and don't know how to help my patients.

I've heard it gets better with practice, that allowing patients the space to cry while preserving my own emotional energy is simply a part of this learning curve during the initial years out of residency -- akin to improving efficiency or becoming more confident in procedures and clinical knowledge.

In the meantime, I've learned to ask, "How can I help myself right now?" It works. It brings me back to the present moment and refocuses me on what I can and cannot control. I've connected myself with a mental health clinician. And I'm learning to give myself empathy so I can continue to be compassionate when my patients cry.

Lalita Abhyankar, M.D., M.H.S., is a family physician practicing in New York City. You can follow her on Twitter @L_Abhyankar.(twitter.com)

Read other Fresh Perspectives posts by this blogger.

Posted at 03:59PM May 06, 2019 by Lalita Abhyankar, MD, MHS

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