Shedding tears with patients no longer taboo

In the movie "A League of Their Own," a member of a women's professional baseball team in the 1940s becomes upset during a game and begins to cry.

Tom Hanks, as the team's crusty manager, reacts with disbelief and disgust: "Are you crying? There's no crying in baseball!"

But is there crying in medicine?

Certainly, the practice of medicine can move physicians to tears. But doctors often refrain from shedding them in front of patients or colleagues.

"Traditionally, physicians are trained that tears are unprofessional and represent a kind of professional weakness," said Rachel Naomi Remen, MD, a clinical professor of family and community medicine at the University of California, San Francisco School of Medicine and the best-selling author of Kitchen Table Wisdom: Stories That Heal.

For years, the model of a "good doctor" has been a physician who remains calm and dispassionate, said Howard Brody, MD, PhD, a professor of family medicine and director of the Center for Ethics and Humanities in the Life Sciences at Michigan State University.

That model works well in acute, crisis situations when a physician needs to remain calm in order to be effective and to reassure the patient, Dr. Brody said. But, he said, some physicians go too far in thinking "that any display of emotion is unscientific and bad and that it harms the patient."

Moreover, some doctors use emotional detachment to protect themselves from their feelings, he said. "They didn't ask if it's good for the patient to be cold and distant. They asked: 'Is this comfortable for me?' "

But the culture of medicine is gradually shifting away from the "cold and distant" model and toward encouraging more emotional openness in the patient-physician relationship.

Dr. Remen is a nationally recognized leader in this effort. She's the founder and director of the Institute for the Study of Health and Illness at Commonweal in Bolinas, Calif., which offers programs on the human dimension of medicine.

More than a decade ago, the institute developed a course called "The Healer's Art" that embodies these principles. The course is now taught in 38 medical schools nationwide.

And in working with veteran physicians who may not have had a course offered in medical school, "we address the importance of listening generously to people who are struggling with loss and in emotional pain, rather than walling yourself off," Dr. Remen said. "Open-hearted listening and genuine presence can be deeply healing to others."

Those shifting attitudes within medicine also reflect changing attitudes in the society at large, said William H. Frey II, PhD, director of the Alzheimer's Research Center at Regions Hospital in St. Paul, Minn., and author of Crying: The Mystery of Tears.

"We've come a long way from the days when men in particular had to maintain the James Bond persona -- always in charge, always in control, never showing emotions," said Dr. Frey.

In addition, the increased presence of women in medicine is widely perceived as having influenced attitudes on expressing emotion and crying.

"Having more women physicians is a natural corrective," Dr. Brody said.

Putting the patient first

Despite the changes in medicine and society at large, doctors are still very conscious of whether -- and when -- it is appropriate to tear up in front of patients.

"It's not an issue of whether the doctor feels better by expressing emotion or not," Dr. Brody said. "The issue is always what impact it will have on the patient."

In certain situations, patients do seem to appreciate doctors' willingness to expose their own emotional vulnerability as an expression of empathy, according to a study, "The Doctor Who Cried," published in the July/August 2005 Annals of Family Medicine.

The study found that physicians report positive reactions from patients when they shed tears or express emotion in ways that convey empathy and expose their own vulnerability.

In one case, a doctor described being visited by a patient whose husband was expected to die of cancer within a few days. Tears welled up in the doctor's eyes when the patient described how difficult it was to tell her two children about the seriousness of their father's illness. After her husband died, the patient described the event publicly and said it meant a great deal to her that the doctor was so visibly moved.

Study authors Kirsti Malterud, MD, PhD, and Hanne Hollnagel, MD, PhD, conclude that "a spontaneous exposure of emotions from the doctor may help the patient."

But doctors walk a fine line in choosing how to express their emotions in front of patients.

Dr. Remen, who has lived with Crohn's disease for 52 years and has undergone multiple surgeries, said she has felt deeply moved when her own doctors had tears in their eyes while giving her bad or difficult news. "It has made me feel less alone."

But doctors have to be careful not to put their own emotional issues center stage, Dr. Remen said.

If her doctors "had actually broke down and wept in those circumstances, I might have felt that they were asking me to take care of them or to comfort them at a time when I could barely take care of myself."