The Tissue Controversy, Tears in Hospitals

“I’ve gone home, cried…” Penny a nurse in a neonatal intensive care unit told me as she talked about caring for babies that are dying. “But when I’m here [at the hospital] you have to remind yourself that you have limits and while it’s sometimes appropriate to cry with your patients… you’re the professional….you’re not there to have them comfort you… you do have to be sort of the strong one in the situation...”

I thought of Penny recently when someone at an educational program I was attending with healthcare providers asked the group what they do when a patient or family member starts to cry. A collective sigh went up and the nurses, physicians, social workers and chaplains started talking about how they respond. Some talked about whether they offer people who are crying a tissue – is a tissue a gesture of support or a sign that the healthcare provider wants the person to stop crying? Others spoke about whether it is ever appropriate to cry with patients or their families. Some said such tears were a mark of human connection while others called them unprofessional. This is the “tissue controversy” one of the chaplains said with a little laugh reflecting the many opinions healthcare providers have about how to respond to tears - their own and those of the people in their care – that they don’t talk about much in public.

I learned a little more about tears in interviews I conducted with intensive care unit staff about their work. Physicians rarely mentioned tears – their own or those of patients or family members. Aside from some first person narratives, there is little in the medical literature that describes when and how physicians cry– or can cry – and how they respond when patients do. This may be because so much has been written about detached concern, the ways physicians and other healthcare providers learn to keep patients at emotional distances. It isn’t that physicians don’t cry, but talking about crying or crying publicly remains quite taboo.

One of the few studies I found about doctors’ tears reported that 69% of medical students and 74% of interns in a small web-based survey said they cried for job related reasons. Women cried more than men, and many participants cried more than once. Overwork and burnout were the top reasons physicians in training said they cried followed by being criticized or humiliated, a patient dying, a patient suffering, feeling inadequate or guilty, or other reasons. Many cried in private thinking it was unprofessional to cry in front of patients or colleagues and that crying could negatively influence professional evaluations. Many wished for more discussion and guidance about crying in their training.

More of the intensive care nurses I interviewed talked about crying, though it was still not a common subject. Some, like Penny, thought they should not cry with patients or their family members. Others, like Jennifer, thought tears were sometimes all right. “I definitely cried,” Jennifer told me as she talked about withdrawing care from a seriously ill baby. “I was feeling bad I was crying. Maybe I should be the strong one for the parents, but then other people – other nurses like my co-workers said….sometimes it’s okay with them [the parents] because it is a human passing. That’s their baby….It is sad.” Another nurse reflected on a similar situation telling me that a parent once thanked her for crying, “When I was leaving the father came up to me and he said, ‘Thank you so much for crying with me, for my baby – that made me know how much this all means to you.’”

It was when I asked intensive care unit staff about their most memorable patients that I learned the most about tears. Many shared detailed stories of patients they cared for over multiple hospitalizations. They described small gifts they exchanged with some patients. A few receive holiday cards from family members of patients that have died. It was in the details of these stories that their eyes sometimes brimmed with tears, quietly, as they remembered.

When healthcare providers cry – as they almost all do at least occasionally - in hospital stairwells or on their way home, I encourage all of us as their family members, friends, colleagues, and sometimes patients to offer them an ear, a tissue, and a reminder that even though it is rarely talked about, they are not crying alone.

Published in the Huffington Post 11/26/12