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Tearful patient

A weeping patient can trigger sympathy, irritation and even panic in doctors ­ but a few well-chosen words (and a hanky) can help, says

Dr Melanie Wynne-Jones

Tears are a non-verbal cue that few of us fail to spot. They can often be very revealing or even a turning-point in the consultation.

Why do patients cry?

 · Sadness

 · Anger

 · Exhaustion

 · Frustration/powerlessness

 · Fear

 · Stress/depression

 · Bad news

 · Despair/hopelessness

 · Pain/other suffering

 · Manipulatively

 · Easily ­ some people are more emotional than others

 · Inappropriately ­ some psychiatric or neurological conditions

When do patients cry?

 · Some patients arrive in turmoil, and burst into tears as soon as they sit down.

 · Others weep appropriately as they tell you what has been happening to them, especially if asked sensitive questions.

 · If someone looks distressed, it's easy to provoke tears by reflecting that back ­ 'You look very upset' or 'Is that worrying you?'.

 · Some look tearful in response to an apparently straightforward inquiry ­ the slightest hint of empathy then sets them off.

 · When they are told bad news.

 · A few cry when they are denied something they want, such as a particular drug.

How do patients feel when they cry?

Some are embarrassed at losing control, appearing weak or revealing their true thoughts, and apologise profusely while trying to regain composure. Men in particular are 'not supposed to cry'.

Some patients are so focused on their problems they seem oblivious to their tears, and need to carry on with the consultation.

Crying is not always cathartic, and we do not have an automatic right to ask intrusive questions.

It's therefore vital to check that patients are comfortable about where things are going, by asking whether they are 'all right talking about this?' or would they rather 'leave this for now?'

How do we feel when patients cry?

Doctors can experience a wide range of emotions, including sympathy, pity, irritation, sudden understanding, inadequacy or even panic.

A patient who suddenly dissolves into tears can be quite alarming, particularly if the crying does not abate quickly, or the patient is too upset to say what is wrong.

Some people's situations are so awful that words seem inadequate ­ we feel desperate to help make things better.

We may become tearful ourselves if the story chimes with events in our own lives or is particularly upsetting (the death of a child). This is not necessarily a bad thing, and patients are often appreciative we

care.

However, it's important to remember that we are there to support the patient, not the other way round.

Responding to tears

 · The moment when tears start to flow is often very intense for the patient. A short empathic silence allows them to get through this while you try to assess the situation.

 · Show acceptance of patients' need to cry by deliberate use of body language, verbal reassurance or offering a tissue.

 · Holding a patient's hand or putting an arm around their shoulder is often appreciated (but sometimes inappropriate).

 · Check the patient wants to discuss their worries (they are at a temporary disadvantage and may later regret the discussion; but someone who needs a lot of encouragement may actually be grateful afterwards).

 · Try to identify what emotions, as well as events, have triggered the crying (see list above).

 · If you feel uncomfortable, analyse your own feelings ­ they can provide useful insights.

 · Avoid upbeat platitudes.

 · Don't feel you have to have all the answers ­ listening sympathetically to a sleep-deprived new mother or someone coping with intractable symptoms can be a therapeutic intervention.

 · Discuss possible ways forward.

 · Offer a follow-up appointment if appropriate; the patient may choose or avoid you next time.

 · You may need to reflect or take a break before seeing the next patient.

 · Tears can often be revealing or a turning point in the consultation

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