Tearful Patients

[BigSib]

I am a rural primary care doctor. I would estimate that at least a fourth or third of my visits - especially new visits - are related to mental health in some way. I see about 15-25 patients per day on average and frequently AT LEAST one patient per day becomes tearful for various reasons. It's become kind of a thing in my office where my MA and/or RN notice the box of tissues is misplaced. At one point in starting my practice I was somewhat tracking it for a few months, celebrating when a day passed when someone was not tearful. In reviewing that past few months before this post it looks like there has been at least 1-2 visits per day specifically for mental health problems (again, a lot of this is involved in other chronic health problems not specific to a mental health-related visit). We do a PHQ-9 screener for every patient which is somewhat of a driving factor in starting these discussions, but I'm just curious whether this is normal or whether I'm just 'good' at drawing out an emotional state from patients. I am more curious as to whether this is a good or a bad trait in general.

Is this something that you guys experience regularly or do you think this is because I'm in a primary care setting - seeing patients at the onset of their search for improvment?

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[Mass Effect]

Being tearful isn't necessarily a mental health issue. We'd need to know the context of the tearfulness first. But, thankfully, the stigma of mental illness is improving (still there though) and people are more willing to admit to anxiety or depressed mood these days. That doesn't mean they have GAD or MDD. Most people have periods in their life in which they feel anxious or depressed but don't necessarily meet criteria for MDD or GAD. They may just be more willing to admit to it these days.

I also think there's more anxiety out there in general, given our current political climate and social media. I'm perplexed by the number of patients I see who have anxiety that's triggered by something on cable news or something they read on a forum or Twitter. I had one patient frequently involved in Twitter arguments that have a negative affect on his mood and he even has insight about it, but calls himself a political junkie and won't stop.

 

[SourceOfDenial]

First off, no reason to pathologize crying. Being tearful is as human of an expression of emotion as laughing.

Secondly, for many folks crying requires vulnerability, so instead of viewing it as ‘I’m good at getting someone to cry’ it might be helpful to think about the framework of ‘Ive helped to create an atmosphere that patients feel safe to show emotions’ and thinking about what that means.

Finally, eliciting emotion for our own sake—not a great way to practice medicine(‘if they cry I must be doing a good job’) but asking questions and creating a space where folks can be vulnerable and open—almost uniformly helpful and certainly not pathological.

 

[BigSib]

First off, no reason to pathologize crying. Being tearful is as human of an expression of emotion as laughing.

Secondly, for many folks crying requires vulnerability, so instead of viewing it as ‘I’m good at getting someone to cry’ it might be helpful to think about the framework of ‘Ive helped to create an atmosphere that patients feel safe to show emotions’ and thinking about what that means.

Finally, eliciting emotion for our own sake—not a great way to practice medicine(‘if they cry I must be doing a good job’) but asking questions and creating a space where folks can be vulnerable and open—almost uniformly helpful and certainly not pathological.

I guess I'm trying to figure out whether I'm navigating the conversations and their concerns properly. Of course it's hard to generalize for all patients and highly dependent upon the context of their unique history/life/etc. It's kind of unpleasant to be around so frequently and I'm wondering whether I should try to alter my approach to attempt to avoid them becoming tearful or whether, in some small way, this is somewhat of a therapeutic reaction in that they are open and building rapport. I would say it seems like things are going well in a general sense in my management of mental health problems, but again it just seems there's a heck of a lot more emotional patients around here than I ever expected. Typically tearful patients are gushing about specific situations that are stressful in their lives and, in finding out this information, I am either able to provide some kind of personal advise or alternative approach to their emotional reaction (e.g., mindfulness among other relatively easy psychotherapy strategies). I'm certainly not trying to get them to become tearful, but certainly it seems like it's easy for it to happen. I did quite a few months doing inpatient/outpatient psychiatry and psychologist/therapist in my training and I just feel like it's not the same environment as someone seeking out care for the first time in the primary care setting.

Anyway, it's not really that big of a deal. I just figured some psychiatry geeks online would be interested to discuss.

 

[Sushirolls]

Be you. Do your best. Patients know if you give a darn or not. That's what matters more. Folks know your not the mental health person, and that may be why they are choosing to open up to you. Let them know your strengths, weaknesses, hash out a plan, offer up some hope, more on to otis media in the next room.

Keep on truckin'

 

[Mass Effect]

I guess I'm trying to figure out whether I'm navigating the conversations and their concerns properly. Of course it's hard to generalize for all patients and highly dependent upon the context of their unique history/life/etc. It's kind of unpleasant to be around so frequently and I'm wondering whether I should try to alter my approach to attempt to avoid them becoming tearful or whether, in some small way, this is somewhat of a therapeutic reaction in that they are open and building rapport. I would say it seems like things are going well in a general sense in my management of mental health problems, but again it just seems there's a heck of a lot more emotional patients around here than I ever expected. Typically tearful patients are gushing about specific situations that are stressful in their lives and, in finding out this information, I am either able to provide some kind of personal advise or alternative approach to their emotional reaction (e.g., mindfulness among other relatively easy psychotherapy strategies). I'm certainly not trying to get them to become tearful, but certainly it seems like it's easy for it to happen. I did quite a few months doing inpatient/outpatient psychiatry and psychologist/therapist in my training and I just feel like it's not the same environment as someone seeking out care for the first time in the primary care setting.

Anyway, it's not really that big of a deal. I just figured some psychiatry geeks online would be interested to discuss.

Talking to distressed patients is a skill that's tailored to the situation. For example, if I have a patient in my office who is tearful about childhood trauma and we have 10 minutes left in the appointment, the last thing I'm going to do is talk to her about her childhood trauma, even if she's crying. I'm going to ask her what's making her upset right that moment and what I can do about that, but I don't want to trigger her and send her out distraught. It would be dangerous and irresponsible (and even malpractice) on my part if I attempted to peel away at the trauma itself or details of her history if I don't have the time to truly help her put herself back together and insure safety when she leaves.

As others have said, the fact that your patients open up to you shows you're a good doctor and they trust you.

 

[Crayola227]

Life sucks, and usually when you go to the doctor, even if it's primary care, even if you're not even all that sick, you're still dealing with the less savory components of existence as a physical being destined to break down and die.

People will open up to their bartender or barber. That said, our occupation is on the list of the most vaunted for trust, next to the likes of your priest or attorney, literally, the few people you can talk to and give your deathbed confession, the people you can tell anything to. So maybe even higher than bartender or barber for who you can trust, and we certainly have an edge over the common spouse, mother or child, for who you can safely confide in.

The intersections of these two principles, (you're at the office of one of the few humans in your life you can trust, dealing with the always-heavy-in-its-way issue of having a body and being mortal) the way I see it, by being a doctor, you've signed up to wipe away someone's tears every working day of your life. That doesn't end up being everyone's daily practice, but as I see it, it's an occupational hazard of receiving the MD and title of Doctor.

You're a professional advice-giver, through and through. Your job is people's problems. What's funny when someone goes to someone with a problem, is how people will then want to see what else they can get by you. If you were a divorce attorney and helped someone with their divorce, they would ask you about their father's will. If you were a tree cutter and took down someone's oversized tree, they would ask if you could fix the property damage it did. It's a compliment, certainly, if still an annoyance when it seems like "yes, I solve problems, what makes you think I solve these?)

It's par for the course. I think the thing to evaluate is whether or not your patients, individually and as a panel, are getting the best care, and also looking after your own well-being.

 

[thoffen]

I guess I'm trying to figure out whether I'm navigating the conversations and their concerns properly. Of course it's hard to generalize for all patients and highly dependent upon the context of their unique history/life/etc. It's kind of unpleasant to be around so frequently and I'm wondering whether I should try to alter my approach to attempt to avoid them becoming tearful or whether, in some small way, this is somewhat of a therapeutic reaction in that they are open and building rapport. I would say it seems like things are going well in a general sense in my management of mental health problems, but again it just seems there's a heck of a lot more emotional patients around here than I ever expected. Typically tearful patients are gushing about specific situations that are stressful in their lives and, in finding out this information, I am either able to provide some kind of personal advise or alternative approach to their emotional reaction (e.g., mindfulness among other relatively easy psychotherapy strategies). I'm certainly not trying to get them to become tearful, but certainly it seems like it's easy for it to happen. I did quite a few months doing inpatient/outpatient psychiatry and psychologist/therapist in my training and I just feel like it's not the same environment as someone seeking out care for the first time in the primary care setting.

Anyway, it's not really that big of a deal. I just figured some psychiatry geeks online would be interested to discuss.

I think the idea that you could identify discreet illnesses in these patients and manage them appropriately or refer to someone else to do that management is a fantasy for many. I think you're probably here because you know that on some level. Care about your patients. Do it with appropriate boundaries. Recognize that sometimes in medicine you won't know what's wrong or if there's something wrong or won't be able to help or your role requires respecting the autonomy of someone who is rejecting help. The worst cases are when you know help exists but is just not accessible to someone. But if you you're able to live in those realities with the people you care for instead of reaching for any of a number of fantasies of control, you'll have done the best that can be done.

 

[FlowRate]

It's kind of unpleasant to be around so frequently ... Typically tearful patients are gushing about specific situations that are stressful in their lives and, in finding out this information, I am either able to provide some kind of personal advise or alternative approach to their emotional reaction.

I'm not trying to cut this to misrepresent what you're saying, so please let me know if you feel that's what I've done.

Sitting with crying patients can be uncomfortable for all sorts of different reasons relating to both the patient and the physician. It sounds to me like you're feeling really ambivalent about these interactions. On the one hand, it's unpleasant and you want them to stop (giving advice or suggesting an alternative emotion); on the other, if your provision of a "safe space" is helpful, then maybe it's worth tolerating?

This is a pretty typical psychiatristy thing to say but it could be worth engaging in a therapy of your own (like many psychiatrists do) to explore those feelings further (explicitly, I'm not saying there's a pathology here).

 

[thoffen]

I will add that you might consider adding a psychiatrist or therapist to your practice or to have regular consultations. If you are skilled at providing a safe environment for expressing needs, you'll benefit from that expertise, and the environment you establish with patients will help carry over to reduce barriers to getting external help in this setup.

That said, I am not recommending a different version of handing off uncomfortable expressions or illnesses to someone else. If someone becomes specifically comfortable with being vulnerable with you, one of the worst things to do either through words or actions is communicate that there is not a role for those feelings here. That is despite the fact that getting help when you need it being the most important thing to do. Instead, it is more a referral to co-manage where you might not direct treatment but maintain an important safety of expression and line of communication with other providers. One area where this often goes badly is in any expression that might be interpreted as containing suicide risk.

 

[BigSib]

... it could be worth engaging in a therapy of your own (like many psychiatrists do) to explore those feelings further ...

Yeah I've considered this more to hone my own therapy skills, if possible, but I never felt it would really be worth it (excuses like anybody else). Particularly because a lot of this stuff permeates many other chronic health conditions: psychologic factors of chronic pain, diabetes mgmt, etc. I'm doing well and pretty resilient overall, but yeah I would consider if I was feeling burned out. I always felt the therapy sessions I sat in on were just plain boring and I'm an introvert outside of the professional setting anyway, so I in the end I never felt it would be particularly helpful for the time I may put in there. And, as someone pointed out above here, I am somewhat ambivalent about the whole 'too many tearful patients' thing because I don't want this stuff following me outside the exam room. I would be curious to read a resource/book of some kind for my own reflection though if someone has any leads.

I will add that you might consider adding a psychiatrist or therapist to your practice or to have regular consultations.

Most of the providers here would love this but we're a small organization with a lot of big organizational changes coming up soon, so it's been tabled for a number of years. I do some curbsides here and there for atypical situations or medications I'm not used to using. My former job had a psychologist in the building and we'd have them come in for a brief introduction if starting down that pathway. The whole region here has a dearth of psychiatrists though; there's 4 for a county population of 120k so we tend to take on more than usual I'd say.

 

[birchswing]

If somebody's crying, it might be the best they've felt in a long time.

That's been my experience often. It's often an inflection point.

Much worse to be in a slog and not even be relaxed enough to cry.