*originally published online 12/24/20 in the International Journal of Academic Medicine as part of The women in medicine summit: An evolution of empowerment in Chicago, Illinois, October 9 and 10, 2020. (Perspective #4).
“She didn’t even smile.”
This was the startling reply to my open-ended question with which I had learned to start all second-opinion consultations. “What is it that brings you to see me today?”
At their unexpected rejoinder, I became immediately self-conscious of my own facial expression. My smile laid bare. Uncomfortable and exposed to their scrutiny, I did not know how to respond. My face froze, the smile becoming brittle, a shield. For in truth, why should I – or any physician – display a smile if the news is bad? From their words, it was clear that my colleague had not greeted them with one. And that, to them, was the problem.
Second-opinion visits for advanced cancer can be complicated. The patient and their family can attach anger and blame to the first physician who revealed the diagnosis. Hoping, understandably, that the initial oncologist got it wrong.
However, this time, their anger at my colleague seemed to go beyond that.
“She was horrible,” the family continued to say to me. “Just horrible – not even a smile.”
I hoped my still-frozen expression hide my shock and puzzlement while I tried to gather my thoughts. There was nothing remotely horrible about my colleague, far from it. Her academic credentials and experience far outshone mine. If anything, she was the brave one to have the courage to be straight with her patients from the moment she walked into a room. Yet, this patient and their family had eschewed her care and instead come to see me, and all for what?
It would seem, for a smile.
I told myself there was perhaps a layer to their response that came from the normal human denial reaction to bad news. Anger is a common first step on the path of human grief. Yet, when I look back on this situation now, with the hindsight of over a decade of experience since, I cannot help but see something different.
If the first oncologist had been a man and had entered the room with an appropriately somber expression on his face, and then sat down and offered a kind and compassionate presence, all still with a befittingly serious set of his mouth, would these people have been in my examination room for a second opinion? Would they have labeled a man as “horrible” for not having a smile for them? (Or, as seems to be still the fashion in 2020, other misogynistic terms for confident women such as “mean” or “nasty?”) I think the answer is easily no.
As I proceeded with the consultation, a part of my mind asked myself, why did I enter the room with a smile? After all, I knew that I, too, was going to discuss with them the unfortunate, terminal nature of their illness. There was no facial expression that I, or any person, could make that would change that. Hadn’t my colleague’s choice of not smiling been in actuality the more appropriate approach?
I reviewed the diagnosis with them and explained that I, unfortunately, concurred 100% with my colleague on the expected prognosis and limited treatment options. There was more anger, and then, there were tears, and in the end, they thanked me.
All these years later, I am still not sure if they were thanking me for my professional opinion and expertise or for my smile.
When I think back on it, I wish now that I had not smiled. However, the truth is that it would have been hard for me, not to. I have been socially conditioned to smile, as a woman in our society, since practically birth.[1] When I meet a new patient. When I step into an elevator with a stranger. When I am introduced at a conference.
When I am addressed by my first name instead of my title. When I am mistaken for the nurse instead of the doctor. When I have to repeat myself multiple times at a meeting for my words to be heard. And even, apparently, when I am about to tell a fellow human being the worst news of their life.
I have been thinking a lot about this as I prepare to return to clinical work after taking a leave from practice (dating back before the pandemic). I have been wondering what it will be like to have to deliver life-altering news while wearing a mask, my expression hidden. When no one can see if I smile or not.
Moreover, I realized, perhaps, it will be a small relief. Because maybe, for all of my life, the smile has been the mask.
Reference:
- Smith RI. The Sexism of Telling Women to Smile. The Atlantic; 4 October, 2016. Available from: https://www.theatlantic.com/notes/2016/10/the-sexism-of-telling-women-to-smile/502826/. [Last accessed on 2020 Aug 20].