Opinion
A PIECE OF MY MIND Lisa Simon, DMD Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, Massachusetts.
Corresponding Author: Lisa Simon, DMD (lisa_simon @hsdm.harvard.edu). Section Editor: Roxanne K. Young, Associate Senior Editor.
Whose Story Is It, Anyway? When I was 18 years old I went camping in the snow and, through a combination of bad decisions and worse luck, contracted hypothermia. After a long midnight hike of which I have no memory, and a few days of resting under piles of blankets, I recovered with no ill effects. It’s not much of a story, really, the way I tell it, and it doesn’t come up often. I am a newly graduated dentist and an aspiring public health practitioner. At a recent conference for studentrun free clinics, I was surprised to run into an adored college friend. A fellow outing club member, he too had been on that ill-fated trip. Now, seven years hence, we smiled at each other in the Tennessee sunshine and compared stories from our respective clinics, the stress and joy of being an almost-doctor. “You know,” he told me after an hour’s nostalgia, “I still tell that story all the time.” “What story?” “Oh, just that time you almost died and we had to drag you half-conscious through the woods. People love it, that learning-to-take-care-of-people angle.” There is a go-to narrative for students of health, and it usually goes like this: we are new and ignorant, we encounter a patient, and their suffering makes us grow or change in some way. We write about that first death, a meaningful mistake, or the patient we just couldn’t help. We tell stories of our empathy as catalyst. This is, of course, because in our inexperience, empathy is about the only skill we have. How scary yet thrilling the experience of caring for me must have been for my friend. He, persevering through the woods with me, a drooping rag doll! That is a much more engaging tale than my own, one that could regale crowds. I was the sick one; it seems like I should, at least, get a story out of those miserable hours. But it doesn’t work that way. I’m not the hero, I’m the plot. “You can have it. I bequeath the story to you,” I told him jokingly, as if I could, as if he cared. There are so many stories that I would like to tell. Teeth lack that romanticism innate in the stories of physicians-in-training; there’s a reason so many television shows take place in hospitals and none in a dentist’s office. But what about the woman who cried tears of joy to find out she could keep her four front teeth, the toothless man who could not afford dentures because his wife was pregnant, the teenager who, when I asked him what hurt, replied, “Everything”? Each of these tells more about the social justice of dentistry than a hundred papers full of dry statistics about inequality and access to care. They illuminate a less-seen piece of the health care experience of the underserved. As a patient once told me, “Being poor is hoping the toothache goes away.” I struggle with these stories, though. Because it’s still me, with my braces-straightened white teeth and layer
jama.com
upon layer of privilege, telling you that I saw someone vulnerable hurt. As a society, we consider empathy to be the hallmark of a good clinician. Before we treat our first real patient, we practice interviewing professional actors trained to act as model patients. In addition to our diagnostic skills, we are graded on our ability to convey empathy. The student made regular and unforced eye contact, five out of five points. The student responded with appropriate statements, five out of five. We are taught phrases, like, “It sounds like you feel really upset about that” and “That must be hard for you.” The latter line, which felt so forced, became a punch line my first year of school. But take away the act, and true empathy is to take on the emotions of others as one’s own. To do this fully, for each and every patient I saw, would be devastating. An episode of Star Trek: The Next Generation concerned an alien who experienced empathy with every sentient being he encountered; he went insane. But even the appropriate, professional level of empathy takes its toll, especially when the suffering to which you are exposed is the side effect of a callous and broken system. I spent my last months of dental school in a rural free clinic. My final patient there, like too many others, arrived terrified and in pain. A lifetime of bad experiences in a dentist’s chair had made her avoid them whenever possible, an unfortunate self-fulfilling prophecy that meant that each visit involved pain and, usually, the extraction of a tooth. Already, I saw, half of her teeth were gone, and I knew more were due to follow as she moaned and clutched her jaw. Even in this state, the necessity of an anesthetic injection caused a wave of heaving sobs and a resigned, barely audible refrain of “No, no, no … .” My softest words and gentlest touches were no match for the magnitude of her fear, and I extracted three heavily infected teeth as quickly as possible, while her hands clamped the chair in a vise grip and her whole body shook with terror. I am telling you this story because I think it might surprise you, and because I hope it might help make dental care more accessible in our country. I am telling you because I felt empathy for my patient, and if I couldn’t stop her suffering, perhaps I can prevent someone else’s, in part, by saying what I see. Yet I know that you read this now, in my words, because I am luckier and more powerful than the patients I treat. They might disagree with what I say, or wish I wouldn’t say it. I can only guess what they would tell you about their teeth if given the chance. And I am also telling you this story because it makes me feel better. It is difficult to be the inflictor of pain upon another, however indirectly, and there is inherent violence in the removal of a piece of someone’s body. I am telling you beJAMA June 11, 2014 Volume 311, Number 22
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 05/24/2015
2273
Opinion A Piece of My Mind
cause, like my friend carrying me through the woods of New England, I was a little bit scared by my responsibility for another person’s wellbeing. I am telling you this story because I am hoping you are empathetic too. Certainly, it is inappropriate to make others’ lives into a thesis statement. And yet I find some stories sloshing out of me, like water from an over-full pail. It is difficult to participate in the chaos of someone’s pain. It is even harder to merely bear witness to it. When we tell a story culled from our experience, it has a beginning, a middle, and an end. From that imposed linearity springs meaning. It is like turning a handful of different beads into a necklace. Does it really matter who strings it? Homer, after all, Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.
was not the first to describe the Iliad. Then again, we’ll never know what Achilles thought of that tale. It’s tricky, this calculus of appropriation. Like actual calculus, I can’t quite make sense of it. I want to empower my patients to tell their own stories, to me and to others, until those stories change for the better. But I was there too. I saw the whole thing. They were not my teeth, but I took them out. I have heat and running water, but I spent an hour on the phone trying to get the same for another. They were not my tears, but they wet my shoulder. Is that enough? Can I share these experiences with you? Can I stop them from happening again? Whose story is it, anyway? I know it’s not mine. But please. Listen.
Acknowledgment: My most sincere gratitude to Katherine Schiavoni, for helping start this conversation, and Nina Gold, for helping to finish it.
I have an unshakable belief that mankind’s higher nature is on the whole still dormant. The greatest souls reveal excellencies of mind and heart which their lesser fellows possess—hidden, it is true, but there all the same. The unborn goodness renders it possible for most people to recognize nobility when they see it, as the latent poet in a reader enables him to appreciate a fine poem. Helen Keller (1880-1968)
2274
JAMA June 11, 2014 Volume 311, Number 22
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 05/24/2015
jama.com
A PIECE OF MY MIND Lisa Simon, DMD Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, Massachusetts.
Corresponding Author: Lisa Simon, DMD (lisa_simon @hsdm.harvard.edu). Section Editor: Roxanne K. Young, Associate Senior Editor.
Whose Story Is It, Anyway? When I was 18 years old I went camping in the snow and, through a combination of bad decisions and worse luck, contracted hypothermia. After a long midnight hike of which I have no memory, and a few days of resting under piles of blankets, I recovered with no ill effects. It’s not much of a story, really, the way I tell it, and it doesn’t come up often. I am a newly graduated dentist and an aspiring public health practitioner. At a recent conference for studentrun free clinics, I was surprised to run into an adored college friend. A fellow outing club member, he too had been on that ill-fated trip. Now, seven years hence, we smiled at each other in the Tennessee sunshine and compared stories from our respective clinics, the stress and joy of being an almost-doctor. “You know,” he told me after an hour’s nostalgia, “I still tell that story all the time.” “What story?” “Oh, just that time you almost died and we had to drag you half-conscious through the woods. People love it, that learning-to-take-care-of-people angle.” There is a go-to narrative for students of health, and it usually goes like this: we are new and ignorant, we encounter a patient, and their suffering makes us grow or change in some way. We write about that first death, a meaningful mistake, or the patient we just couldn’t help. We tell stories of our empathy as catalyst. This is, of course, because in our inexperience, empathy is about the only skill we have. How scary yet thrilling the experience of caring for me must have been for my friend. He, persevering through the woods with me, a drooping rag doll! That is a much more engaging tale than my own, one that could regale crowds. I was the sick one; it seems like I should, at least, get a story out of those miserable hours. But it doesn’t work that way. I’m not the hero, I’m the plot. “You can have it. I bequeath the story to you,” I told him jokingly, as if I could, as if he cared. There are so many stories that I would like to tell. Teeth lack that romanticism innate in the stories of physicians-in-training; there’s a reason so many television shows take place in hospitals and none in a dentist’s office. But what about the woman who cried tears of joy to find out she could keep her four front teeth, the toothless man who could not afford dentures because his wife was pregnant, the teenager who, when I asked him what hurt, replied, “Everything”? Each of these tells more about the social justice of dentistry than a hundred papers full of dry statistics about inequality and access to care. They illuminate a less-seen piece of the health care experience of the underserved. As a patient once told me, “Being poor is hoping the toothache goes away.” I struggle with these stories, though. Because it’s still me, with my braces-straightened white teeth and layer
jama.com
upon layer of privilege, telling you that I saw someone vulnerable hurt. As a society, we consider empathy to be the hallmark of a good clinician. Before we treat our first real patient, we practice interviewing professional actors trained to act as model patients. In addition to our diagnostic skills, we are graded on our ability to convey empathy. The student made regular and unforced eye contact, five out of five points. The student responded with appropriate statements, five out of five. We are taught phrases, like, “It sounds like you feel really upset about that” and “That must be hard for you.” The latter line, which felt so forced, became a punch line my first year of school. But take away the act, and true empathy is to take on the emotions of others as one’s own. To do this fully, for each and every patient I saw, would be devastating. An episode of Star Trek: The Next Generation concerned an alien who experienced empathy with every sentient being he encountered; he went insane. But even the appropriate, professional level of empathy takes its toll, especially when the suffering to which you are exposed is the side effect of a callous and broken system. I spent my last months of dental school in a rural free clinic. My final patient there, like too many others, arrived terrified and in pain. A lifetime of bad experiences in a dentist’s chair had made her avoid them whenever possible, an unfortunate self-fulfilling prophecy that meant that each visit involved pain and, usually, the extraction of a tooth. Already, I saw, half of her teeth were gone, and I knew more were due to follow as she moaned and clutched her jaw. Even in this state, the necessity of an anesthetic injection caused a wave of heaving sobs and a resigned, barely audible refrain of “No, no, no … .” My softest words and gentlest touches were no match for the magnitude of her fear, and I extracted three heavily infected teeth as quickly as possible, while her hands clamped the chair in a vise grip and her whole body shook with terror. I am telling you this story because I think it might surprise you, and because I hope it might help make dental care more accessible in our country. I am telling you because I felt empathy for my patient, and if I couldn’t stop her suffering, perhaps I can prevent someone else’s, in part, by saying what I see. Yet I know that you read this now, in my words, because I am luckier and more powerful than the patients I treat. They might disagree with what I say, or wish I wouldn’t say it. I can only guess what they would tell you about their teeth if given the chance. And I am also telling you this story because it makes me feel better. It is difficult to be the inflictor of pain upon another, however indirectly, and there is inherent violence in the removal of a piece of someone’s body. I am telling you beJAMA June 11, 2014 Volume 311, Number 22
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 05/24/2015
2273
Opinion A Piece of My Mind
cause, like my friend carrying me through the woods of New England, I was a little bit scared by my responsibility for another person’s wellbeing. I am telling you this story because I am hoping you are empathetic too. Certainly, it is inappropriate to make others’ lives into a thesis statement. And yet I find some stories sloshing out of me, like water from an over-full pail. It is difficult to participate in the chaos of someone’s pain. It is even harder to merely bear witness to it. When we tell a story culled from our experience, it has a beginning, a middle, and an end. From that imposed linearity springs meaning. It is like turning a handful of different beads into a necklace. Does it really matter who strings it? Homer, after all, Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.
was not the first to describe the Iliad. Then again, we’ll never know what Achilles thought of that tale. It’s tricky, this calculus of appropriation. Like actual calculus, I can’t quite make sense of it. I want to empower my patients to tell their own stories, to me and to others, until those stories change for the better. But I was there too. I saw the whole thing. They were not my teeth, but I took them out. I have heat and running water, but I spent an hour on the phone trying to get the same for another. They were not my tears, but they wet my shoulder. Is that enough? Can I share these experiences with you? Can I stop them from happening again? Whose story is it, anyway? I know it’s not mine. But please. Listen.
Acknowledgment: My most sincere gratitude to Katherine Schiavoni, for helping start this conversation, and Nina Gold, for helping to finish it.
I have an unshakable belief that mankind’s higher nature is on the whole still dormant. The greatest souls reveal excellencies of mind and heart which their lesser fellows possess—hidden, it is true, but there all the same. The unborn goodness renders it possible for most people to recognize nobility when they see it, as the latent poet in a reader enables him to appreciate a fine poem. Helen Keller (1880-1968)
2274
JAMA June 11, 2014 Volume 311, Number 22
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 05/24/2015
jama.com
