By Maggie Augustyn, DDS

Narrative writing is a more humanized form of documentation, wherein the ideas of empathy, active listening and lived experience are viewed equally to scientific expertise.(1) In healthcare, it is hypothesized that implementing narrative writing is a way of humanizing the role of a provider.(2) It brings about a capacity to “recognize, absorb and metabolize, interpret and be moved by stories.”(3) In this article, I will take a narrative approach — introducing examples of my own life and my own struggles — to drive home the idea that we must change the way we view the doctor-patient relationship. Instead of an authority figure treating a sick person, we must think of the healthcare relationship as one human being caring for another. Changing our perspective will result not only in better patient care but also better provider mental health.

I hope to inspire dentists to reach out and learn more about the ways patients lead their lives, what drives them, whom they love and why they struggle. Knowing more about our patients and relating to them on a universal level can open a window into understanding why they get sick and how our proposed treatment can best be presented. My ambition is to allow us dentists to understand the impact of the human connection on each other and our patients.

The Parsons Model

Seasoned dentists with decades more experience than I introduced to me a certain model of providership. I was mentored to be the kind of dentist who always presented herself in a white coat, stood up straight, was stoic and showed only a mild amount of emotion. Above all, I was to appear educated. Explanations to patients were to be scientific in nature. This would make the patient aware of the vast knowledge and experience that I, the dentist, had gathered. And this is how I offered myself to many of my patients for more than a decade, a neatly starched white coat always in tow.

Unbeknownst to me, I was following a very outdated model introduced in 1951 by Talcott Parsons, who talked about the “sick role” of a patient, as well as their obligations, rights and representations.(4) As Parsons defined the characteristics of a sick person, he also made a point to outline the rights and obligations of “the doctor.” There was status and reward owed to “the doctor” as a way to encourage future individuals to suffer through the long years of training. Parsons believed that doctors were authority figures — trained experts in the field and gatekeepers between those who were labeled “healthy” or “sick.” He also specified that each provider had an obligation to be not just objective, but also emotionally detached from the patient. Empathy or compassion toward patients was frowned upon, partly because that type of display made the physician less of an authority and not in control of the relationship.

Years after Parsons’ theories, French philosopher Michel Foucault agreed that society continues to elevate the status of a health practitioner above the patient due to an inequality of knowledge, creating a power misperception.(5) A 2021 article on postoperative care in surgery warned that “[physicians] should be aware of the significant potential for knowledge deficits among their patients and should make specific efforts to identify and correct those deficits.”(6)

The vast space between physician and patient continues to be evident in popular culture. In “Grey’s Anatomy,” a television show running 20 seasons, the concept of separating provider from patient is used in training fictitious doctors. A seasoned mentor advises young Meredith Grey that “when giving the patient bad news, you have to be polite and detached but not cold. You show that you care without actually allowing yourself to care.”(7) Part of this could be understood to serve as a self-protective measure against the turmoil of watching other humans suffer, but it is still taught. Doctors, then, continue to practice withholding emotions like empathy because they feel less likely to feel blamed for the news — and to prevent themselves from facing their own mortality.(8)

The teachings of my senior mentor left me arrogant and unkind in the perception of my patients, and I have the Yelp reviews to prove it. I can’t blame my predecessors for misteaching me or giving me faulty advice. It’s how they’d been trained, and, having made them successful, it wasn’t something worth challenging.

We know that levels of empathy are highest in the first year of dental school and diminish in the years following, being lowest as the level of education increases into specialty programs.(9) There is an array of reasons that can potentially explain this phenomenon. The greatest reduction occurs as dental students begin to practice on real patients. Some of the deflection in empathy might have to do with the realization that patients are not always willing to change their behaviors at the advice of the doctor.(9) Their noncompliance can drive the provider to feel that, despite their training and years of education, their opinion simply isn’t valued. So why care for someone who doesn’t care back? Further, dental students focus greatly on graduation demands, as opposed to patients, protecting their self-interests and years of study.(9) We also know that education in dental school focuses more on procedures and scientific knowledge as opposed to social science. Patient-(pre)doctor relationships are not encouraged; camaraderie among peers is. With the amount of focus and attention it takes to get through clinical training, the mind often doesn’t have the capacity to focus on anything other than passing boards and gaining a license.(10)

What disturbs me most is that the imbalance between provider and patient, as I was taught to follow, leaves patients confused and unable to understand their diagnoses.(11,12) Patients feel intimidated, unable to ask the appropriate questions. They likely agree to treatment they don’t understand to either please the doctor or end an uncomfortable appointment. They may also altogether dismiss the treatment recommendation, putting their health in jeopardy.

The Parsons model would have definitely fallen out of favor with today’s crowd. The hundreds of thousands of women who have joined the workforce as doctors in the last several decades have had an opportunity to redefine what truly matters in taking care of patients. We have made space for skills that were previously thought of as “soft skills.” It’s our movement — the Women’s Rights Movement — that might have bridged the gap initially observed and defined in the 1950s. It likely is what has allowed me to step outside of the advice and mentorship I’d been offered upon graduation. Before, it was not uncommon to misconstrue traits such as kindness, compassion, empathy and trust as indicators of vulnerability and weakness. Today, we understand and accept that expressing compassion and thoughtful consideration underscores an individual’s adeptness at navigating complex interpersonal dynamics and fostering a nurturing environment. An empathetic provider, deeply attuned to the emotional currents and well-being of others, is uniquely positioned to discern and dismantle barriers by keenly sensing the internal experiences of those within their care. By cultivating an atmosphere of psychological safety wherein individuals feel empowered to voice their ailments, the “soft” provider not only enhances mutual understanding but also fortifies collective resilience, leading to a more cohesive and harmonious community.

Reevaluating the Provider-Patient Relationship

When power imbalances between patient and dentist are removed, a newly facilitated communication allows the patient to disclose past experiences and preferences in treatment and can also increase compliance with treatment. Though ostracized by mentoring practitioners, I share a lot about myself with my patients. I step out of the role of gatekeeper between healthy and sick (as Parsons believed) and allow myself to become human in their eyes. I humanize myself by talking to them about my daughter and husband, my own health struggles, and even the disproportionally large amount of dental work in my mouth. And, though warned by those same seasoned practitioners that sharing my experiences with depression would have a debilitating effect on my career, it has done just the opposite. Patients are able to visualize me in a different dimension. I can empathize with their fears and insecurities. Often, it’s my own story that puts them at ease. The previously seen gap of status and education disappears in the operatory. What comes to light is one human, who is skilled to do so, taking care of another. An example of this would be my personal disclosure of anxiety as I’m facing a patient with an elevated heartbeat and labored breathing. It is during an onset of that patient’s panic attack that I hold their hand, face them directly and make prolonged eye contact. I gently and slowly repeat as often as I need to: “I get it. I have been here, too.”

That which allowed me to reexamine my own role within the Parsons model didn’t necessarily boil down to a single interaction. But it was a single interaction that sparked the shedding of the above dynamic. Several years ago, I entered an operatory where an older Polish woman was suffering with a toothache. She was accompanied by her daughter, a woman who seemed to be close to my mother’s age. A transplant to this country myself, I moved to the United States at the age of 14, leaving behind all my family and everything I’d known. I looked at the pained woman and was transported back to my old life. I felt myself back in the presence of my beloved grandmother, the kindest human I had known, someone whom I hadn’t seen in a decade, and, at that time, was nearing her end. In that moment, I was not taking care of the woman sitting in front of me, I was taking care of my grandmother. It was with that particular encounter that my heart fully opened to compassion and empathy, drawing a previously unfelt honor, service and fulfillment from the interaction.

Innate Characteristics of Prosocial Behavior

Most people believe that the presence of empathy and the ability to connect to another human, to offer help and guidance, are prosocial characteristics inherent only to humans. In a 2011 study, researchers found evidence that rats possess characteristics we previously thought were solely reserved for humans.(13) Rats cohabiting following two weeks of daily interaction were separated, with one of them being placed in a plexiglass cage. Within a week of the disunion, the freed rat learned to open the glass cage, via door, and free the caged mate. The free rat uncaged its companion regardless of reward. Furthermore, when given the choice between freeing a tasty treat or its rat companion, the free rat indiscriminately opened both doors. This study demonstrated that prosocial behavior is a phenomenon that may be present among many living beings. And, as such, it may be innate rather than learned. If we know that empathy and compassion are part of our evolutionary development, perhaps utilizing it in our daily lives and to the advantage of our patients will come easier than previously thought.

A 2012 Journal of the American Medical Association article described a child’s drawing of a doctor seated in front of a laptop while examining a patient, with no stethoscope or tongue depressor in sight.(14) Unlike the drawings we saw years ago, this one showed the physician typing on a computer, looking away from a patient, a common occurrence today during our medical evaluations. This drawing also brought front and center the new reality that, as providers of any kind, we listen more to patients and look at them less. While we are multitasking, checking different screens for images and tests, and scrolling through notes, we miss out on a very important aspect of human relationships or healing; we eliminate what scientists call neuron mirroring.

Neuroscientist Giacomo Rizzolatti, MD, with his colleagues at the University of Parma, were the first to discover neuron mirroring in the early 1990s.(15,16) In this experiment, animals were attached to monitoring equipment, allowing scientists to examine which neurons fired and when. During the course of the experiment, a scientist near one of the monkeys reached for a sandwich. Though the animal had not moved even a fraction of an inch, the computer recognized brain function within the animal. The same neurons fired within the monkey’s brain that would have fired had the monkey actually reached for the sandwich himself. Other studies have come to solidify this concept. For example, in a study of participants watching videos of subjects putting their hands in ice buckets, scientists found that the participants experienced a reduction in their own hand temperatures.(17) We are capable of sensing that which another is feeling, but only if we engage with them and make eye contact. And thus, if we only listen to our patients’ concerns and complaints without looking at them, we miss messages that could be invaluable in treating the patient.

How Compassion Can Help the Practitioner

Now, the age-old question, a driving force for creating change: “What’s in it for me?” Burnout among healthcare professionals is very real.(18) According to the latest literature, 80% of oral care providers are suffering.(19) Burnout presents a hardship that can lead to job desertion, reducing the overall presence of healthcare providers in the field. We have seen and experienced that in dentistry after the COVID-19 pandemic. However, creating deep relationships with patients, though many of us were taught the opposite, can actually be healing not just for the patient, but also for the practitioner. That’s what is in it for you.

Many call it “helper’s high.” This concept first emerged in the 1980s and has been validated by numerous studies over the years, including some recent ones in 2021.(20) Surveys have shown that more than 70% of people experience a helper’s high when giving meaningful aid to those in need.(21) Seth Gillihan, PhD, a professor of psychology at the University of Pennsylvania, says, “Coming together (in compassion) works a sort of alchemy, transforming one person’s pain into a shared feeling of uplift.”(22)

Giving meaningful help to others activates reward pathways in the brain, producing a profound sense of positive affect and a myriad of uplifting emotions.(23) One mechanism at play activates the parasympathetic nervous system by stimulating vagus nerve activity. This activation essentially produces a calming effect that counterbalances the fight-or-flight response governed by the sympathetic nervous system. It allows for a profound engagement with empathy, illustrating how deeply our biological systems are intertwined with our capacity for compassion.(24)

Another mechanism involves boosting circulating neuromodulators, such as oxytocin, which not only buffers stress but also evokes feelings of calm and closeness. This potent hormone, often dubbed the “love hormone,” underscores our instinctual drive, weaving a tapestry of emotional warmth and communal harmony that can profoundly impact our overall well-being.(25) Researchers, ergo, concluded that “helper’s high” is linked to better health and increased longevity.(26) Studies also show that practicing compassion reduces depression.(27) The beauty of compassion and empathy is that it truly comes full circle. As we engage deeper into the relationships with our patients, as we listen to them and heal them, as we take those extra few minutes to show concern, we also heal and thrive.

My hope is that, as we move to the next juncture in our evolution of dentistry, we not only focus on the strength of what technological or clinical advancements can bring to patient care, but also on humanizing the experience. A part of this will have to include holding each other accountable in conversations. I would encourage a paradigm shift away from the over-displayed doctor confidence and rushed appointments and transition instead to remembering that the mouth is attached to a human, a human like our mother, brother, best friend or child — a human who ought to be related to and inquired of, not just prescribed to.

I remember, as a young dentist, I was confused as to why my patients didn’t follow through with my proposed treatment. I assumed it was because I looked too young. Today, I know it had everything to do with the arrogance of entering the room as the authority, barking a treatment plan in their direction with little concern for the person in front of me. I might have been skilled in reviewing radiographs, evaluating periodontal conditions, and examining hard and soft tissues, but I was not skilled in showing compassion or prioritizing relationships. We will not be able to move our profession forward until we can unselfishly ask about others and genuinely care for them. And, just as important, we will not be able to recover from the unforgivingly difficult days as providers unless we emotionally connect to the patients in our care. The final prescription on all of this is quite simple. In the words of the Dalai Lama: “If you want others to be happy, practice compassion. If you want to be happy, practice compassion.”

Maggie Augustyn, DDS, is a practicing general dentist, owner of Happy Tooth, faculty member at Productive Dentist Academy, author and inspirational speaker. She is also the AGD Impact Wellness columnist. To comment on this article, email impact@agd.org.

References

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