“The Patient Has The Disease”
I will never forget having that epiphany. It was in early on in my oral & maxillofacial surgical residency at the University of Maryland Medical Center probably in the wee-early hours of the morning on call where I heard another surgical resident in another discipline make a statement about a mutual patient, his/her plight, condition, circumstances – whatever…he said “Well you know after all, the patient has the disease”.
Those nights were frantic – my pager going off about a post-surgical patient in the unit – or the emergency room with an infected patient – or the trauma center with a gun shot wound to the face – or a phone call from a patient who was experiencing bleeding after routine 3rd molar surgery. But on that night what that surgical resident said just kept reverberating in my head.
Sometime thereafter – post call – maybe on my way driving home before I had to do it all over again – some place where I could quietly engage my own thoughts – I weighed those words over and over again. Why was it such a novel concept to me? And then it finally hit me.
Indeed yes, the patient does has the disease – always. But why does that create such cognitive dissonance? And then, I recalled everything.
The Epiphany
In dentistry, my early years were a mix of basic science and learning technique – “basic technique” as it was – waxing crowns, learning how to cast molten gold, setting denture teeth in wax, designing framework for partial dentures, pouring models and trimming them, taking alginate impressions, and so on. The kind of things you never ever do in the real world. Nevertheless, neatness counts in the never ending pursuit of perfection in it’s most absolute pristine form. You would never know what makes a perfect stone model versus a mediocre one. Remember – neatness counts.
Until this point, I was accustomed to doing the heavy lifting – studying…burning the midnight oil if need be, and reaping the rewards of my efforts. And I did well though it is not the point to boast. I expected to continue to do well. I needed to do well – I had aspirations. But dental school was different. Nothing was ever good enough to get an “A” no matter how hard I tried even before I ever encountered a patient.
Before “we” (my classmates and I) ever touched a patient we had – naturally – pre-clinical sciences…cavity preparation; cut the cavity (drill a hole) perfectly, at the perfect depth and only encounter essential anatomy. Cut the cavity (drill a hole) too shallow, points off. Cut the cavity (drill a hole) too deep, mega points off. Cut a Class II cavity (drill a hole on the side of the tooth next to another) and not extend enough, points off. Cut a Class II cavity (drill a hole on the side of the tooth next to another) and extend too much, you fail. Nick the adjacent tooth, you fail.
And then there was pre-clinical crown and bridge. In retrospect, “we” came face to face with what could only be The Gestapo. My God – you’re going to grind a tooth down to a peg the degree to which is determined by the tolerances of the materials used in the final restoration? Your object future dental professional is to preserve tooth structure AT ALL COSTS!!! To the uninitiated it would be difficult to understand the number of variables. It’s easy to understand now, but then it was really challenging to – remember – make it perfect. But then that wasn’t enough – you had to yourself fabricate your own prosthetics keeping in mind to have perfect contact in between adjacent and opposing teeth. Too many variables to have perfection at each check point, including shade (color).
Then “we” finally ascended to actually treating patients. “We” might have treatment plans created by faculty distant from a current point of encounter, only to be berated by the faculty covering clinic (Gestapo) in front of our patients for the difference of opinion whether it be factual or philosophical. Cancel the appointment. Send the patient home – no matter how far they traveled to attend a “student clinic”. That was of no concern.
The epiphany? Here it is: talk to any dental licensee – dentist or dental hygienist – and you will hear a similar theme; perfection is the goal, but you’re never good enough. Contrast that to our medical colleagues – do they get marked down on the design of their incisions or whether their suturing technique is perfect? Do they get points off for a post op infection? Do they fail if their patient gets readmitted to the hospital?
No…in medicine “the patient has the disease”, but in dentistry “the clinician has the disease”.
Imposter Syndrome (IS)
What is IS? People who struggle with IS believe that they are undeserving of their achievements and the high esteem in which they are, in fact, generally held. They feel that they aren’t as competent or intelligent as others might think—and that soon enough, people will discover the truth about them. Those with imposter syndrome—which is not an official diagnosis—are often well accomplished; they may hold high office or have numerous academic degrees.
There are 6 factors attributed to IS:
- The Imposter Cycle: A repetitive pattern of self-doubt.
- The Need to Be Special: A belief that one must be exceptional to be successful.
- Superhuman Expectations: Setting unrealistic, high standards.
- Fear of Failure: An intense fear of not meeting these standards.
- Denial of Competence: Downplaying successes or attributing them to luck.
- Fear and Guilt About Success: Anxiety about achieving success and its implications.
What causes “Imposter Syndrome”? IS is driven by traits like perfectionism, anxiety, and a high level of self-criticism. Authoritative figures can foster feelings of inadequacy. These same figures can create pressures and stereotypes, especially in competitive environments such as academic environments.
Academic settings, including undergraduate, graduate, post-graduate, and professional education, create social constructs with multiple levels of internal and external attributions. While IS can occur in any person, a disproportionate amount of high-functioning individuals in healthcare are burdened with IS.
What are the long term effects of IS? Anxiety, depression, decreased job satisfaction, lack of confidence, and an inability to achieve goals. Studies show that imposter syndrome can cause more burnout and lower job performance.
Dentistry, Perfectionism, & Imposter Syndrome
In dentistry, clinicians “have the disease” as described. Is it little wonder mental health disorders are perceived to be rife within dentistry? This author would consider it to be a repetitive dance of professional gaslighting beginning at the pre-doctoral level – where students are academically pressured to assimilate beliefs and behaviors of authoritative figures (teachers) – only to be embellished by professional licensing boards the principals of which having acquired the same belief system through their own indoctrination thus holding the Sword Of Damocles over the head of a licensees financial viability. This is coercion. It is emotional slavery.
We Turn On Each Other
It’s bad enough young aspiring future health professionals encounter a well entrenched system of behavioral remodeling at the doorsteps of their education. It’s another trauma when professional licensing entities propagate the same belief system of perfection leveraged against one’s ability to practice and financial livelihood. It’s even yet another when professional safety net systems mandated by state legislatures to “protect the public” profit from the misfortunes of those who’s ills itself created.
The Golden Rule
You have the ability break free of the IS your were enculturated with. Your continence is completely dependent on how you view yourself and your role in healthcare. State governments grant you, the licensee, the privilege to render healthcare services to the public. It’s about what you can give of your talents to humanity. As long as you keep that precept in mind, and you faithfully conduct yourself in a manner that puts others ahead of yourself, you will never ever go wrong. Unfortunately, in today society, this premise runs counter-current to conventional practice.
Here we have come full circle. The whole precept of “the patient has the disease” is predicated upon the notion that you, the clinician, place your patient’s interests ahead of your own. Deviate..and yes, you have the disease.
Closing Remarks
If your motive is to do your best – within reason – and to dedicate yourself to put your patient’s needs ahead of your own you will never falter. And instead of lamenting that your work is not perfect, when considering the same just reassure yourself as did one of my attendings back in residency – during the wee-early hours of a morning – “the enemy of good enough is better”. Because “the patient has the disease”! Go with that!
Never forget it.