health

'Why "smile more" is not medical advice.'

It all started with a headache.

A first-thing-in-the-morning headache. Not uncommon for me, after a middle of the night wake up for my toilet training toddler. 

I had a big glass of water, some headache medication, and moved on.

As a busy working mum, my morning juggle consists of a 20 minute shower/hair/makeup/dressing/coffee routine. That day, I made a point of not skipping breakfast. But the headache continued. I tried to ignore it and ensured my son’s lunch was packed for preschool, and that the essentials were safely tucked away in his bag. My husband is wonderfully in charge of the morning prep, but there are just some things I like to do before I leave the house. 

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Next step was the work commute. Despite the early morning starts, the Sydney traffic rears its ugly head even at 7.30am. Finding a parking spot took longer than expected. By the time I walked in the door at work, I'm stressed, tired, and hangry.

But I cannot let this affect me today. I’m a GP, so my day is divided into 15 minute blocks of other peoples' problems that I try to help with. My headache can wait. I make myself another coffee, put on my mask, and start my workday.

First patient. Cervical screening. That’s funny - her voice sounds pretty soft. I suspect it's the loud traffic outside my consult room window. I close the window, move my chair closer to her, and continue.

Next patient is here for a mental health care plan. She’s a teenage girl presenting with odd symptoms, and she has come with her parents who give me a detailed history. Normally, I’m all ears. But today, my ears seem to be out of action. All of their voices sound muffled. I strain to hear and luckily I catch most of it. I come up with a plan. My job is to remain cool, calm and collected, and I work hard on presenting this facade to them today. I want to instil confidence in my patients. 

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But today, I am struggling inside. I’m in a panic. I suddenly realise what’s wrong.

I can’t hear.

I complete the consult, take a few breaths, and formulate a plan. I have a list of 20 patients booked for the day ahead. They’re all relying on me and have booked appointments. I feel indispensable.

But for the first time ever, I realise I have to leave work mid-schedule.

I can’t hear.

I inform my practice manager that I have a headache and need to go home. And I do. I assume it's an atypical migraine and remain in a dark room for the rest of the day. The following day I wake up with the same hearing loss. 

I decide to go see an ENT - an ear nose and throat specialist. I go see the Professor. He has an excellent reputation amongst patients.

The consult is brief. I go through my symptoms; he does a quick examination. Formulating a diagnosis, he tells me that my headache and hearing loss is a myofascial pain syndrome that occurs with temporomandibular joint (TMJ) dysfunction. TMJ syndrome is associated with bruxism, otherwise known as teeth grinding. It is associated with stress. Unsurprisingly, the most commonly affected demographic group is women of reproductive age.

Think about it. Women aged 20 to 40 years old are the ones looking after children. Running a home. Building relationships. Holding together jobs that were not created with flexibility in mind. 

No wonder we are stressed. 

We take on the mental load, and what do we do with it? We hold it.

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We hold it in our hearts, our minds, and yes, our joints - especially our TMJ.

When he tells me this, I think of how my stress manifests while looking after my family.

Some examples:

You’re hungry? Again? Even though I’ve given you several types of delicately prepared snacks satisfying all food groups? I clench my jaw, grab those crackers with no nutritional value, and submit.

Remember that birthday party on in one hour, with no present at home? I clench my jaw, get in the car, and rush to the toy store.

You want me to stay late to fit in that urgent consult? Yes, of course - I clench my jaw, and furiously text my babysitter to stay late. 

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School has a special dress up day, and those blue pants are still wet on the line? I clench my jaw, shove them into the dryer (sorry Earth) and end up 10 minutes late to work.

So when the Professor ENT tells me this is my diagnosis, I’m shocked but not surprised. Even being medical, it seems extreme that a bit of stress can cause hearing loss. He explains to me that the muscle tension can "kink" a peripheral nerve, causing hearing loss. It makes sense but my jaw does not seem particularly tense today, nor has it in weeks. I assume maybe this is my norm so I’ve been playing it down 

He tells me the treatment - a dental splint (tick), hot packs (tick), massage (tick), relaxation (when?). 

On my way out, he utters two words that hit me like a slap in the face.

"Smile more."

Wait, what?

I didn’t realise this was medical advice. No where in my many years of training have I ever considered telling a patient this. And general practice is the specialty of holistic care. I see a lot of worried patients, but my job is to remain neutral and provide solutions for patients to heal themselves with my guidance. 

"Smile more" is not a medical treatment I have ever advised. It is condescending and paternalistic. Paternalism in medicine is the principle whereby doctors - as figures of authority - instruct patients on their medical treatment without consideration of a patient’s own preferences. It is an ethical principle warned against in medical school. We do not practice medicine in this way - we haven’t for many, many years.

So it was a shock to my system being faced with this principle on the other side.

It didn’t sit right with me, and I did not accept it. Especially as with Professor ENT’s treatment, nothing changed. I was still deaf in one ear.

I sought another opinion (which, thankfully, we are allowed to do in Australia), and found a wonderful ENT who practised with empathy and skill, and ensured my dignity in a crisis.

Instead of assuming this was just stress, he yielded an alternate diagnosis - myringitis, which is an infection of the eardrum. It had nothing to do with my TMJ. And his tailored treatment worked. I recovered. I can happily say that I can hear again.

This was an important lesson on the value of finding a doctor I trust, who carefully considers me as a person instead of as a textbook case.

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This should apply not just to doctors. Finding a lawyer, an accountant, a tradesman, or a hairdresser who celebrates and considers your individuality is so important for your wellbeing.

There was a recent study on female patients which found that one in three women have had their health concerns dismissed. If you told me about this a few months ago, I would have rolled my eyes. After all, as a medical practitioner, I have always made a point of taking valuable time listening to my patients, especially women. There is often more meaning hidden within the consult than what is said straight up. Generally, as women, we feel more, say more, take on more. This takes time to sort through.

But only after being on the other side have I realised how stigmatised we are, just being female. And conversely, so are the men - the blokey attitude of "toughen up" commonly brushes male patients off. They are doomed to labels before they even walk in the door. Both attitudes are wrong.

If only we could start tailoring our treatments to each person. We are all unique.

Maybe then, I’d smile more.

Dr Sam Saling is a general practitioner in Sydney, with special interests in women’s health and skin. She has a young son, which has taught her more about parenting than any textbook. You can follow Dr Sam Saling on Instagram here.

The feature image used is a stock image from Getty.

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