John Launer: Watch out for that indulgent smile

I spend a lot of time teaching communication skills, although I prefer to call them interactional skills, which suggests more of a two way street. Much of what I cover relates to speaking and listening, although you can’t ignore body language too: eye contact, sitting position, and so on. One experience I mention quite often is seeing a video of my own consultations for the first time. I was horrified to see how much I fidgeted, played with my pen, and looked at the computer—and how much more distracting this was for the patient than stillness.

Since then, I’ve always been on the lookout for different forms of bodily expression, whether positive or negative. A couple of years ago I identified one I now call the indulgent smile. I first noticed it when I had a clinic appointment as a patient myself. I’d explained my problem to the doctor and then mentioned, in as unthreatening a manner as I could, that I was a doctor myself. I also added, in a carefully understated way, that I’d often dealt with the condition myself as a GP but was interested to know their view and what they might advise. It was at this point that I received the indulgent smile.

Afterwards, I realised what the smile implied. It was something like: “You’re old and I’m young, so your knowledge is likely to be out of date and inferior to mine.” It may also have meant: “You may be a doctor, but you’re not the doctor in this consultation.” Either way, I’m afraid that its effect on me was to make the doctor’s effort at charm seem like a thin veneer for patronising me and disqualifying my lived and professional experience.

Of course, the indulgent smile isn’t necessarily dependent on the patient being older or a doctor—although these factors might elicit it most strongly. Once you start looking out for it by observing consultations or videos, you spot doctors doing it almost every time a patient hints at expertise in their own condition. It also goes without saying that the indulgent smile isn’t specific to one condition or specialty. Since identifying it, I’ve seen it on the faces of everyone from senior surgeons to GP residents. I’m sure that I’ve purveyed indulgent smiles myself down the years, and I blush to think how often. I now feel guilty about having surrendered to yet another of our profession’s institutional vices.

A lot is said and written these days about doctor-patient partnerships, shedding power, shared decision making, and similar concepts. But I wonder if the first step in adopting such approaches would be to notice when that indulgent smile starts to creep across your lips. You may decide to wipe it off your face, as our schoolteachers used to say. You might think you know better than the person who is across the desk or lying in a hospital bed, but possibly you don’t.