The Sad Smile
Authors: Richard M. Boulay
Journal: Journal of Clinical Oncology (2011)

DOI: 10.1200/JCO.2011.38.3901 It was perfect. A symphony of complex emotions elegantly combined into a single facial expression. Eyes turned gently downward, conveying a sense of sorrow and deep empathy. These eyes said to the recipient, “I know this is a rough patch for you. I know you don’t deserve this. I know you are hurting.” Lips, held together and curved slightly upward, portraying kindness and optimism, saying, “I’ll be with you throughout this. We must embrace hope.” The head position was key. A slight bow implying deference to upcoming trouble, whereas a faint tilt said, “Go get ‘em! I know you can do this.” I used this face often. This was how I told people they had cancer. Accessory maneuvers—a hand on the shoulder, or the single hand hold—often accompanied the expression, but it was the Sad Smile that did most of the work. (I preferred the double hand hold myself; it brought me in closer to the patient and seemed unique. And I am an overachiever.) Despite no formal role in the curriculum of fellowship training, the Sad Smile has gained wide acceptance within the oncology community. Innumerable clinical experiences have broadened and deepened our knowledge of the craft that we practice, although humanistic skills such as the Sad Smile are rarely discussed— even though for many of us, these humanistic motives led us to pursue oncology in the first place. As students, some of us learned from our mentors how to keep our humanity intact throughout the grueling hours of training; others were left to their own devices. And yet, somehow, among both the taught and the autodidacts, the Sad Smile has been replicated with alarming genomic integrity through successive generations of oncologists. One ironically beautiful June morning, while my wife and I were standing in the atrium of our cancer center discussing how relatively pain free her bone marrow biopsy had just been, a colleague approached. “So sorry to hear the news,” he said, placing his hand gently on her shoulder. “Yup,” was all she was able to reply. Recognizing the lump in her throat, I took her hand. The three of us stood for what seemed like hours until he checked his watch and broke the uncomfortable silence with, “Well, let me know if you need anything.” We both thanked him as he disappeared down the hallway. I turned to my wife and asked, “What was that?” “What was what?” she replied, choosing to ignore his odd grimace. “That weird expression he made,” I said. “Oh, that.” She reached up and patted my cheek. “That’s your Sad Smile.” Pulling herself back together, she removed the bandage covering her intravenous site and moved toward the door. “My what?!” I could not believe I had ever used an expression like that. “Your Sad Smile. You guys all have one. Anytime you talk to someone about their cancer, you get that expression.” Genuinely insulted, I scoffed, “That expression? No way!” “You all do,” she insisted. It was horrible. A cacophony of incomplete and insincere emotion, consoling no one. Eyes turned gently downward, betraying the feelings beneath. Those eyes said, “I pity you.” Lips, held together and curved slightly upward, allayed the oncologist’s reality: I don’t have it within me now to deal with your loss, your pain. But I’m sure you guys will figure it out. The head position, locked and cocked, meant, “I’d love to hang around and chat, but this is really uncomfortable, and I’m already behind schedule.” Taken as a whole, thisoddexpression, thisgrimace,wasacontraction of the complexity of the human emotion playing out in our lives at the time, with each feeling—fear, anger, and hope—crowded out by the others. All in all, the toxic confusion was portrayed brilliantly by the Sad Smile face of my colleague. The saving grace, however, was the hand to shoulder—the maneuver I had previously thought of as only an accessory. The hand was the human touch that connected us, that bound us together as caregiver and cared for. This small gesture let us know his true feelings: empathy, compassion, and hope. JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 29 NUMBER 33 NOVEMBER 2