By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer
“Listen with your eyes as well as your ears.”
In the days before virtual visits and patients wearing masks, I would enter the exam room by greeting the patient, smiling and looking at them. So much information is communicated in this way. With our demeanor, we can convey caring, respect, and dignity. The patient, in turn, communicates mood, level of confidence, social/language/economic status, and (importantly) understanding.
My visits with patients are now either virtual (video or phone) or in-person with both provider and patient wearing a mask to prevent potential COVID transmission. This is affecting my ability to assess the patient’s mood and understanding, and makes it harder to quickly gain the trust of new patients.
Neuro-psychology experiments show that many human interactions (including social learning, empathy, and transfer of emotions) depend on the Mirror Neuron System of the brain. This system works best when a person experiences more complex sensory input. For example, a 2-dimensional view of a face on a video screen is less effective at influencing the Mirror Neuron System than an in-person interaction, where body posture, body motion, and context add meaning. The greater activation of the Mirror Neuron System when we are in the presence of others helps explain the excitement we now feel with interacting in-person with friends and colleagues, compared to previous video interactions.
The Mirror Neuron System also rapidly and unconsciously allows us to interpret the emotional state of others based on facial expressions. The eyes and the mouth are most expressive, so covering the mouth with a mask to prevent disease transmission decreases the information available to our Mirror Neuron System.
In many health care settings, routine mask wearing is still required. How can we make up for the loss of ability to see the facial expressions of the mouth? Interviews of women in countries where face coverings are common for religious reasons suggest three compensatory mechanisms that we can learn.
Eyes: First, learn to communicate emotion more effectively with our eyes. This takes a bit of practice. It requires us to spend a little more effort making eye contact and intentionality in connecting eye expression with emotional status.
Non-facial body language: Gait, character of a handshake, posture, and use of hand expressions can convey much emotional context. Clothing and grooming contain additional clues. These are difficult to see over video visits, but can be very helpful for in-person visits where the patient is masked.
Voice: Verbal expressiveness can convey information lost when visual cues are not present. This can be more subtle, depending on language concordance, personalities and habits of the clinician and their patient. I have seen a few clinicians who have remarkable natural capacity to strongly connect with patients, even on phone visits. Most of us can learn to master our greeting of patients on phone or video visits to build a sense of trust and empathy. As the clinician starts thinking about the differential diagnosis, options for testing, how many patients are waiting, and any personal stressors, our verbal expressiveness may lose some of its empathic quality.
For an excellent and very readable review of the many ways we communicate non-verbally, see The Power of Body Language, by Tonya Reiman.
For leaders and managers engaging with co-workers and community partners, these same compensatory mechanisms can be used for virtual interactions, but at a price. The level of engagement from virtual conferences and meetings is often significantly compromised, resulting in less interactive dialogue, less productive debate, and less synergistic learning. In particular, partners and policymakers are not cooperating and solving problems as effectively. To overcome this, we must strive to leverage in-person interactions. If infection safety is a concern, we can meet outdoors (particularly good for meetings with a meal) or in a well ventilated indoor setting with sufficient distance to minimize risk of airborne infection but close enough to see each other’s expressions and body language. Judicious use of rapid COVID antigen tests also has a role.
This is our new normal. We owe it to our patients, our organizations and ourselves to put our Mirror Neuron Systems back to work.