When I shadow other physicians on their rounds I am sometimes struck by the variability of the social skills the physicians demonstrate. The most skilled have a manner of speaking, a tone of voice, a rhetorical capacity and body language as well as facial expression—a demeanor, perhaps— that ingratiates the patient. These skills invite the confidence of the patient and give the patient permission to reveal, often rapidly, the intimate details of their lives. At times I wonder when I watch these excellent communicators work if what I am really observing is an actor or a con artist at work. I have seen this in all walks of life that require intense communication and relational skills. I am wondering if these skills can be learned or if they are attributable to some genetic sequence, already or soon to be discovered? This leads me to recall the skills of my eldest daughter, Rachel.
When she was very young, around seven or eight years old, my wife and I noticed something a bit startling. If we went out for an evening and hired a baby sitter, the following day she would be able to tell us in great detail all about who the baby sitter was. The babysitters, almost exclusively teen age girls, would put her siblings, toddlers at the time, to bed early, then sit up for some hours with Rachel. The curious thing that we noticed was that my daughter, even if she had never met the baby sitter before, appeared in an evening to come to know her well and could tell us about intimate details related to her life—school events, relationships with boyfriends, problems with her parents, her aspirations and fears.
This became something of a joke between my wife and me. We knew that whenever we hired a babysitter for the evening the following day we would learn far more about her than we cared to hear. Yet, looking backwards, this wisp of a daughter had been prematurely verbal, very garrulous and socially engaging. I do not think she learned these skills; her capacity to be disarming and charming, able to make a teenager feel that they were old friends and to quickly form a sort of intimacy and mutual confidence. It turns out that her talents probably were in her ability to read a stranger’s face.
I am reminded of the work of Oliver Sacks, a neurologist and writer who sadly died a couple of years ago, a physician who was fascinated by the brain but also by people. He left us with volumes of insightful writing about neurological syndromes and the people who suffered from and dealt with them. One group of people he wrote about and videoed had Williams syndrome.
People with Williams syndrome have a rare genetic disorder that expresses itself with a mixture of physical tendencies, facial features, neurological defects and superior skills. They tend to have elfin eyes and rounded noses. They have a higher incidence of certain cardiac anomalies. They are virtually anumeric, unable to sort numbers at all and they cannot comprehend simple spatial relationships. If you draw a simple cross and ask them to reproduce it on paper they might draw an L-shaped figure and be perfectly convinced that they have succeeded. Yet they are musically very adept, verbally highly skilled and socially they can make strangers think after a few minutes of conversation that they have been BFF’s. In a typical video, Sacks walks hand in hand with a girl who has the syndrome, about ten years of age, into a sandwich shop she had never visited and within minutes the girl is sitting on the counter making friends with the waitresses and cooks, almost working the crowd as if she were the favorite neighborhood child come home from a long period of absence.
In my admittedly brief research on these Williams syndrome people I have discovered that they make eye contact with other persons much more intensely than the average. Anecdotally I have almost always associated that behavior with the best physician communicators. Looking someone in the eye implies the observer is reading the face of that person, and that is a quality or a capacity, an intelligence that can be measured and which some researchers link to social intelligence. It appears to be inherited; identical twins share that capacity or lack of it more than non-identical twins, as do persons with Williams syndrome.
The question that arises for anyone who tries to teach communication skills is whether the ability of reading a human face for emotional content can be taught. In other words, can the skill of one physician in reading anger or anxiety in a relatively subtle facial expression be taught to another whose visual cortex is relatively “blind” to facial expression?
It turns out the answer is affirmative and there is a huge area of scholarship surrounding this. Darwin asserted about a century and a half ago that human facial expressions are universal and cross all cultures. This has been widely accepted, and researchers have also divided facial expressions into two groups, those that are maintained for a few seconds and those that are formed for as little as one thirtieth of a second. These latter “microexpressions” appear to represent emotions that are difficult to suppress. Logic would suggest then that creating a favorable rapport with a patient would entail, in part, a keen eye for what are almost, perhaps, subconscious facial expressions and then molding communications to correspond to and deal with those emotions. That skill just might trump all others.
So should medical schools be employing psychologists who specialize in evaluating and teaching people to read emotions in facial expressions? Should they be screening us in our competencies?