Eye Contact

by Academy of Clinical Excellence on May 5, 2011

“Look at me when I speak to you young man” was a primary parental injunction of my childhood and passed “en loco parentis” to my teachers. I learned that eye contact, at least in Western culture, was important to the development of a respectful attentive relationship. My mentor, Dr. Rammelkamp, as I said in a previous post, taught that relationship is the most important tool in the physician’s bag. Even if my childhood fantasy, that my mother, Beatrice Kraus (z’l) could look into my eyes and see my mind with all of its thoughts, was untrue, she was savvy to the cues that would betray my brother and me. I believe that we may be losing eye-contact and thus a critical element in the development of relationship to the escalating demands for efficiency.

Fast forward 50 years…I had to stop my teaching on rounds several weeks ago and command some attention. Except for the presenter, each of the residents had his or her face buried in a “cow” or some other electronic device. Giving them the benefit of the doubt, I surmised that they were each diligently writing notes or orders on their patients, albeit even on ones that we had not even seen! After all, reduced work hours without corresponding increases in resources demand efficiency. My wife, Joanne, visited her internist in the new 301 Building’s clinical space. She noted the configuration of the spacious exam room. There was a small desk with a keyboard and a large computer screen, a chair for the provider in front of it and one for the patient at the side. Even with robust visual fields you couldn’t see the screen and the face simultaneously! Joanne and her physician sat across the room from the computer and commiserated that there was an implied expectation that data should be input at the time of the interview. The pernicious assumption that it increases efficiency to be able to question, listen and input data simultaneously is likely an error. The problem is that if you don’t look, you’ll miss the twinge on her face or the tear in her eye. “Multitasking” divides our attention. State legislatures around the country have outlawed texting while driving for just that reason. It doesn’t make much sense, then, to allow, it if not to encourage it when meeting with our patients and discussing their presentations in Rounds.

Joanne and I watched a table of 6 young people, likely natives in the digital world, each with a device, texting one another across the table. It’s hard for me to believe that emoticons and abbreviations will ever efficiently convey my mother’s “look” of disapproval or her “look” of love. Even if there is an evolution of mores regarding eye contact amongst the generational sub-cultures triggered by the online and electronic opportunities, the majority of us are digitally naïve. Our adult patients expect us to look at them and we should not lose sight of our sight as a source of clinical information. We’ve not “evolved” to the point that eye contact is the sole province of the security credential, of an iris scan!

Edward Kraus, MD
Division of Nephrology
Johns Hopkins University School of Medicine

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4 Comments

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meg May 5, 2011 at 3:42 pm

You've got so much more experience with EMR than I (4 days now) but I don't think I've much of an issue with the kind of use you describe in an office setting. And part of my un-ease may be related to my lack of familiarity with the EMR program so it's not yet second nature. When we round as a team at each patient's bedside on the inpatient psychiatric unit, though, I can take notes while never breaking eye contact with the patient. I could also type without breaking eye contact. However, I can't negotiate drop down boxes, etc without looking at the screen; and I don't like the idea of a machine coming between the two of us, even a small, benevolent one. I like the intimacy of a direct human-to-human encounter. Maybe I'm just old-fashioned that way...

Anne Marie May 5, 2011 at 11:32 am

I don't think that using computer notes should really cause any less eye contact than paper notes. I work in UK general practice where we schedule appointments every 10 minutes. Most of us have been using electronic records for years. When a patient comes into the room I always maintain eye contact with them during the first part of the conversation. Our monitors swivel so when we are talking about the medications, or how their test results have changed over the last few months, I can turn the screen round for them to see. We can look at diagrams and patient information leaflets online together. It would be crazy to try and look at the patient and at a screen at the same time- could you look at paper notes and a patient at the same time? No, the important thing is that the professional and the patient can access the records together. A large screen allows that much more easily that paper notes.Paper was just as distracting. Test results and letters from secondary care staff still needed to be reviewed but it could take much longer to find them so even less time was given over to conversation with patients.With regards to the behaviour of the residents, I am less sure. What happens on a teaching ward round? Do they happen away from patients? Are the residents breaking eye contact with you to look at a screen? That does seem strange. It sounds as if they are not really engaged in the teaching round. What could be done to interaction?It is good to be critical of the impact of increased use of technology on our relationships. We have to be aware of these issues and discuss them.

meg May 5, 2011 at 10:54 am

Great post. The electronic medical record was just introduced to inpatient psychiatry this week, where I'm privileged to be attending. Using the computer during team rounds interferes a bit with being fully "present" for teaching but frees up more time for teaching on bedside walk rounds. I'm resisting using a computer on these walk rounds as I believe that each patient deserves my full attention and, if my eyes are on the computer screen, I'm really not connecting fully with the patient, both visually and emotionally. It's this connection that establishes the basis of the mental status examination. Using a computer in this setting would be like performing cardiac auscultation with cotton in my ears. Also, the strength of this patient-doctor connection determines the success of our psychotherapeutic interventions (which occur with each patient, even on the inpatient unit). So, I'll still be looking at my patients and teaching my students and residents to do the same. Yes, it means that I have to play catch-up entering my exam notes after rounds, but it's worth it to my patients and to me. Connecting with patients is what makes medicine and, for me, psychiatry so fulfilling and meaningful; and that's something of which I never want to "lose sight."

meg May 5, 2011 at 10:52 am

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