I have pondered over the past several years about the stampede to join social media. I understood the wish to be connected to friends or reminding one of a birthday, but so far, I just don't understand the use professionally. I did some time ago sign up for Facebook, Twitter, LinkedIn, and others, but I dropped out of each after a few months. There was too much traffic, too many notices to recognize this or that person or event, and too many invitations to “follow” people I didn't know or care to know. Most of the chatter that came my way seemed inane and time-wasting. Email seems more direct, private, and simple to me. I recognize that many others find great value in social media—and that does seem to be becoming more the rule than the exception—but I gradually sensed that the whole process turned me off for a reason I couldn't quite put my finger on... until now.
A recent New York Times op-ed piece by Stephen Marche titled “The Epidemic of Facelessness” (14 February 2015) comes as close as anything to the basic reason for how I felt.
Marche begins by describing people who (anonymously, of course) repeatedly tweeted threatening and violent messages. One man was sent to jail and he couldn't understand why the victim, a Member of Parliament in England, was afraid for her life and well-being, forcing her finally to install a panic button in her house. A more common scenario, the piece notes, is young women and men sending notes threatening to rape a person, and then are surprised that the victim took the threat seriously when the police showed up at their door. Surprising to me was that often the perpetrator and even the parents are surprised that the threats were taken seriously: “you can't believe anything you see online, anyway. Right?”
Marche points out, “There is a vast dissonance between virtual communication and an actual police officer at the door. It is a dissonance we are all running up against more and more, the dissonance between the world of faces and the world without faces. And the world without faces is coming to dominate.”
In a recently leaked memo, Twitter CEO Dick Costolo lamented his company's failures to deal with the Internet trolls that infested it: “I'm frankly ashamed of how poorly we've dealt with this issue during my tenure as CEO.”
But Marche believes that this is no simple technical problem, as Costolo hinted, because faceless rage is inherent to its technology—“The faceless communication that social media creates, the linking distances between people, both provokes and mitigates the inherent capacity for monstrosity.”
‘The Gyges Effect’
This is not a new idea. The Gyges Effect was recognized millennia ago. The Ring of Gyges is a mythical magical artifact mentioned by Plato in Book 2 of his Republic. It granted its owner the power to become invisible at will. Through the story of the ring, Plato considers whether an intelligent person would be moral if he did not have to fear being caught and punished.
The philosopher Emmanuel Levinas believed that the encounter with another's face was the origin of identity—the reality of the other preceding the formation of the self. The face is the substance, not just the reflection, of the infinity of another person. And from the infinity of the face comes the sense of inevitable obligation, the possibility of discourse, the origin of the ethical impulse.
A study by Marco Iacoboni, a neuroscientist at UCLA explained the connection: “Through imitation and mimicry, we are able to feel what other people feel. By being able to feel what others feel, we are also able to respond compassionately to other people's emotional states.” The connection goes the other way, too. Inability to see a face is inability to recognize shared humanity with another.
Speaking on the telephone is a poor substitute for looking into someone's face, unless one has already seen the face often and thus can reimagine it while speaking. Skype is only slightly better than the telephone because one is seeing a digital image, which is not the same as seeing and sensing all the complex nuances at play in live face-to-face communication in a specific environment.
As Relates to Medicine
So what does this have to do with medicine? A lot, I fear. Here are a few examples of facelessness that I have observed or, mea culpa, been guilty of myself.
- The surgeon who wafts into the patient's room just before surgery wearing scrubs including a cap and mask hanging from his neck. He has not seen the patient before because a resident did the workup and checked on the lab results. He grumbles some inanity, such as, “Your operation is straightforward, Mr. Jones, and I have done hundreds of these.” He may have palpated the abdomen briefly, but soon flies out of the room with an entourage without ever really connecting with the patient or offering to answer any questions. (Full disclosure: I tend to pick on surgeons first.)
- The patient sits in a clinic exam room for a follow-up visit wearing a paper gown. The internist knocks and enters saying hello. He sits at the desk and starts paging through the digital medical record on the screen, while occasionally chatting with the patient. He shifts screens to check on the lab results and then turns to see the patient. Everything seems on track, he says, so we just need to check up on you in three weeks. He never sat full-facing the patient, he never looked at the patient's daughter who brought her to the clinic. Within a few seconds, a nurse with a clipboard knocks and enters, asking if 2 pm on the 21st is a good time for a return visit. And that is it.
- A nurse enters a patient's room and says, “It's time to take you to the colonoscopy room. Put your arms under the sheet.” And he proceeds to wheel the patient out. The patient has never seen this nurse before and he never introduced himself. The patient is simply #8 on the colonoscopy schedule. The patient is afraid of this test and she is groggy from pre-exam medications. Next thing she knows she is looking up at a strange face whose lips are moving but she cannot understand what is being said. There has been no meaningful face-to-face contact.
- And just to prove my lack of bias, my next example involves pediatricians: The oncology clinic waiting room is full of sneezing, coughing children and worried parents. The doctor enters the exam room and nods to the mother. He asks her a few questions, writes in the chart, and does a brief physical exam. But he never faces and speaks to the patient. Yes, children are people and the few minutes needed to make direct face-to-face contact with them and telling them what he is doing is invaluable.
- One of my mentors, a master of engaging children, would ask those over two years old if they were married. They would laugh and break the ice. Babies are harder, of course, but there are ways to face them and engage them. My favorite ways are to make funny faces, stick my tongue out at them, cross my eyes, or gently pinch their cheeks or tickle them. It doesn't always work but when it does, things generally go much smoother from then on. It helps if you love babies as I and most pediatricians do.
Digital communication is certainly here to stay, but that does not mean that we should skip the more intimate and traditional ways of connecting with and respecting people. I know the two are not mutually exclusive, but the personal touch is especially important for medical personnel because patients and their families are often afraid, depressed, or otherwise rattled. Two minutes for the parent and/or patient is a very wise investment.