Crozet Annals of Medicine: Smiling with My Eyes

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She was my first patient of the day on a crisp, bright fall morning. She was 82 years old and had had some chest pain at three in the morning. She didn’t want to disturb anyone so she waited till daybreak to call her son. Now, at 8 a.m., she was here and her chest pain was gone. It was COVID times so she and I were both wearing surgical masks covering our noses and mouths.

“You have very kind eyes,” she said to me by way of greeting.

“What a lovely thing to say,” I told her.

“Now your eyes are smiling,” she said. Indeed, they were. 

I am starting to like the COVID mask thing. By regulation and good sense, everyone at work is constantly masked, patients and caregivers alike. Only my eyes show, and all I can see of my patient’s faces are their eyes. 

So, I concentrate on the eyes. It helps that I am “face blind” (prosopagnosia). I cannot recognize the jumble of features that make up a facial recognition pattern for most people. I tend to look for one prominent feature, a large nose or a small chin, for example, to recognize people. 

Being forced to look at only the eyes has simplified my life and my social interactions. I have found that eyes can be a very prominent feature to prod recognition if you look at them closely enough. Between eye color (which I had never really noticed before) spacing, lashes, eyebrows and of course kindness, I have developed a new pattern of recognizing people. It requires a probing look into other’s eyes though.

I think it is this intense focus that my delightful patient perceived as kind eyes. And as her smiling eyes comment indicated, we are all learning to emote and perceive emotion using only our eyes. Eyes can smile just as brightly as lips. 

There is a medical term for this type of smile with the eyes and a colloquial term as well. The colloquial term was coined by the model Tyra Banks who calls it “smizing” i.e. smiling with your eyes. 

The medical term is a Duchenne smile. Duchenne was a French doctor who researched the facial muscles of smiling. Duchenne would visit mental hospitals and place electrodes into patients faces and electrically stimulate various facial muscles. This apparently was so painful for the patients that he moved on to use the severed heads of criminals for his studies. What Duchenne discovered was that while there are many false ways to imitate a smile, a genuine smile involves two muscles in the face, the zygomaticus major, which lifts the corners of the mouth toward the cheekbones and the orbicularis oculi, which encircles the eyes and causes wrinkles in the corners of the eyes similar to “crow’s feet.” 

In 1862 Duchenne wrote that the zygomaticus major can be willed into action, but that only the “sweet emotions of the soul” can force the orbicularis oculi to contract. “Its inertia, in smiling,” Duchenne wrote, “unmasks a false friend.” 

A large body of psychology research supports the concept of a genuine or Duchenne smile as promoting psychological well-being in both the giver and the receiver of a genuine smile. In fact, it is difficult not to return a Duchenne smile reflexively. Joy is contagious. 

Listening With My Eyes

Many years ago when my daughter was young, she would get up early to have breakfast with me before my early morning shifts. At 5:30 a.m. she would have me to herself and she would chatter happily while I read the paper and muttered an occasional response in between bites of toast. I would occasionally muse on the French philosopher Sartre’s remark that Hell is other people and add my own understanding; Hell is other people at breakfast. My daughter obviously is an exception to this philosophy, but I think you get an idea of our dynamic. 

One morning we were having our usual gabfest when Bridget said, “Dad, listen to me!”

“I’m listening, Bridget,” I replied reflexively. 

Suddenly she swatted the newspaper away.

“Listen to me with your eyes,” she demanded.

And that is how I learned about active listening.

 

Speaking With My Eyes

The senior resident was presenting a patient to me. I try to keep my expression blank during these presentations so as not to steer the residents’ thinking, but to force them to reach their own conclusions. 

In COVID times, this has become much easier as my facial expressions are literally masked. Another benefit to universal masking. 

Patient presentations are a game of chess between the attending and the resident, who are often at cross purposes. The residents, for various reasons, want to do the minimum workup for the patients, and the attendings, for different reasons, want to be as thorough as possible. 

This was one of those encounters. The patient was fluid overloaded in congestive heart failure and had so much fluid backed up in his lungs that he couldn’t walk from his bed to his bathroom without getting winded. I knew he needed to be admitted for several days of medication to remove the fluid via stimulating increased urination. The resident was proposing one dose of medicine here in the ED and then discharging the patient home to fend for himself. 

I stared at the resident and did what I call the reverse Duchenne. Keeping my zygomaticus flat and engaging my orbicularis oculi I narrowed my eyes at him. It was enough. He exclaimed to the medical student, “There it is. The Reiser judgmental eyes. I guess I’ll go ahead and admit him.”

Child’s play. I didn’t even have to speak a word.

And so, masks have come to the ED. They have brought one other highly significant and important change that I need to share with you all. 

We have been treating COVID patients up close and been involved in many invasive procedures with the really sick ones for over nine months and not one ER resident, not one ER faculty, not one ER nurse, no member of the ER staff, so far has gotten COVD from a patient. We wear masks 100% of the time and we insist that our patients do as well. 

Masks work. My mask protects you and your mask protects me. Wear a mask when around others. 

And then smile with your eyes. It is contagious in the best possible ways. 

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