“Good morning! I’m Dr. Saksena. It’s a pleasure to meet you.” I wave my introduction as I enter the room. Two women sit beside each other. One of them wears a mask that reads “lipstick optional,” and the other dons a surgical mask. This is a new visit for breast cancer, but I haven’t yet deciphered which one is my patient. I look toward the lady with the witty mask: “Are you Mrs. Q?” She nods. I’m not wearing any lipstick either, I admit, and our conversation begins.
Rujuta Saksena, MD
The reason I had trouble with which woman was my patient was partially due to the physical masking of nuanced facial expressions to help me gauge the situation. Faces reveal nervousness, trepidation, curiosity, even approximate age.
What Is Special About Faces?
A great deal! We are unique among animals, as evolution has allowed for tremendous diversity in facial features that make us “one of a kind.” This is what we fall in love with first. This is what endears us to loved ones, what enamors us to those on the big screen. Faces help with individual recognition but are also a salient means of communication. The average human face has around 43 muscles that orchestrate the impressive spectrum of facial expressions. The face is a medium for initial communication, before words are articulated or gestures are formed.
During the COVID-19 pandemic, I am reminded of how face-centric human interactions are. We “see” each other during conversations: a beaming smile during a happy interaction, a budding frown during a disagreement, a developing grimace during pain. These visual cues allow us to process situations more gracefully and add a singular perspective to our experiences.
Our ability to note faces and expressions is a genetically programmed skill in pattern recognition. However, genes can sometimes misbehave. Face blindness or prosopagnosia, which affects 2% to 3% of our population, is a disorder characterized by the inability to recognize faces—the result of abnormalities in neural systems that control facial perception and memory. Individuals with prosopagnosia learn to use “piecemeal” or “feature-by-feature” recognition strategies. They seek clues from clothing, hair color, skin color, body habitus, gait, and voice. Because the face functions as an important identifying feature in memory, it can sometimes be difficult for these individuals to remember information about people, and it may also impair socialization. After our experiences with masks and COVID-19, those of us not afflicted with face blindness will be able to relate more with those who suffer from it.
The New Vernacular of Medical Visits
As states ease stay-at-home restrictions, medical offices will open doors for nonurgent needs. Some offices encourage patients to wait in their car until the doctor is ready to see them, effectively transforming a vehicle into a waiting space. Masks are mandatory, promoting a homogeneous look. The entrance to our cancer center is studded with gatekeepers, who take temperatures and ensure face coverings. Every individual is screened for symptoms suggestive of COVID-19 as well as asked about travel history and contact exposure. Hellos and goodbyes are waves not handshakes. Waiting rooms are reconfigured; patient rooms are purged of pens, notepads, magazines to reduce “high-touch” surfaces; they have a minimalist, bland look. Between appointments, sanitation procedures are amplified. This has helped eliminate germs, but it does little to eliminate anxiety.
Before the COVID-19 pandemic, patients would typically be accompanied by family members or close friends. We would shake hands, and I’d sit on a stool close to them as we engage in conversation. It would be easy to see their smiles or concerns. Sometimes, conversations would settle into a pleasant discourse because of a recent trip or even a certain facial feature, such as a peculiar moustache or a bold lip color.
“Behind every mask is a face, and behind that is a story. Our face is the key to our individuality, and our connection to others.”— Rujuta Saksena, MD
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The physical exam would be peppered with small talk, to gain insight into their lives. Physicians observe faces for cues but also for signs of illness. A pale face would suggest anemia. Alternatively, a ruddy complexion may signal polycythemia, a heightened emotional state, or use of certain medications. A yellowish hue would hint toward a biliary ailment. “Moon facies” may suggest chronic steroid use. A malnourished person might have hollow cheeks and sunken temples.
Now, physical exams are usually “focused.” Typically, family members are present just for pivotal appointments. Often, they phone in, given travel restrictions and social distancing. The icebreakers revolve around how they are dealing with quarantine. We accessorize with masks instead of jewelry. The restrictions related to COVID19 have sprinkled an anodyne flavor over medical visits.
The Bright Side
Agatha Christie once wrote: “The human face is, after all, nothing more nor less than a mask.” She could not have imagined the literal meaning her words would take on in 2020. This crisis has taught us not to take anything for granted, not even our face and the value it holds for personal identity and societal interactions.
As in any crisis, imaginative measures have improved the experience. Sometimes I ask new patients to describe their faces and have gotten some unique responses. An elderly woman described herself as having a “baby face.” Another gentleman told me he looks “exactly like Brad Pitt.”
Even though our facial uniqueness is masked, this is an opportunity to discover the traits that make us special. We are unearthing aspects of ourselves that may have been submerged before. Many patients are bringing to light their singularities, amazing me with their resilience and creativity. Some are trying new recipes, learning new skills like baking bread or playing the harmonica; others are focusing on staying calm and nourishing their health. As with all things, injecting humor into the situation has been revitalizing. My patients and I joke about the perks of not having to apply makeup and hiding certain expressions in unpleasant situations; many men confess to enjoying their facial scruffs and stubbles.
Behind every mask is a face, and behind that is a story. Our face is the key to our individuality, and our connection to others. Last week, I saw a new patient for a blood disorder—a veteran in his 70s. He had kind eyes and sparse hair, and he wore a cloth mask with a checkered design. I said to him, “Isn’t it funny that we don’t know what the other person looks like.” He replied: “Oh, I know what you look like. I googled your image before the visit.”
DISCLOSURE: Dr. Saksena reported no conflicts of interest.
Dr. Saksena is an oncologist at the Carol G. Simon Cancer Center in Summit, New Jersey.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.