Because the United States is a melting pot, a medley of cultures are obliged to live and work together. As such, eye etiquette may differ from subculture to subculture. Americans are careful about how and when they meet another's eyes. In normal conversation, each eye contact lasts only about a second before one or both individuals look away. In Puerto Rican subculture, however, children learn not to look into the eyes of those who are, in the opinion of the children, their superiors, such as teachers, priests, doctors, or others in positions of authority. For these Puerto Ricans, according to Professor Louis Forsdale, looking into the eyes of authority figures is a sign of disrespect. No problem occurs so long as the Puerto Rican is with other Puerto Ricans, but cross into white-land and the stateside teacher is apt to feel that the child who is not looking at her is showing disrespect.
Perhaps it would behoove every practitioner to take notice of which patients make direct eye contact before, during, and after a treatment, and which ones do not. Is it possible that a correlation exists between doctor-patient eye contact and responsiveness to treatment?
In connection with eye contact, it is also important to note that the eyes do not work independently of the other 80 muscles of the face. They work synergistically and, in the process, contribute to the potential creation of approximately 7,000 other facial expressions. Consciously or unconsciously, patients may, facially, communicate any number of different macro- and microkinesic blends of emotions. It is the presence or absence of one or a combination of these blends that may account for why we enjoy treating certain patients and not others. These microfacial displays may appear on a patient's face for only a split second and still communicate a very emphatic message; a smile could turn into a grimace, a look of disappointment into one of surprise. According to Psychologist Robert Levenson, this is because emotions are often associated with the need to behave in a certain way on very short notice. Ralph Waldo Emerson said it best when he wrote, "The eyes of men converse at least as much as their tongues."
Eye movements deserve equal consideration when studying eye contact. For example, a downward glance suggests modesty; staring suggests coldness; wide eyes suggest wonder, naivete, honesty or fright; and excessive blinking suggests nervousness and insecurity.
You are probably aware that physicians have the reputation of being poor listeners. Such an indictment may well be related to poor eye contact. Do you look at your patients when they tell you something or you tell them something? While taking a case history, are you too busy writing down what they say? Not looking at a patient could give the impression that you aren't really listening. To avoid this visual omission, some doctors tape record their case histories (with the patient's permission, of course) in order to give patients their undivided attention. Such a procedure also guarantees an exact record of the patient's complaint.
Throughout history, the eyes have had more significance than any other body or facial cue. They have been known as both the windows of the soul and gateway to the mind. Good eye contact establishes authority. Studies indicate that individuals of higher status maintain better eye contact than those of lower status. Hence, patients tend to rate doctors who look at them as being more instrumental to their expectations than those who do not.
Whatever the therapeutic situation, it is essential that your eye contact reinforces your authority. In their study concerning power and dominance, Dovidio and Ellyson note that attributions of power increase as the proportion of looking increases. This should not be taken to mean that you should stare at your patients. Simply tell them with your eyes that their problem and what they have to say is your paramount concern. To repeat: Good eye contact with your patients indicates that mutual channels of communication are open.
Good eye contact is especially important when asking questions and giving instructions; however, it should be balanced. Excessive eye contact could make the shy or retiring patient feel uncomfortable. Conversely, too little eye-contact could cause a patient to feel unimportant or disconfirmed. Either extreme could jeopardize a positive doctor-patient rapport.
In accordance with the theory of pupilometrics, the size of a patient's pupils may also have diagnostic value. Their size will vary not only to the amount of light, but also, according to the reaction of the observer, to what is seen or felt. Most doctors don't "read" this signal with any degree of awareness, although it is a diagnostic skill that can be developed. Dilated pupils, for instance, suggest friendliness, warmth, interest, and attractiveness -- constriction suggests coldness, selfishness, and boredom. Adjusting a patient's cervicals in the supine position provides the doctor with an excellent opportunity to observe the pupillary response to an adjustment. In anticipation of pain, do the pupils dilate? After the adjustment, do they dilate or constrict? An interesting project for the research-minded among us.
Anthropologist Edward Hall reports that PLO Leader Yasir Arafat wears dark glasses to take advantage of the pupil response -- to keep others from reading his reactions by watching the pupils of his eyes dilate.
How long someone looks at another individual in our culture is another relevant consideration. Julius Fast, author of Body Language, suggests that we stare at individuals we believe to be "non-persons." While it is socially permissible to look at someone for a second or two, staring is considered rude. This admonition, however, does not seem to apply to members of the healing arts. The very nature of a physical examination or treatment often dictates the need for sustained and concentrated observation. Patients understand this and are not usually intimidated by such visual attentiveness. In fact, it is often taken to be a sign of therapeutic thoroughness.
Few things upset patients more than being ignored. To stand in front of a receptionist's desk and not be acknowledged is unconscionable. Positive eye contact in a doctor's office should establish an immediate open line of communication. Waiting is decidedly more tolerable once a patient has been duly recognized -- particularly by name.
Determine the quality of your own eye contact. Have members of your staff evaluate it. If necessary, practice by engaging a waitress or waiter in a restaurant with direct eye contact while ordering your meal. Don't just talk to the menu.
Developing better eye contact takes time and practice. A great many people tend to have better eye contact when they listen to someone, but less when they are speaking. Tomorrow, take special notice of your eyes and those of your patients -- how they behave before, during, and after your treatment. Detect with which patients you have more eye contact than others. You will soon discover that developing disciplined and appropriate eye contact with your patients can make a significant difference in the quality of chiropractic health care you deliver.
Abne M. Eisenberg, D.C., Ph.D.
Croton On Hudson, New York