Finding Hope in the Face-to-Face

This touching paper by Jennifer and Julian Edgoose have captured well the precious, privileged and intimate experience of meeting patients "face-to-face" and listening for what matters the most as well as responding as a human more than as a technician. The patient's story can run deeply into the patient's life as well as ours if we look and listen intently and respectfully while not distracted by the technology and hustle of daily practice. Thank you.

Mac Baird, MD

Competing interests: none

"Doctors look at the computer now; they don't talk to me anymore, they don't look at me."[1]

Edgoose and Edgoose's superb reflection, Finding Hope in the Face-to-Face is an extremely important and timely contribution.[2] Their application of Emmanuel Levinas' work, if taken seriously, offers a radical shift in how we think about the clinician-patient relationship. It just may help rescue us from both our most current challenges (the consuming presence of electronic documentation; metric, protocol and productivity driven care) and the more enduring ones (the persistence of a reductionistic, biomedical model; clinician burnout).

To counter the din of these challenges, I want to highlight the authors' message by using some of Levinas' boldest language about the face-to-face clinical encounter.

Do not kill me. According to Levinas, when we come face-to-face with another person, death and the potential to kill are immediately present. He says "The face is not in front of me but above me; it is the Other before death, looking through and exposing death. Secondly, the face is the Other who asks me not to let him die alone, as if to do so were to become an accomplice in his death. Thus the face says to me: you shall not kill."[3] The face of the Other conveys a nakedness, a weakness, a fear of being killed.[4]

At one level, we recognize that fear and the fear of death are often immanent in patients' minds when they come for visits. We can easily understand that they may fear what might occur (an unexpected hospitalization; the need for more aggressive treatment) or what they might be told (a diagnosis of cancer; the worsening of their disease). These fears may also include mistrust in our clinical competence that may lead to bad outcomes and concerns that we may not care about them as people which may result in substandard care. While we may not always overtly acknowledge patients' fear of death at our hands, the endurance of the oath to "first do no harm" suggests that we do recognize the power we have.

Levinas' argument would encourage us, though, to take this a step further. He believes that the self, for its own survival and in its own interest, desires to dominate and control the Other.[5] In the clinical setting, therefore, we must also realize that we have the ability to "annihilate" patients' uniqueness by creating our own one-sided narrative of who they are and interacting with them as a cluster of diseases rather than people. The dominant biomedical approach, with its emphasis on reductionism and categorical thinking, can lead us to unwittingly invalidate patients, erasing their differentness and increasing their vulnerability. We can begin to see patients not as the distinctive people they are, but as members of disease groups, to be tracked, categorized, and analyzed on panels and registries.

Such invalidation also occurs when our implicit biases, based on patients' characteristics such as skin color, gender or religion, guide our clinical decisions and interpersonal interactions. We can annihilate the uniqueness of the Other by focusing on their Otherness. Differentness becomes the reason to distance ourselves from the Other rather than the reason to embrace them and protect their uniqueness. When we understand that the objectification of the Other is a type of killing, we might better appreciate how patients from marginalized communities can perceive daily invalidations and slights, by well-intentioned health care clinicians, as "microaggressions." In the face-to-face clinical encounter, we meet a vulnerable person who asks us not to kill them and their uniqueness as an individual. How would our work change if we clearly focused our clinical encounters on the relational command-"you shall not kill"?

In addition, the clinician is also the Other in relation to the patient's self. Given the power dynamic of the patient-clinician relationship, how does our face convey to the patient--"do not kill me?" As clinicians, we face the possibility of patients causing us physical harm and the transmission of infections, but we also face risks of not being seen as unique, complex people who do not want to be categorized by patients (e.g., "my doctor is like my parent, I don't want to disappoint them; "my doctor is like all the other doctors; they don't really care about me"). Edgoose and Edgoose note how we are vulnerable to patients' agenda and to the "unknowability of what is to come." The health care system can also rob us of our uniqueness, as we can become faceless providers following protocols rather than caring for people. We also have our own fears of annihilation--concerns about the sustainability of clinical care over a career, worries about our own competence, rethinking decisions we made, wondering if we will ever catch up with the documentation, and taking our work home, literally and emotionally. Some of these are of our own making, and some are from the larger system in which our individuality is forsaken. Would exploring and acknowledging our own fear of being "killed" in the clinical encounter provide greater motivation to engage with patients as people first as a way to consistently ground our work in what is most meaningful?

Love. For Levinas, we have the responsibility to abandon our own self-interests and our ability to annihilate the Other in the face of their frailty. Their face demands us to protect them. He says, "my duty to respond to the Other suspends my natural right to self-survival."[3] Levinas sees this abandonment of self-interest as love: "Love is to fear for another and to come to the assistance of his frailty."[5] This love is given generously without expectation that it will be reciprocated.

Clearly, as clinicians we are dedicated to caring for the patient and at least consciously gear our self-interest towards providing the best care. However, the dominance of the biomedical model can subtly funnel this self-interest towards over-focusing on outcome to the detriment, at times, of patients' and families' overall health and well-being. Edgoose and Edgoose recognize this tendency when writing that what we need to do is "bear witness to the relationship in an act of fidelity, not to the outcome, but to the Other."[2 ]

The sacrifice of our own self-interest in the service of the Other then might require us to refuse to control, catalogue or objectify them. The act of relinquishing our dominant frame (I have to get this diabetic to better control their disease) to learn who the patient is represents an act of love (What is important for you in your life? How does your health fit with that? How are you thinking about diabetes? How can I help you? ). We have the opportunity to infuse love into our encounters by engaging with patients' uniqueness, resisting our need to assert our view of who they are and what they must do, and diving into the complexity of their lives, health and illness.

Edgoose and Edgoose suggest that this "deep empathic connection" may be the "best remedy for burnout."[2] It is an antidote to "heart sink." Could loving the patient, not as someone to fit into our narrative but as a unique human person who needs our help, prevent us from falling out of love with our work? What if we enter each clinic room, privileging this frame over an outcome driven one, and expect that we will love, generously, whoever is on the other side of the door?

Holiness. Levinas writes that "Man as Other comes to us from the outside, a separate --or holy--face."[5] It is the sacrifice of one person for another that is holiness,[6] a term he preferred over time to that of ethics.[7] For Levinas, "...holiness awakens the self to its individuation, and with that awareness comes the possibility of recognizing the sanctity of the other human being--an awareness that simultaneously hints at the deeper mystery of the Wholly Other."[8] Edgoose and Edgoose reflect this holiness as they remind us of the importance of mystery in each face-to-face encounter, the willingness to leap into the unknown, the suspension of disbelief and the possibility of hope. This may seem to run counter to the demands of 15 minute office visit and thus seem unrealistic. However, could embracing the deeper mystery of the face-to-face encounter actually enhance clinician and patient satisfaction and improve care? At its worst, a reductionistically driven visit that results in the clinician managing numbers and spending time "face-to-the computer screen" can feel viscerally profane for everyone. What would happen if we treated each clinical encounter with a deep reverence that something holy could occur?

Edgoose and Edgoose's Levinasian framework opens the door to consider other key face-to-face interactions. For example, how do we apply this thinking to our education of the next generation that has entered a high tech, performance-pressured health care field? Is the milestone driven evaluation process the educational corollary to the metric driven clinical practice? Are we engaging with learners in face-to-face interactions, seeing them as the Other and allowing them to see us the same? With the increase of team based care, do we assert our own vision of who our colleagues are and how they should function (How can I better use my team?) or do we resist this temptation, defend their distinctiveness, and as a team engage in a creative, respectful collaboration ? Could health care organizations embrace this notion of face-to-face encounters in their daily decision making and interactions between leadership and staff?

At our best (which no doubt happens more often than not) we have answers to all of these questions, because we genuinely acknowledge and guard the uniqueness of our patients, learners and colleagues. Edgoose and Edgoose in part are offering a timely course correction in the face of substantial "high tech, metric driven" demands. It is not that the accurate diagnosis of disease, the proficient skill in procedures, the necessity to screen for prevention, the appropriateness of treatment and financial stability of a practice are unimportant. Rather, we fundamentally know that these factors can be better addressed when grounded in an interactional context that acknowledges the interconnectedness, uniqueness, complexity and uncertainty of human existence and allows for hope and joy.

But Edgoose and Edgoose, I believe, offer something more than just a response to today's ills. On a small and large scale, implementing this framework, I believe, would ground us in forging the human connections required to address the quadruple aim and other thorny issues such as racism in medicine and the persistence of health inequities. Alongside the advantages of using high tech tools and "big data" to improve patients' health, I think we should also embrace the boldness of Levinas' framework of human relationships--1) Do not kill: acknowledge our tendency to objectify patients and force them to fit our narrative, and resist when we face objectification as well; 2) Love the Other: actively refuse to do so, knowing it will makes us more vulnerable, and rush to protect our patients; and 3) Holiness: by this sacrificial act of love enter more humbly and humanly into a relationship that can foster true healing. Turning away from the computer to face the patient does not have to result in poorer quality of care. It might just provide the context, information courage and partnership needed to truly help the individuals with whom we share a gaze, and, in the process, help ourselves. Edgoose and Edgoose's application of Levinas to the clinical encounter represents an ocean of thought, which should be read and reread many times in order to fully grasp that death, love and holiness lay waiting for us in every face-to-face encounter.

References

1. Thom D, Wolf J, Gardner H, DeVore D, Lin M, Ma A, Ibarra-Castro A, Saba G. Qualitative study of how health coaches support patients in making health-related decisions and behavioral changes. Ann Fam Med 2016;14:509-516.
2. Edgoose JYC, Edgoose JM. Finding hope in the face-to-face. Ann Fam Med May/June 2017 15:272-274.
3. Levinas E, Keeny R. Dialogue with Emmanuel Levinas. In RA Cohen (Ed) Face-to-face with Levinas. New York: State University of New York Press, 1986, pp 13-33.
4. Levinas E. The strong and the weak. "Penser Aujourd'hui: Emmanuel Levinas". 1991. Accessed @ https://www.youtube.com/watch?v=-1MtMzXNGbs. 20 May 2017.
5. Levinas E. Totality and infinity. The Hague: Martinus Nijhoff Publishers, 1974.
6. Levinas E. Being in the principle of war. "Penser Aujourd'hui: Emmanuel Levinas".1991. Accessed @ https://www.youtube.com/watch?v=-1MtMzXNGbs. 20 May 2017.
7. Derrida J. Adieu to Emmanuel Levinas. Stanford CA: Stanford University Press, 1999.
8. Caruana J. "Not ethics, not ethics alone, but the holy": Levinas on ethics and holiness. Journal of Religious Ethics. 2006; 34.4:561-583.

Competing interests: None declared

We wish to sincerely thank Dr. Epstein for his thoughtful comments to our essay.

Dr. Epstein eloquently reminds us that the experience of the Other's face is always dissonant in that it cannot be smoothly melded with the medical gaze. As clinicians, we must strive to both observe and see, auscultate and listen, palpitate and feel. We must, he writes, "turn toward dissonance;" turn toward the Other to become face to face. This intentional act is an offer of our own vulnerability, curiosity and humanity.

His central question is, "why aren't these qualities of attentiveness, curiosity and presence routine in clinical care?" Dr. Epstein's work on mindfulness has served as a deep source of inspiration for the lead author of this paper. Perhaps we sometimes need a prompting framework to guide us toward a more intentional and inquisitive stance. A simple tool called BREATHE OUT is one example to draw us into the rich qualities inherent in face to face experiences.

Edgoose JY, Regner CJ, Zakletskaia LI. BREATHE OUT: A randomized controlled trial of a structured intervention to improve clinician satisfaction with "difficult" visits. J Am Board Fam Med. 2015 Jan- Feb;28(1):13-20. doi: 10.3122/jabfm.2015.01.130323.

Competing interests: Author of referenced paper