“Masked” empathy—A post‐pandemic reality: Psychodermatological perspective

Dear Editor, The pandemic caused by novel coronavirus disease 2019 (COVID-19) is still disrupting normal life and anxiety of contracting the infection is spreading like wildfire. Health care providers (HCP) are being stigmatized by the public and many incidences of social isolation and ostracization of HCPs have been reported globally. The main reasons for stigmatization are the widespread public perception of its high infectivity, which is supported by scientific evidence that respiratory droplets can transmit the infection even in the initial incubation period (up to 14 days), along with the high prevalence of the disease among HCPs. This has caused fear in minds of doctors and patients which has prompted them to use proper protective measures like personal protective equipment (PPE), N95 or triple layer masks, face shields, etc., and they are trying unprecedented social distancing practices, even inside consulting room, to control the alarming spread of infection. Many dermatologists have even stopped practicing rationalizing the non-emergent nature of the service. After multiple flip-flops in consensus on mask usage by the community, now most people consider this as the only strategy which can protect one from other asymptomatic infected patients. People are using many types of masks like self-made cloth-based masks, traditional scarves, etc., which will cover their face in the best belief to protect from cross-infection from the hospital. Hospitals and HCPs are encouraging patients to use it and to maintain social distancing to minimalize the risk of exposure. But this has created a new normal in medical consultation practice. It has made a huge communication barrier, especially in psycho-dermatology liaison clinics. Facial expression is the most powerful, natural, and direct way to communicate emotion in everyday social interaction. Nothing can replace a good face to face session in reading a patient's emotion which can be useful in making credibility assessments, evaluating truthfulness, and detecting deception. After Darwin's theory of universality of facial expressions, researchers were preoccupied with the debates on the cultural specificity of it, but later converged to the consensus that expressions are trans-cultural which can be summarized to reactions to seven emotions: anger, contempt, disgust, fear, joy, sadness, and surprise. Reading these emotions have a tremendous role in traditional psychologic counseling and psychodermatological evaluation. Facial expressivity in reaction to emotional stimuli and during social interactions is characteristically reduced which can be seen as a behavioral indicator of emotional processing deficits. Conversely, lack of visibility of doctor's expression will impair rapport building with the patient. It is difficult for the doctor to express empathy to the patient's sufferings without showing his expressions, which will again hinder treatment success. To avoid these negative impacts of mask culture in psychodermatology outpatients, we suggest minimizing the use of opaque facial coverings. If the distance is adequate between the patient and HCP, a transparent face shield without a mask will help to understand facial expressions better. It can be a workable idea to the mask industry to produce transparent masks itself with materials of scientifically proven protective benefits. It will be useful to record the whole consultation to rewind and search for microexpressions after the session if doubt persists. The help of artificial intelligence and machine learning in automatic facial expression interpretation can improve the accuracy in assessment, which should be encouraged.