Will Smith’s Oscar smackdown of comedian Chris Rock proves one thing: violence should never be a response to insults – or any other inciting factors – in the heat of the moment. Will Smith knows it, and so do the millions of television viewers who witnessed the assault. Yet, despite Smith’s written apology to Rock, Smith may likely believe his actions were justified. Why do I say this? Because if you look at Smith’s facial expression as he does an about-face on the stage and returns to his beloved Jada, he grins, looks upward, and appears completely satisfied with himself, maintaining a stoic appearance after the scene played out and refusing to leave the Dolby Theatre as requested by Academy officials. Smith’s emotional coolness and detachment from the incident signal self-righteousness.

As a psychiatrist, I’ve studied facial expressions for 40 years, even prior to medical school, when, as an undergraduate psychology major, one of my first book purchases was Charles Darwin’s “The Expression of Emotion in Man and Animals.” Darwin explained the origins of human facial expressions in the animal world and argued that facial expressions are largely innate and the same in all societies, reflecting their evolutionary and genetic rather than cultural origins. Since Darwin’s time, however, evolutionary theorists have documented that much of our behavior (though perhaps not our facial expressions) is also learned and therefore the result of social factors and interactions.

Putting aside the nature-nurture controversy, facial expressions provide a compelling window into people’s psyches. Any expression or body language expert will tell you that facial expressions provide valuable signs for recognizing people’s true emotions. Facial expressions reflect six “universal” emotions of surprise, fear, disgust, anger, happiness, and sadness, and they can be important clues to deceit by masking, simulating, or neutralizing emotions. A physician’s ability to interpret the emotion behind a patient’s facial expression makes them more adept at the practice of medicine.

Emotional awareness is just as important as emotional intelligence. But too often, we are pressed for time and ignore or inaccurately read our patients’ facial expressions. Given the sometimes awkward positioning of computers for data entry, many of us barely look up to see our patients. If we can’t visualize them, how can we possibly understand their expressions or glean clues from other non-verbal responses? How can we judge whether their answers to critical questions belie their non-verbal behavior? In my experience, discrepancies between verbal and non-verbal behavior often surround answers to questions related to pain and mental health. Patients may paint a rosy picture of health when, in reality, they are suffering from pain, depression, or addiction.

Emojis have become a cheap and quick workaround to understanding our patients’ feelings. According to Doximity, emojis are becoming more common in the medical setting, and clinicians are advocating for their adoption. Doximity recently conducted a poll among clinicians, inquiring whether emojis should be used in a professional setting. The good news (in my estimation) is that more than two-thirds of respondents answered definitely not, or only with colleagues, but not with patients. We should not be fooled into thinking that simplistic caricatures can substitute for signs of observable distress in our patients or replace what is at the heart of the doctor-patient relationship – good eye contact, personal communication, and the ability to interpret and discuss our patients’ facial expressions and non-verbal gestures.

Despite the increased use of clinical simulations in medical school, the importance of identifying emotional facial expressions remains largely overlooked in the medical curriculum. The “proof” comes from a recent study conducted in India where 106 medical students were shown static images of the six universal facial expressions. About half of the students misidentified negative emotions (fear, anger, etc.), whereas the recognition of positive expressions such as happiness was much better (greater than 90 percent accuracy). There were no significant differences between male and female medical students, but the accuracy of identifications showed significant variations with respect to the gender of the expressors (images).

The study authors concluded that the findings were “troubling [because] future doctors might have potential difficulty in picking up subtle non-verbal cues that are so important in a doctor-patient relationship and communication with the family members.” Furthermore, most emotions are expressed in real practice situations with lesser intensity than static images, making their detection more difficult. Fortunately, physicians and physicians-in-training can effectively learn to recognize emotion by interpreting facial expressions through a short workshop or similar didactic program. As doctors, it is imperative that we learn to recognize and explore patients’ non-verbal cues in their speech patterns, facial expressions, and body posture.

The identification of facial expressions in patients presenting with medical emergencies may be very problematic. A study found that patients with serious and sometimes life-threatening heart or lung problems tend to have less than the normal range of facial expression, particularly when it comes to registering surprise in response to certain emotional cues. The study authors speculated that underlying serious illness may make it more challenging for patients to process emotions as a healthy person would. Accurate detection of facial expressions during an emergency is of utmost importance as it could give doctors a life-saving clue.

Some of the most effective ways to assess a patient’s condition don’t involve a high-tech test or scan, but rather human interaction with the patient. I always remind medical students to look at the patient before they look at the computer. Life has been stressful these past two years. Many of our patients have reached their breaking points, manifested in record rates of suicide attempts, opioid overdose deaths, and in verbal and physical attacks on others. We can’t afford to overlook serious psychopathology by neglecting our patients’ appearance. Indeed, “general appearance” is the first category addressed on a routine mental status exam.

Stress has also taken a toll on providers. We need to be aware of our own non-verbal behavior – eye contact, body position and posture, movement, facial expression, and use of voice – as these can all influence the tone and course of an office visit or consultation. Patients frequently refer to our facial expressions and other non-verbal communication to describe and evaluate their interactions with us. This is where our emotional intelligence comes into play – the ability to understand, monitor, and control our own behavior – verbal and non-verbal – towards our patients.

Will and Jada Pinkett Smith’s emotions were on full display Oscar night, and understandably so. Jada’s rolling of her eyes clearly signaled she was disgusted with Rock’s insulting joke comparing her to G.I. Jane, a reference to Pinkett Smith’s shaved head which was similar to that of Demi Moore’s in the original film. Will’s initial laughter at the joke morphed into rage and sanctimoniousness after smacking Rock and returning to his seat. Smith should have kept his cool, talked to Rock afterward, and asked him to apologize. At the very least, Smith could have benefited from a moment of reflection or meditation and might have responded differently. We’ll never know. But we know that after he struck Rock, the nature of his facial expression will always question the sincerity of his apology.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. His forthcoming book is titled Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine.

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