It's Not Only Words that Influence Doctor-Patient Relationships

    • November 1, 2011

A doctor and patient can do a lot of communicating without even talking, Stephen Henry, MD, says. That is because nonverbal clues—the kind we subconsciously rely on every day to read and react to other people—also play a role in the examination room.

"Face-to-face communication is still an important part of medical care in the United States," says Henry, a Robert Wood Johnson Foundation (RWJF) Clinical Scholar (2009-2012) at the University of Michigan and the VA Ann Arbor Healthcare System. "A lot of treatment decisions are made that way, and it’s also how doctors and patients evaluate each other and learn to trust or distrust each other."

Henry is the lead author of a study published in the September 26 issue of the Journal of Evaluation in Clinical Practice that examines the importance of these unspoken messages. He authored the study with Michael D. Fetters, MD, MPH, MA, an alumnus of the RWJF Generalist Physician Faculty Scholars program and the RWJF Clinical Scholars program, and Jane H. Forman, ScD, MHS, a core faculty member in the University of Michigan RWJF Clinical Scholars program.

The researchers set up video cameras to record doctors and patients interacting after health maintenance exams (routine physicals), and then played them back for doctors and patients in separate interviews. Participants were given the opportunity to talk about the nonverbal clues and behaviors they observed on the video, which they may not have directly noticed during the interaction.

While both doctors and patients relied on nonverbal clues to navigate communication during visits, there were noticeable differences in the types of clues they identified and how they later discussed them.

While watching the videos, all of the patients' comments about nonverbal clues addressed the doctor-patient relationship. "Patients commented on whether they felt rushed, and whether the doctor was giving them their full attention," Henry says. These tacit clues helped them decide whether they were comfortable with a physician and whether they liked or trusted him or her, even if they could not articulate the particular reasons for their conclusion.

Doctors also used nonverbal clues to gauge the doctor-patient relationship, and some were more conscious of these clues than others. Most doctors described deliberately adjusting their own behavior to develop and maintain good rapport, based on a patient's behavior or how they thought a patient was interpreting their own nonverbal behavior. Some specific examples included sitting at eye level to convey honesty and humility, or laughing at appropriate times to encourage the patient to continue sharing.

Doctors also reported relying on nonverbal clues to diagnose a patient and to inform medical judgments. Doctors discussed using the clues to set priorities or gauge a patient's overall health. For instance, if a patient seemed depressed or anxious, the doctors reported that they used this information as a clue to investigate whether the patient had any unspoken medical concerns.

The Importance of Communication

"It's important to note that this was an exploratory study. We did not study whether relying on these nonverbal clues led to better or worse medical decisions," Henry cautions. But he hopes the study's findings have implications for physicians as they interact with patients.

Although communication skills are formally taught in most medical schools, nonverbal communication is only discussed in anecdotal terms, if it is discussed at all, Henry says. "It's an understudied aspect of doctor-patient communication, and it's very hard to study in a rigorous way, using real patients and real doctors." For that reason, Henry and Fetters plan to continue their research on the topic. They have a forthcoming paper that will help other researchers utilize their method.

Henry also hopes to build on the research to evaluate other aspects of medical decision making and doctor-patient communication. His research as an RWJF Clinical Scholar involves using measures of communication—both verbal and nonverbal—to evaluate its role in racial disparities related to pain management.

"I don't know of any other research fellowship program that would have allowed me the space, time, resources and mentorship to take on a difficult but important topic such as nonverbal, face-to-face communication," Henry says of the RWJF Clinical Scholars program. "It has been very important in kick-starting my research in this area."