Article from the Boston Globe’s On Call Magazine
January/February 2006

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

When healthcare providers make eye contact and smile, patients are likely to get a sense of caring and compassion. But when providers look away or frown, patients may interpret the encounter as unfriendly or even hostile. Facial expressions, tone of voice, body language, and even how you deal with interruptions or distractions all have an impact on health communication. Indeed, nonverbal actions can be at least as powerful and memorable as words, says David B. Abrams, PhD, a clinical psychologist and director of the Office of Behavioral and Social Sciences Research (OBSSR) at the National Institutes of Health (NIH) in Bethesda, Maryland.

Abrams explains that certain parts of the brain, collectively known as the limbic system, control how people (as well as most mammals) understand feelings and respond to various types of nonverbal communication. The use of nonverbal communication is evident even in the first year of life, as parents and their babies interact. Instead of using words, they communicate mainly through touch, facial expressions, eye contact, and the baby’s cries or parent’s soothing sounds. Abrams says that the limbic system not only helps newborns and their parents interact, but also serves as a blueprint for a lifelong understanding of communication.

Similar to the way parents and children communicate, patients and providers pick up a variety of cues from each other. Abrams offers the following suggestions for making the most of nonverbal actions when communicating important health information.

Be aware of what your body is saying.

Even before you speak, patients take meaning from how you look. To enhance the effectiveness of your communication, face patients directly and adopt an attentive and calm presence. When you convey a posture of neutrality or curiosity, patients can sense the unspoken message, “I care about you. Tell me how you are feeling.”

That doesn’t mean try to maintain a “poker face” that reveals nothing. Given patients’ expectations or anxieties, they may read more into your stoic expression than you intend to convey.

Be sensitive to emotional overlay.

Abrams refers to an “emotional overlay” of life experiences that affects how people interpret nonverbal actions. For example, if a patient’s mother always stared at the ceiling before giving bad news, the patient might assume this means the bad news is coming when healthcare providers do the same. Being sensitive to the way patients respond to such gestures can help you get the message across you intend.

Trauma, too, can affect how messages are understood. Patients who have experienced abuse, violence, or war may be hyper vigilant and take a while to “warm up” to providers. Likewise, someone diagnosed with a serious disease may be extra sensitive to bad news and read a lot into the provider’s body language.

Use tone and pacing to help convey the right message.

Tone of voice, pacing (i.e. the speed at which you speak), and sighs or other nonverbal utterances can be very expressive to patients. Talking quickly and in a loud voice may convey impatience, which then gets in the way of how others listen to you. A more relaxed and quiet tone can indicate caring and concern.

Temper your responses.

A patient may come to the reception desk upset or angry, talking loudly about how long he or she has been sitting in the waiting room. Abrams suggests a calm response rather than reacting reciprocally or becoming defensive. As soon as possible, staff should show empathy and validate the patient’s feelings. One way to do that is to say something such as, “I know it must be hard to have to wait so long, and I apologize for the inconvenience.” A calm nonverbal attitude to accompany that response conveys the message, “I won’t escalate to your level.” It also shows that you are listening and willing to deal with the problem at hand.

Minimize interruptions and distractions.

Abrams compares effective communication between patients and providers to a dance in which the limbic brains are in rhythm with one another. As with any form of dancing, interruptions and distractions can break the rhythm of communication and be disruptive. Here are some ways to deal with potential interruptions:

• Pagers, telephones, and office interruptions. Prepare for inevitable electronic interruptions by having guidelines about how and when you’ll respond. Let your office staff know not to beep you when you are meeting with patients, except in emergencies. Being uninterruptible conveys the message that you place a high priority on your interaction with the patient.
• Emergency calls. When you must be interrupted, excuse yourself and let the patient know both verbally and nonverbally that this situation is important. If you have to leave, tell the patient when you expect to return. Also, forewarn patients if you are on call or otherwise anticipate a series of interruptions.
• Recording data and other information. Updating electronic medical records as you speak with a patient has many benefits. But one drawback is that providers may need to interrupt the flow of conversation while entering data in the computer. This can be particularly disruptive when the provider turns away physically to do so. One way to maintain communication continuity is to periodically — not continuously — enter data. Another way is to engage patients in what you are doing, such as reading aloud what you are typing.

Respect personal space.

Sometimes, especially when talking about particularly sad or bad news, a provider may be tempted to give the patient a hug. This may or may not be appropriate. Everyone has a sense of personal space — how near or far away they want others to be. Standing too close can be taken as an invasion of personal space, while being too far away may seem overly remote. Take your cues from patients about how close or far away to be and whether a hug is needed, wanted, or appropriate.

Stay attuned to cultural differences.

While some nonverbal actions are universal, such as tapping your toe to indicate impatience and smiling to show approval or pleasure, others are more culturally bound. Eye contact, for example, while desired by most people in the U.S., is not equally appropriate in other cultures. Likewise, in this country a nod is commonly interpreted as meaning agreement. In other parts of the world, however, it simply means, “I hear what you are saying.” Confirm through dialogue that you correctly understand what the other person is nonverbally communicating, and be alert to how your own culturally determined behavior may be coming across.

Use the environment appropriately.

Beyond body language, the environment in which you communicate is equally telling. For example, when a provider sits in an executive chair behind an imposing desk and the patient sits on a nondescript small chair, the patient gets a sense of unequal power. More open and useful conversation can happen when patients and providers sit in similar chairs with, at most, a low coffee table between them.

Listen.

Words, body language, and the physical environment tell just part of the story. Abrams says that some of the most powerful communication happens at times of silence and inaction. Being an active listener, quieting your own nonverbal behavior, and sitting in silence can create space for patients to ask questions they need to ask and to respond in meaningful ways.

How to Find Out More

The Office of Behavioral and Social Sciences Research (OBSSR) at the National Institutes of Health (NIH) (http://obssr.od.nih.gov) supports research to investigate ways health communication enhances health, well-being, and adherence to medical instructions. To learn more, contact David B. Abrams at AbramsD@od.nih.gov or visit the OBSSR Web site at http://obssr.od.nih.gov.