Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, president of Health Literacy Consulting, founder of Health Literacy Month, and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations with some really remarkable people, hearing what health literacy is, why it matters and ways all of us can help improve health understanding.

Today I’m talking with Tom Mucciolo, who is president of Media Net Inc., a presentation skills company based in New York City. For many years Tom has been helping leaders effectively communicate their messages using scripting, visual design and delivery skills. He also is on the faculty at NYU.

Tom writes extensively about teaching and presentation effectiveness and is co-author of the book, A Guide to Better Teaching. Welcome, Tom.

Tom: Hello, Helen. Thank you for inviting me.

Helen: I met you when I was at the annual conference of the National Speakers Association and you were leading a workshop about using nonverbal gestures in presentations. I learned so much from you that day and I’ve tried to put it into my presentations ever since.

I’ve also since realized that what you were talking about applies to health communication as well. Let’s take this one from the top. Why is good communication a matter of gestures and not just our words?

Tom: I would look at communications in two sections of a person’s style. One is verbal and the other is nonverbal. The verbal skills are actually the content itself. The nonverbal skills are the tone of voice and the visual cues we get if we can see someone.

Imagine that these two things are the components of any type of communication with another person, part of it being what you said and the other part being what you looked like when you said it.

Helen: In healthcare, we’re always talking to people. Often it’s in a person-to-person interaction, but sometimes it’s not. Sometimes health communicators also speak to large groups. What are gestures? What do you mean when you say gestures?

Tom: The best way to separate it is to look at the concept of the difference between conversation and presentation. A conversation between two people is basically that either person can take control of the conversation at any point.

If you and I are having a cup of coffee and I’m looking out of a window and say, “Helen, I’m looking at that new car across the street. I’m thinking of getting a new car,” you could not have predicted that. It was conversation. I decided to throw it in because I saw the car.

The concept is how predictable conversation is. Generally it really isn’t. Fifty percent of everything you say is what you look like when you say it and the other 50% is what you said. The verbal and nonverbal cues, if you want to use that term, are equal in conversation because either party can change the direction and can contribute.

Helen: I’m thinking of health communication. It’s really not an equal-to-equal conversation, nor is a presentation.

Tom: I would move that into the presentation side. Somebody has prepared something. Let’s say a clinician already has experience or has a patient’s medical record and thinks, “I’m going to talk on a subject that the patient doesn’t really know as much about.”

That would allow the clinician to have one side of the coin or piece of this communication puzzle completed while the listener doesn’t. We call this completed content “prepared speech.”

This would be no different than when you send me an email. I’m going to read it for the first time, but you’ve already prepared it. In a conversation, if you’re a clinician you already know what you want to say about a particular health matter. I’m just waiting to hear how it applies to me.

This changes the dynamic of what we start to observe. What used to be half verbal and half nonverbal skews this ratio dramatically.

Helen: In what way?

Tom: Some studies indicate that a very high percentage is nonverbal. Over 55% of it could be what you look like when you say it and 38% could be more how you actually deliver it, leaving 7% to be the content. It’s an over 90% and under 10% ratio of the nonverbal to the verbal.

Helen: That’s astounding to me. What can we do about it?

Tom: It doesn’t mean the content is not important. It certainly is, but it has to be the right content. We’re dealing with quality of content and not quantity.

That leads to nonverbal cues. People will begin to judge how the person looked when they said it and what their mannerisms were. Did they look appealing and inviting? This is why the nonverbal cues become a skill.

The greater you are in predictability, meaning I understand what you’re saying even before you almost say it, the clearer the impact of the message. I’ll give you a perfect example.

If you were asking me a question as to whether I wanted a drink of water, let’s assume there are only two answers to this question. You are waiting for me to give you an answer. The message I’m about to deliver of whether I want a drink of water is the unpredictable part. You don’t know what I’m going to say.

If I do say yes and nod my head up and down, the nonverbal action of my head and even the word yes are congruent. Hence the action is quite predictable. If I were to move my head side to side and still say yes, you might not be sure what I mean. That’s because they were incongruent or unpredictable.

When people present information where they have pre-planned knowledge, the receiver looks for predictable actions that are nonverbal. Those actions are what they use to interpret the message itself.

Helen: Tom, my world is in healthcare and my listeners are all involved in some kind of health communication. Let’s think about this like test results or something. You’re talking with a patient and the results are not what the patient wants to hear. Other than your words, how can you communicate that clearly but perhaps also show some empathy, caring or hope?

Tom: In reality, once you know the body’s language, the nonverbal cues will dominate in this situation. You can work on three possible things in that body’s language that would make the other person have a reaction, hopefully in a very positive way, if you’re using these skills correctly.

One issue is proximity, another issue is openness and a third issue is invitation. I’ll briefly explain them. Proximity is very simple. It’s the distance we are from one another. As two people get closer together, the level of intimacy rises.

It’s not like you’re going to be dancing with someone, but a lot of times this happens with the distance someone stands away or the distance someone uses their head to back away or come closer to us.

Imagine if just your head alone wanted to create a bigger picture for someone. The tendency would be to tilt the head slightly backward, away from the person, and this would give someone a bigger view of what you’re about to say.

Many people use this to say things like, “A lot of studies show,” or “Information in the field has this evidence.” Sometimes the tilt of the head away is a larger perspective.

Helen: You’re not talking about dramatic gestures here. You’re talking about a slight shift.

Tom: That’s right. Very slight moves of the head, for example, would change the level of proximity. The literature likes to use the word “immediacy.” How immediate is the person to me? Can I ask them a question? Can I feel like they’re close to me? Do they have a friendliness about them or approachability?

Helen: When we’re talking about proximity, we’re talking about the head and the small, little movement we might make. Does it deal with the whole body too or just the head?

Tom: Absolutely. In a setting where I’m not just one-to-one with someone who is sitting 3 feet away from me but I’m standing in front of a small group, then it would be movement of the body. If the body is farther away from the audience, that farther back move of the body tends to be focused on something larger.

Helen: Actually, I remember seeing you do this in the workshop. We were in the audience. You talked about where your body would go when you make your grander points or where you want to be a little bit more conversational or engaging of the audience.

Tom: Exactly. Usually as you get closer to an audience, that style of more personal attachment will rise and the level of immediacy or intimacy with the audience rises. A person who is standing can move closer to someone to create this degree of proximity and immediacy or be farther away from them. Even a head tilt toward someone would be much more personal than a head tilt away.

By making conversation with patients, clinicians sometimes tend to play what I call “big picture.” The head tilts back when they speak, yet the patient who is vulnerable may have been looking for the head tilting forward.

Helen: That’s interesting.

Tom: It’s just an action of the body that would have been congruent with some type of closeness to the person. You don’t want to pretend to make this happen. This has to be something out of someone’s nature.

Helen: Can it be learned, too?

Tom: Absolutely.

Helen: You talked about proximity. You also talked about openness. What’s that?

Tom: The degree of openness is really where your shoulders face someone else’s shoulders.

If I’m standing across from just one other person and my shoulders are basically matching their shoulders, as if you could draw two straight lines from each of our shoulders matching, that would put us at a high degree of openness for both of us at the same time. That’s a difficult position to be in because your bodies are both in what we call power positions of the body.

Helen: You’re really looking straight at that person, right?

Tom: Yes. Your body is facing them straight on. You could be looking at them. That’s not a problem, but it’s the shoulders we’re dealing with.

Imagine the body being at a 45-degree angle to another person. You could still be looking at them with your head, but the body’s angle is away. The degree of openness has shifted back slightly so that one shoulder is closer to them than another.

This is what we call a rest position of the body, which offers less impact. This would be no different than the concept of voice where voice could get very loud if it needs to but tends not to get loud all of the time.

Helen: I’ve tried using some of that in my presentations based on what I saw with you where I’m not looking absolutely straight on at an audience, but I tilt my body just a little bit.

Tom: When people are presenting content they might have a slide, for example. If the body can be at a 45-degree angle to the audience and to the slide, then the body is open to people and open to content.

It’s only when we’d like impact when we would square the body to the back of the space if it was a group. That creates a power position for the audience to think, “This must be slightly more impactful or more important.”

Helen: That’s interesting. I’m thinking of this almost like punctuation. We wouldn’t write in all capitals and we wouldn’t use all exclamation marks. It’s varying it back and forth that engages the other person.

Tom: That is critical to the delivery skill, which is why you’ll see on the news at night where the two anchors are angled to one another. When the lead story comes in there’s a squared-off shot. It’s a little picture over the shoulder.

Helen: I’m learning a lot. I wanted to ask you about invitation.

Tom: Invitation is really the most powerful of all skills. It’s the ability for someone to feel that they can trust you, and trust in the body and the nonverbal cue of the body.

One form of trust does exist in the face with the smile, for example. Another form of trust is even more of a body-language issue, which is the open palm. How often does a person use an open gesture, opening the palm to another person? We do this in the Western culture very quickly with a handshake when we greet someone.

Helen: An open palm is when your palm is straight up.

Tom: It’s open, but you don’t want to make it look too harsh like it’s a karate chop. It’s more of an open gesture and fingers are relaxed. When the palm opens to someone, it looks like you’re extending an invitation to communicate, especially for groups.

You might have a group of people. If you asked a question and never made any inviting gestures like the open palm to show the group that they all can communicate, most people will reliably predict that whoever you looked at last has to answer a question because they went off where you were looking.

If you make gestures and if both palms are open to the group saying, “How many of you agree with this?” the group knows that this person must be talking to all of us.

It would even work one to one because when there is an open palm to someone, it’s almost as if you’re handing them a gift. That invitation is so critical to allowing someone to speak, for example, or holding someone from continuing to speak.

Helen: That’s a tip I learned from you that I’ve probably used more than the other ones. It’s the easiest to remember and manage. It makes such a big difference.

As an aside from this, I have a little toddler grandbaby. Her favorite book is Head, Shoulders, Knees and Toes. That sounds like what you’re talking about. Pay attention to your head, shoulders, knees, toes and palms. It all makes a difference.

Tom: Those would be the nonverbal things. A lot of times you’ll see this in a person’s body language where someone’s response might be, “I didn’t get a good feeling when I talked to that person. They just didn’t make me feel right.”

They can’t really put their finger on what it was other than it didn’t feel right. Chances are it was some type of nonverbal action that did not appear congruent or consistent with the words they were hearing.

Helen: Tom, you and I and our listeners all have a challenge. We’re not looking at each other. I haven’t seen you in six months. What can we do when we’re communicating and there is no visual cue?

Tom: When there’s no visual cue, about 85% of the communication is tone of voice. It could have to do with the ability to avoid distractions. A typical distraction in conversation is not a problem for people, which would be the filler such as “um”or “uh.” Don’t worry about that in a conversation because the nonverbal and verbal cues are very equal.

In prepared speech, these sounds we make in between the words we say will be noticed and picked up, not to a tremendous degree, but the sound may be something that affects people.

Another example would be a parenthetical intrusion. I know it’s a big phrase. It’s drifting away from the content that you started with. If you asked me, “Tom, what do you think about the weather?” I could have said, “The weather has been pretty bad lately where I live.” That’s pretty simple.

What if I had said, “Don’t get me started a topic like the weather. Topics are things that are distracting. In fact, the most distracting topic could be about animals and I don’t even have any pets. Some people love pets.” I haven’t even gotten to the original question.

Helen: You have to stay focused on what you’re doing.

Tom: Yes. One way to do it is to establish presence in speech. This can be done very quickly. If someone asks you a question and you answer it followed by an explanation, you have a high degree of presence. If you explain and then answer, your degree of presence is dropping.

Helen: Can you give an example?

Tom: Let’s say I go to the doctor and I notice my blood sugar is high. I say to the doctor, “Can I have a Coke for lunch?” The doctor can say, “No, and here’s why. Your blood sugar is high.”

The doctor could also say, “A lot of people like different types of soft drinks. There’s debate of which kind of soft drink is better or worse. In my opinion, I would probably not go with the Coke.” That’s weaker.

You have to decide how much strength you want in presence when you choose to respond to something. I prefer power when people speak with prepared speech. They should answer a question immediately followed by an explanation rather than hedge, unless it’s a debatable topic.

Helen: If it’s debatable, could you say, “That’s a debatable topic. Experts don’t agree on it”?

Tom: Yes. Opinion is a debatable topic. For instance, “Do you think people should be able to vote at the age of 15?” Then someone might say, “There’s a lot of debate on what age someone can make a rational decision as an adult.” That’s a debatable argument, versus, “Do you think a 6-year-old should drive a car?” You would say, “Absolutely not.”

Helen: You’ve told us about presence, the gestures, the tone and the physical part. You’ve shared so much. I think with these tips alone, if all of us just put them into place in our communication, we could keep moving the dialog further along. Is there any way people can learn more about this?

Tom: Yes. They’re welcome to visit my website, www.MediaNet-NY.com.

Helen: That’s great. We’ll have that on our Health Literacy Out Loud page.

Tom: The way to think of what we’ve said is that nonverbal skill requires a high degree of predictability in order to create the unexpected, which is the message itself. You really have to be very predictable.

Helen: That’s what we’re doing. I thank you for being predictable, engaging and informative. I hope all the listeners of Health Literacy Out Loud learned as much from you as I did. Thank you, Tom.

Tom: Thank you, Helen.

Helen: I learned so much from Tom Mucciolo about using gestures, tone and all those things we do in communication beyond our words. But communicating clearly and effectively isn’t so easy. For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com.

While you are there, sign up for the free, monthly enewsletter, What’s New in Health Literacy Consulting. New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find more information along with important links at www.HealthLiteracyOutLoud.org.

Did you like this podcast? Did you learn something new? If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.