Learning to read nonverbal communication takes a lot of study and practice and we physicians do not have time for that.
However, if we start to manage our own nonverbal cues, we will start to pick up on the cues of others.
Nonverbal communication can be broken down into two categories. One is movement, be it your posture or facial expression, and the other is your vocalization, the tone, cadence, and volume of your speech. According to Blake Eastman, champion poker player and founder of The Nonverbal Group, a think tank that researches nonverbal communication, it is critical that physicians convey interest and authority, that we are genuinely interested in our patients and their maladies, and we have the knowledge to address them.
Interest is conveyed through movement, usually facial expressions, and authority through vocal tonality.
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Movement, sometimes referred to as “body language,” can encompass any body movement, but we have so much to think about during a visit, it is not practical to be thinking about all our movement. Nobody has the attention for that and it is completely unnecessary.
We can isolate our attention to the upper half of our faces, particularly the muscles around the eyes. This is how we convey interest and let the patient know that we are paying attention and care about them. This does NOT mean feign interest. This means that it may be something that could benefit from a little more of your attention so the patient knows you are interested in what they have to say.
“Interest is conveyed through movement, usually facial expressions, and authority through vocal tonality.”
Think about talking to someone whose face is completely motionless. This might be you!
You are listening to the patient, figuring out their diagnosis, documenting in the chart, and because there is so much going on, your expression may be flat. The patient then interprets this as lack of interest. The goal is to intentionally display interest. This may be done by furrowing the brow, elevating the lower lids, raising the brows (or just one at a time). Upon reading this, it may seem forced or contrived, but bear in mind, the lack of these expressions conveys a lack of interest. People can detect forced facial expressions, like a fake smile. The objective is to have our genuine interest show and maybe embellished a little.
Those facial expressions also need to be dynamic. A repetitive head-nod also conveys lack of interest, the same for a brow that is fixed in a furrow the entire visit. This should make you second guess your decision for Botox!
It is important to acknowledge any barriers to communication.
Acknowledging does not mean elimination, but simply mentioning its presence, like the elephant in the room, helps communication flow more smoothly. For instance, personal protective equipment is another potential barrier. If your patient has an infectious respiratory illness and you were wearing PPE so they can barely see that you are a person, mention that verbally. This will humanize you more.
If you have a patient with hearing loss, especially if you are wearing a mask, point out to them that the onus is on us to be understood, so they feel less hesitant to point if they are having trouble. Even the computer is a barrier between physician and patient, so naming that can help break down that barrier a little.
Touch is also important, but when done wrong can go very wrong, so it would be better to avoid touch (physical exam notwithstanding) if it is not something that comes easily and intuitively. But, a reassuring hand on the shoulder can go a long way.
This is a way to demonstrate empathy and compassion.
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Confidence and authority are communicated through vocal tonality, utilizing loudness and cadence speech. Inflection at the end of a statement, making a statement sound like a question, and glottal fry, where there is lack of projection, making it sound crackly, creaky, or bubbly, both imply a lack of confidence. You could be the world expert in a topic, but if you speak without projecting your voice, the audience perceives this as uncertainty.
This authority needs to be tempered with empathy, which must be a dynamic balance, depending on the patient’s needs and where you are in the visit. One patient may need more empathy, whereas another needs more authority; history taking requires more empathy, the plan requires more authority.
When we discuss or vocal tonality this way, it may seem like there is some acting involved, like we are playing the part of doctor, rather than being a doctor. I would push back against this. There is a certain amount of theatricality that goes into the practice of medicine. For instance, if a patient walks in with a nevus on their chest, the moment they show it to you, you know it is a seborrheic keratosis. This visit can be over in a few seconds. The patient would perceive this brevity as lack of interest and caring and may not believe your assessment. The authority piece was there, but the empathy was not.
Picture that same visit again, but this time, taking a few more seconds to ask more questions, look closer, palpate, furrow your brow and purse your lips thoughtfully. This will not change the course of treatment, but is a way of signaling to the patient that you appreciate their concerns and are taking them seriously.
Once the empathy has been established, you can turn on the authority and inform the patient that this is a benign lesion that does not require a biopsy and the patient can sleep that night assured that they do not have skin cancer.
Nonverbal communication can be more challenging in the age of telehealth. This is where vocal tonality becomes even more important as facial expressions are hard to see. One tip is to align the vertical axis of their face with the camera, so at least you are looking at them in one plane; and look into the camera periodically so their perception is that you are looking at them.
This can be a lot to think about while taking a history, documenting, figuring out the diagnostic or treatment plan, communicating this, and documenting even more. It helps to practice these skills outside of the clinical setting, so they become automatic.
Practice with friends and family.
Think about your facial expressions and vocal tonality; concentrate on using them to demonstrate interest and authority, and if your friends and family have feedback about your nonverbal communication, furrow your brow, squint your eyes, and tell them with authority where you acquired these new skills.
