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DISSECTING NON VERBAL
CUES
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TOUCH
More than any other aspect of nonverbal
communication ,touch is believed to serve the goal of
practitioner-patient rapport.
The idea of an association between healing and touch isancient.
Touch can be extremely soothing to ill patients and can
communicate reassurance, comfort and caring.
The pressure of touch in the form of massage usually
induces relaxation accompanied by decrease in
physiological arousal and stress hormones.
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Touch can communicate some other not so
helpful messages as well.
As with all metacommunication,the precise
meaning of a touch cannot be known, but
depends upon the context in which touch takes
place.
Touch can be a powerful indicator of caring,
concern and solidarity; or it can simply be an
indicator of power.
Health professionals touch patients simply be an
indicator of power.
Assumption of touching patients is always good is
not a correct one.
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A study analyzed the videotapes of 34 first time
visits b/w patients and their new family
physicians. Only the initial interview portion was
studied. Trained judges recorded, among other
things whether and how much the physician
touched the patient. After the visit each patient
filled up a questionnaire regarding his or hersatisfaction with the visit.
The surprising finding was that the more patients
were touched by the physicians the less satisfiedwas the visit.
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EYE CONTACT
It can be a powerful nonverbal cue that canintensify the emotion present in a given situation .
A pleasant interaction in which the health
professional is warm and understanding with apatient is likely to experience as positive when
accompanied by eye contact.
An upsetting or threatening situation will beexperienced as even more negative when
accompanied by eye contact.
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If a patient is having a hostile interchange with
the medical professional, chances are good that
things will be worse if the health professional
stares at him/her straight in the eye than if the
health professional fails to make eye contact.
Of course, excessive, almost constant staring at a
patient can have a very negative interpersonaleffect no matter what the context.
In fact, physicians judged to have a high degree
of rapport with their patients have been found toengage in only moderate eye contact, less than
that exhibited by some physicians rated as having
a low rapport with their patients.
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Typically, health professionals fail to maintain
enough eye contact. They look at the chart or at
the patients body more than at the patients face.
They tend to avoid the intimacy and immediacy
that eye contact represents. When the doctors do
monitor their patients through gaze they are
generally better able to identify their patientslevel of anxiety and distress.
Health professionals must gauge the effects of
their behavior on patients, in an effort todetermine what contributes to, and what detracts
from, good bedside manner.
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The patients personality characteristics,
cultural background, gender, and the level of
emotional arousal are all factors that can
influence receptivity to eye contact.
One thing is clear, however that eye contact is a
very powerful means of metacommunication.
Used wisely, it can significantly enhance the
positive emotional impact of the therapeutic
relationship and thus aid in promoting the well-
being of the patient.
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Facial expression Facial expressions can tell a great deal about a person,
particularly his or her physical and emotional state.
Fatigue may appear as along lasting expression ,distrust asfleeting one. But what makes facial expression intriguingand sometimes difficult to pin down is that, more than anyother nonverbal cue, they can be controlled . Researchdemonstrates that when physicians can control their facialexpressions of emotion and convey what they intend, theirpatients are quite satisfied with the medical care theyreceive.
Further, medical professionals who can understand themeaning of others facial expressions of emotion have beenfound in research to be able to elicit greater satisfaction
and cooperation with treatment.
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TONE OF VOICE How a physician or a patient says something is perhaps
as important as what is said. Variations in pitch
,loudness ,emphasis and pacing of speech, as well as
stutters and pauses convey information about emotional
states. They are called extra linguistic cues- languagerelated cues that are outside the verbal content of what
is said.
But emotional impact is rarely missed.
Although patients may be unable to identify preciselywhat cues they have heard, the voice tone and the
specific vocal quality of their medical practitioner does
influence them.
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One study found that the anger perceived in a
physicians voice when talking about alcoholics could
predict accurately their rate of failure when trying to get
alcoholics patients for a treatment program. In another study, the degree of hostility judged to be in
the voices of both physicians and patients reflected
discomfort and interpersonal difficulties that resulted
when patients attempted to ask questions.
Physicians voice tone has also been linked to patients
ability to recall information.
Thus medical professionals convey a great deal, goodand bad to their patients through their voice tone. They
can also learn a lot about their patients emotions by
listening carefully to what is conveyed in their patients
voice.
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BODY LANGUAGE
Body movements and postures can convey aconsiderable amount of information about an
individual's emotional state. This is true particularly
because body cues are typically the least controlled of all
nonverbal messages. People may monitor their facial expressions, but
typically do not monitor their body movements.
Emotional expressions have been found in research toleak unintentionally through the body movement
channel.
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A patients anxiety, depression, and distress or
conversely hid or her energy and positively, may best be
learned by watching patient walks, moves about,
changes position and so on. A persons stride may reveal self confidence and
hopefulness about the outcomes of the medical
condition.
Fidgeting and self-touching may signify anxiety and
individuals unsureness about what she or he is stating
verbally. These behaviors may even signal efforts to
deceive. Body movements and postures do convey certain
important messages. Particularly gestures of health
professional tend to be perceived positively by patients.
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Physicians judged to have a high degree of rapport with
their patients were found in one study to exhibit more
open arm and one leg positions, greater forward lean,
and more orientation of their bodies toward the patientthan physicians judged to have low degree of rapport.
High rapport physicians also sat closer to their patients.
Interactional synchrony which describes the coordinated
interplay between the non verbal behaviors of two or
more interactants.
Synchronized interaction feel comfortable and
harmonious for the participants, they are not awkwardor difficult.
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One study examined the combined impact of many non
verbal cues by medical professionals in order to
determine which were the most important in conveyingan overall positive impression in interaction with a
patient.
Nine family practice residents were videotaped duringthe interview portion of each of the two interviews for
each doctor, the physicians were evaluated by
independent judges on a global measure of their rapport
with the patient. Several non verbal cues were found todifferentially affect judgments of rapport.
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Cues of bodily alignment tended to be more important
in influencing the ratings than did specific non verbal
actions such as smiles,gestures,and nods, although the
latter were still important. body orientation towards the patient and open arm and
leg positions tended to have a very strong effect on
ratings of rapport. These conveyed immediacy and a
strong emotional connection particularly when coupled
with forward lean and mutual gaze.
C i ti f ti
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Communication of emotion
Non verbal messages can be extremely powerful.
Entire medical interactions may be regulated by the nonverbal cues of one or two interactants.
A practitioner may completely determine with his or her
non verbal cues just how much information the patient
is able to convey supportive messages with non verbalcues and the number and quality*-9+30 of questions the
patient is able to ask.
Encouraging patients to voice their concerns and
responding to these in an informative and supportive
way can significantly decrease the anxiety of the patient.
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Understanding patients non verbal communication can
give a medical practitioner an important advantage in
caring for patients.
By identifying cues of dissatisfaction and negative affect
in the body language of a patient, a practitioner canbecome aware of problems the patient has not
articulated.
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Bedside Manner When patients do not feel understood, they are more likely to be
dissatisfied with their medical care. Understanding requires a certain level of emotional connection on
the part of the listener, and its empathy that contributes greatly to
good bedside manner.
Bedside manner is a broad and informal term used to refer to amedical practitioners interpersonal behavior towards patients; it
typically refers to the physicians ability to instill trust and
respond to patients emotional needs.
Hippocrates wrote in the 4th Century B.C the enormous power of
bedside manner: The patient though conscious that his condition
is perilous, may recover health simply through his contentment
with the goodness of the physician.
i i i i i
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Bedside manner is viewed by some as magical, special
edge"," certain something, or even the right
chemistry.
a large part of bedside manner involves being polite, toooften in medical profession it is dispensed off.
Research shows that when medical educators emphasize
bedside manner, somehow their students learn it. On the
other hand, when teachers consider bedside manner
unimportant, heat fact becomes quite clear to us.
Intensive, callous teachers turn out insensitive, callous
apprentices. Many believe that good bedside medicine was once
common and that it has largely fallen by the wayside As
medicine has become dominated by technology.
i i i i f i
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The increasing incidence of long term chronic
illnesses is tending to move issues of
communication in the forefront of medical
practice.
Considerable emphasis is being placed on patient
related psychological issues in training of
primary care doctors during residency programs.
one important research method for studying
medical practitioner-patient interactions involves
the recording of the behaviors that actually occurin medical interaction, the careful analysis of
these behaviors, and the assessment of their
effects on patient satisfaction with care.
O i f th t di i thi h
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One review of the many studies using this approachexamined various aspects of bedside manner and theireffects on patient satisfaction and patient compliancewith medical regiments.
Patient satisfaction with medical care was found in thisreview to be higher when physicians provided moresocial conversation, more positive talk, and less negativetalk; among the most important aspects of bedsidemanner were the specific positive and supportive nonverbal cues of the medical professionals.
Training doctors to be more effective communicatorscertainly can have an effect on the behavior of bothphysicians and their patients.
I t d h f d th t d t h t k
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In one study, researchers found that doctors who took a
brief training session in communication were better at
eliciting active participation from their patients than
those who did not have the training. In this study, the trained physicians were more
facilitative of communication with their patients as they
asked more openended questions.
Further their patients used more positive talk and gave
more information when compared to the untrained
group of physicians and their patients. Furthermore,
trained observers judged the trained physicians to bemore interested and friendly and their patients to be
more dominant, responsive and friendly.
These patients were also more positive,responsive,and
friendly.
A th t d f d th t idi i t i t i i t
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Another study found that providing intensive training to
residents on communicating and understanding patients
led their patients to be more confident in them and to
have a higher level of satisfaction with their care.
The basis of practitioners bedside manner is his or her
recognition of the importance of psychosocial issues in
treating a patient. the medical practitioner must
overcome the purely biomedical view of the patient as a
collection of parts needing an adjustment and approach
the patient as someone whose feelings are worthunderstanding.
But in reality less than half of the average medical visit
is spent dealing at all with psychological or psychosocial
issues related to illness