Establishing Rapport

Patient Dissatisfaction

In a typical business, only 4% of customers voice their dissatisfaction. The other 96% say nothing, and 91% never return. This has led to many practices conducting regular patient satisfaction surveys so that problems can be identified.

Verbal Communication

Much of the communication process in the clinical interview centers on verbal interchange. Symptoms, past medical history, family medical history, and psychosocial data are transmitted primarily by verbal means. The chief complaint is extremely important because it explains why patients believe they need the physician's help.

Patients who do not mention a concern and who withhold requests are less satisfied with their care and experience less improvement in their symptoms. Bell and colleagues (2001) found that 9% of patients had one or more unvoiced desires and were most hesitant to ask their physician for referrals and for physical therapy. These patients were also less likely to trust their physician. This is an important reason to be sensitive to subtle clues that the patient may be suppressing something important to them. What the patient does not say may be as important as what the patient says.

“Slips of the tongue” or major areas of omission (e.g., a married person who never mentions a spouse) may signify problem areas that, when explored, help establish the interviewer as a perceptive person who understands the underlying issues. The interviewer constantly must consider, “Why is the patient telling me that?” Even simple, casual remarks may be the patient's way of broaching issues of great concern; the man who says, “Oh, by the way, a friend of mine has been having some chest pain when he walks a lot. Do you think that sounds serious?” may actually be talking about his own concern that he is unable to face directly. A child may be brought to the office with a trivial problem so that the mother has a chance to discuss with the physician something that is troubling her; the child is a calling card, signaling the need to open the communication channel. The physician who is sensitive to these subtle clues and encourages the patient to discuss what is actually troublesome will find that the rapport established allows future interviews to be much more open and direct.

Hand-on-the-Doorknob Syndrome

The patient's parting phrase is sometimes a clue to the primary reason for the visit, or it may reflect another issue of great concern that is emotionally threatening and could not be voiced until adequate courage was summoned at the moment of departure. It sometimes surfaces as a last, desperate attempt to communicate because, with a hand on door, escape is readily accessible if the physician's reaction is unfavorable. Reasons for this hidden communication by the patient are important and must be recognized and addressed. Because of fear of rejection or humiliation, the patient may test the physician with minor complaints before mentioning the real reason for the visit (Quill, 1989). The physician must be alert to any unusual behavior during an interview (e.g., slips of the tongue, unexpected responses, overenthusiastic denials) and should search further for the underlying reason for the visit when a patient presents with a trivial complaint that appears inappropriate. It is a good practice to ask the patient routinely at the end of a visit, “Is there anything we have not covered, or anything else you would like to ask me?”

Patients with a fear of cancer, for example, often are unable to voice their concern to the physician. Instead, they present with somatic complaints or contrived reasons that necessitate a complete examination. They are hopeful that the examination will allay their fears without it being necessary to express them openly. A female patient presenting for a complete physical examination actually may be concerned over the possibility of a carcinoma of the breast, which her elder sister might have had at the same age or for which a friend recently had surgery. Such situations emphasize the need for a complete family history and a discussion of any patient concerns in an effort to allow these feelings to surface. Attention then should be paid to alleviating the anxiety. Apprehension regarding cancer is widespread, and the only cure for this fear often is a therapeutic conversation with the physician.

Physicians in private practice who have established rapport during an ongoing relationship with patients communicate more easily than do physicians seeing a patient for the first time in an emergency department (ED). Korsch and Negrete (1972) showed that ED physicians did more talking than the patients, although their perception was just the opposite. This was attributed to interaction with unfamiliar patients by house staff in a setting where the stress level is high and the orientation therapeutic. However, Arntson and Philipsborn (1982) found that physicians in private practice for 26 years who knew their patients and saw them in a low-stress situation for diagnosis or health maintenance also talked more than the patients (twice as long). One difference in the two settings was a strong, reciprocal affective relationship between physician and patient in the private office. If either made an affective statement, the other would respond similarly, whereas in the ED, patients expressed twice as many affective statements as did the physicians.

Vocabulary

The use of appropriate vocabulary assists in establishing rapport by ensuring easy and accurate communication. Phrasing questions in simple language appropriate to the patient's level of understanding and avoidance of medical jargon help establish a sense of working together. The patient's cultural background and educational level should be considered, and the physician should avoid using slang or a contrived accent because the patient will detect the artificiality and consider this patronizing.

Patients prefer to be enlightened, and they demand maximum insight into their care. It is best to start all explanations at a basic level and proceed only as rapidly as the patient's understanding permits. An analysis of 1057 audiotaped patient interviews with 59 primary care physicians and 65 surgeons showed that in 9 of 10 cases, patients did not receive good explanations of proposed treatments or tests (Braddock et al., 1999).

Medical terminology should be avoided unless it is familiar to the patient. For example, some patients have interpreted “lumbar puncture” to mean “an operation to drain the lungs.” No longer does the physician gain a therapeutic advantage by writing prescriptions in Latin or impressing the patient with medical terms.

Metaphors can be harmful and are often used without the physician being aware of the negative connotation, unknowingly raising the patient's anxiety level. Attempts to coerce a patient into having surgery with phrases such as “you are living on borrowed time” may cause anxiety and increase postoperative morbidity (Bedell et al., 2004).

Physicians should be sure of what patients mean to convey by their word selection and make certain they are operating at a common level of understanding. When the patient says he or she “drinks a little,” inquire further to clarify “a little.” If the patient “spits up blood,” determine whether it is truly spitting or really vomiting. A major barrier to accurate interpersonal communication is the tendency of people to react to a statement from their own points of view, rather than attempting to interpret it from the speaker's vantage point. If a question exists regarding the clarity of the interpretation, it is best to repeat it to the speaker's satisfaction. Contract negotiators have found that when parties in a dispute realize that they are being understood and each party sees how the situation appears to the other, there is less need to exaggerate and act defensively. Korsch and Negrete (1972) found that some of the longest interviews between physician and patient were caused by failures in communication; they had to spend considerable time trying to “get on the same wavelength.” An analysis of the conversations revealed that less than 5% of the physician's conversation was personal or friendly in nature, and that although most of the physicians believed that they had been friendly, fewer than half of patients had this impression.

Nonverbal Communication

Verbal communication occupies so much of daily social interaction that nonverbal communication often is ignored. However, much that is said is unspoken. Communications specialists have demonstrated convincingly that nonverbal messages play a major role in validating or contradicting verbal messages, with great influence as communication symbols in their own right. When there is conflict between the verbal and nonverbal, believe the latter.

Communication between two people is usually one-third nonverbal, although some say communication is 93% nonverbal and 7% verbal (Secrets of Body Language, 2008). What is said verbally often is emphasized nonverbally, and personal attitudes and emotions usually are communicated at the nonverbal level. Nonverbal communicative signals are under less censorship from conscious control than are verbal messages, so they are likely to be more genuine.

Charles Darwin held that there is a unique pattern of nonverbal actions for each emotion. In Expressions of the Emotions in Man and Animals (1872), Darwin suggested that emotional expressions are evolutionary remnants of previous adaptive behavior that persist even though currently useless. Snarling as a sign of aggression is one example. Although recent knowledge indicates that emotional expression is learned and genetically mediated, Darwin's idea of a unique pattern of actions has been shown for depression and anxiety and is likely in the future to be demonstrated for other emotional states.

Paralanguage

Paralanguage is the voice effect that accompanies or modifies talking and often communicates meaning. It includes velocity of speech (e.g., fast, slow, hesitant), tone and volume of voice, sighs and grunts, pauses, and inflections. Urgency, sincerity, confidence, hesitation, thoughtfulness, gaiety, sadness, and apprehension all are conveyed by qualities of voice. McCaskey (1979) believes that the literal interpretation (i.e., definition) of words accounts for only 10% of communication between two people, whereas facial expression and tone of voice account for up to 90% of the communication.

There is a real difference between verbal and vocal information. The verbal message refers to the words literally transmitted. The vocal message includes the emotional quality, the tone of voice, and the frequency and length of pauses—information that is lost when the words are written. Tone of voice, for example, can reverse the meaning of words. Sarcasm is a common example of a contradiction between vocal and verbal messages. Comparative studies have shown that when the vocal and verbal messages transmit contradictory information, the vocal is more accurate.

Physicians should be alert to subtle changes of tone, such as when patients ask whether everything will be all right. Are they asking for reassurance, showing fear, or doubting the diagnosis? Rather than concentrating exclusively on what patients are saying, the astute physician will concentrate on how they are saying it.

In a study of recordings of surgeons who had been sued and those who had not, the sued group could be identified by their tone of voice. They sounded dominant, whereas the nonsued group sounded less dominant and more concerned. “In the end it comes down to a matter of respect, and the simplest way that respect is communicated is through tone of voice” (Gladwell, 2005, p. 43).

Touch

A close personal interest in the patient can be communicated by the appropriate use of touch. The most socially acceptable method in this country is a handshake, enabling the physician to establish early contact with the patient (Colgan, 2009). The handshake, properly used, can convey to the patient sincerity and interest as well as security and poise. It is an inoffensive intrusion into the other person's area of privacy and can be extended under certain circumstances to include the application of the left hand to the lower or upper arm. This technique is often used by politicians to emphasize sincerity and concern (Figure 13-1). A variation of the politician's handshake is the “double-hander,” which some equate to a miniature hug.

Politicians also “gain the upper hand” by positioning themselves to the right of the other person so that when shaking hands theirs is on top. Another way to show dominance is to make sure they go through a door last, often with a pat on the back. This shows that the one going through the door last is in charge. This was well illustrated when President Clinton welcomed the Israeli and Palestinian leaders into a building and each insisted the other go first. While this would be considered polite in the United States, in the Middle East it reflects a power struggle. The winner (the last one through the door) emphasizes this with a pat on the back as the other enters (Secrets of Body Language, 2008).

The handshake as a traditional greeting of friendship began by the raising of exposed hands by two approaching individuals to give evidence that they held no weapons. This proceeded to the grasping of hands or, in the Roman society, the forearms. In the United States, a firm handshake is most acceptable. Usually, the limp or “wet dishrag” handshake indicates lack of interest or insincerity, especially if it is rapidly withdrawn. A moist palm is a sign of nervousness or apprehension, and the “halfway there,” fingers-only handshake indicates reluctance or indecision. However, the handshake continues to be modified culturally, and a person should be extremely wary of misinterpreting another person's handshake without understanding his or her cultural background.

In the past in China, the Confucian code of etiquette dictated that there should never be a touching of persons, and even today, Chinese officials may appear reluctant to grasp an extended hand; a Chinese man formerly shook his own hand (Butterfield, 1982). Some young people in the United States have modified the traditional palm-to-palm handshake to a grasping of the thumb and thenar eminence and continue to develop new variations reminiscent of the secret handshakes of fraternal groups.

Touching can be an effective method for communicating concern or compassion and can break down some of the defensive barriers to communication. Caution should be exercised, however, not to use it excessively or earlier than is socially permissible. If used without adequate preparation, touch can be interpreted as an invasion of privacy and a forward and inconsiderate act. During the physical examination, it is best to talk before touching by explaining to the patient what will be done next. Studies of primates have shown that touching gestures usually are considered nonaggressive and calming in nature. When used properly by the physician, touch can be facilitative and welcome.

The tremendous symbolic value of touch as a healing power was demonstrated during the Middle Ages, when people sought relief from scrofula (i.e., tuberculous lymphadenitis) through the king's touch, or royal touch, despite the notoriously low cure rates. This power has been transferred to physicians, and patients often feel better after a routine physical examination. Friedman (1979) stated that 85% of patients leaving a physician's office feel better even if they have not received medication or treatment, and 50% of patients in the waiting room feel better in anticipation of the help they will receive.

Touch, or “laying on of hands,” may promote healing, especially if it is imbued by the patient with a special symbolic value. Franz Mesmer (1734-1815) was among the first to emphasize the medical importance of laying on of hands. Mesmer, however, believed that there was a magnetic power in his hands, which he called “animal magnetism” and which he applied to ailing individuals. His theory was unscientific, and although he became famous for successfully treating a number of hysterical patients, he finally was discredited by a committee that included Benjamin Franklin and Antoine Lavoisier. They found his treatments to be without magnetism and essentially useless. They did agree, however, that he had helped many people and had brought about many cures. They attributed these cures to unknown factors rather than to the animal magnetism he claimed. Mesmerism was the forerunner of hypnosis, initially called “artificial somnambulism,” developed by Puységur, a disciple of Mesmer.

The magic of touch can be good medicine, especially when combined with concern, support, and reassurance. Stroking, a special kind of touching, describes a physical or symbolic recognition of a person's finer attributes. A stroke may be a kind word, a warm gesture, or a simple touch of the hand. Infants deprived of touch and stroking suffer mental and physical deterioration. Adults also require stroking to maintain a healthy emotional state. Stroking occurs when an interchange between two people leaves one or both with a good or fulfilled feeling.

Lightly touching someone's elbow for less than 3 seconds can give you up to three times the chance of getting what you want (Pease and Pease, 2004). Elbow touching works better in places where touching is not the cultural norm, such as Great Britain and Germany.

Body Language

It is said that body language is the unspoken truth. The astute physician will cultivate observational skills that enable the detection of hidden or subtle clues to diagnosis contained in the patient's nonverbal behavior. Kinesics is the study of nonverbal gestures, or body movements, and their meaning as a form of communication. However, specific gestures and their interpretation are of importance only when judged in the context of the circumstances surrounding them. Body language alone does not reveal the entire behavioral image any more than verbal language does alone. Just as one word does not make a sentence or even have much meaning without the sentence, a single gesture has clinical relevance only as part of a sequence of actions. Although they have significance, individual signs are not reliable when they stand alone; they are meaningful only when considered in the context of a person's total behavioral pattern.

When there is congruence between the verbal and nonverbal message—when the gesture conveys the same message as the spoken word—communication and its meaning are probably in agreement. When a person indicates something different from the other, however, the nonverbal message usually is more accurate. Unless body language, tone of voice, and words spoken all match, look more closely for the reason.

Attempts by the patient to mask feelings can be detected readily by observing body behavior. True feelings are more likely to leak through conscious efforts to conceal feelings. Likewise, a physician's attempt at deception will be detected by patients and can destroy confidence and damage rapport. Positive verbal communication (e.g., “You're looking better today”) accompanied by negative nonverbal cues will be interpreted by the patient as insincere. For example, a patient who is not told the true nature of a terminal illness usually knows it anyway and may distrust family, friends, and physician if they persist in the charade.

In a medical school commencement address, Alan Alda (star of TV's M*A*S*H) challenged new physicians to be able to read a patient's involuntary muscles as well as their radiographic studies. He asked, “Can you see the fear and uncertainty in my face? If I tell you where it hurts, can you hear in my voice where I ache? I show you my body, but I bring you my person. Will you tell me what you are doing and in words I can understand? Will you tell me when you don't know what to do?” (Time, May 28, 1979, p. 68). The physician will see the fear and uncertainty in the patient's face only if she or he is looking at the patient rather than the medical record. Alda's statement reflects the concern and compassion that patients desire. By using appropriate body language, the physician can convey this attention and concern in the most effective manner possible.

Mirroring

When good rapport exists between two people, each will mirror the other's movements. Some people unconsciously establish rapport with another by mirroring that person's movements or body posture (Key, 1980) (Figure 13-2). Disruptions in this mirroring may signal that one member disagrees with what the other has said or feels betrayed or insulted but cannot express this idea verbally. If the physician notices this sudden disruption of mirroring activity by the patient, more attention should be focused on the comment that led to the change of position. Renegotiation or further explanation may be indicated. A powerful way to establish rapport is to match intentionally the body language of another.

Head Position

Typically, the head is held forward in anger and back in defiance, anxiety, or fear. It is down or bowed in sadness, submissiveness, shame, or guilt. The head tilted to one side indicates interest and attention (Scheflen, 1972) (Figure 13-3); under certain circumstances, this can be a flirtation. The erect head indicates self-confidence and maturity. It is almost impossible to tilt the head in front of someone who is not trusted or of whom we are afraid.

When listening to a patient, the physician should show interest and concern by an attentive position, which is best illustrated by sitting forward in the chair with an interested, attentive facial expression and the head slightly tilted. Darwin was one of the first to notice that animals assume a head tilt when listening intently.

Face

The human face can create more than 7000 expressions using 44 muscles (Cleese, 2001); some say 10,000 expressions are possible (Ekman, 2003).

Darwin (1872) proposed that cultures throughout the world express similar emotions or states of mind with remarkably uniform body movements. His information was gathered from missionary friends working with aborigines, persons under hypnosis, infants, and patients with mental disease. He also studied blind and deaf persons who, without benefit of learning from others, were observed to raise eyebrows when surprised and shrug their shoulders to indicate helplessness.

Darwin held that the facial expression of emotion, when undisguised, is independent of culture and is identical throughout the world. The facial expressions of joy, sadness, and anger are the same in the Australian aborigine, the American farmer, and the Norwegian fisherman (Ekman, 2006). Various cultures, however, do disguise the facial expression in different ways. In American culture, the mouth is used most often to disguise feelings. A person in a social gathering may be smiling, although inwardly sad or angry. The eyebrows, eyes, and forehead are least affected by these cultural disguises and are the most consistently dependable indicators of emotion. The current popularity of Botox injections, however, may mask these expressions by showing no wrinkling of the forehead. “A 50-year-old person with no wrinkling has almost certainly had some kind of cosmetic procedure or treatment.” (Hartley and Karinch, 2010, p. 88). As Shakespeare wrote, “I saw his heart in his face” (The Winter's Tale, Act I, Scene II).

Ekman and Friesen (1975) found that the facial expressions of fear, disgust, happiness, and anger were the same in countries with widely disparate languages and cultures. They used composite facial photographs to show how each part of the face contributes to the expressions of emotion, especially surprise, fear, disgust, anger, happiness, and sadness. In American culture, when people want to disguise their true feelings and convey a more socially acceptable impression, they do so by smiling. This may be especially true in patients who are sad or depressed. Figure 13-4 is a composite showing sadness in the eyes, brow, and forehead being masked by a smile.

Smile

A genuine smile can be helpful in quickly establishing a friendly atmosphere and developing a warm, interpersonal relationship. A grin can be the physician's most effective weapon for breaking down resistance or apprehension in patients, especially children or young adults. A number of studies have shown that patients are more positively disposed to physicians who smile. The smile must be genuine, however; patients can easily spot a phony smile.

Smiles are controlled by the zygomatic major muscles that connect to the corners of the mouth and the orbicularis oculi muscles. The latter are not under conscious control and reveal a true smile that involves characteristic creases around the eyes (crow's feet). A genuine smile lights up the whole face; one that does not is more likely a deception (Ekman et al., 2005). In Figure 13-5, A, the man on the left has a broad nonenjoyment smile whereas on the right there is true enjoyment shown by the eyes. Similarly, in Figure 13-5, B, the genuine smile on the right pulls back both the mouth and the eyes. An excellent overview of facial expressions can be viewed on the DVD The Human Face by John Cleese (2001).

Eyes

The eyes are probably the principal organs of expression. They are so important to a person's appearance that when anonymity is desired, only the eyes need to be covered. The eyebrows have been shown to have 40 different positions of expression and the eyelids have 23. Consider the magnitude of possible combinations when all facial elements are involved as indicators of expression. The message conveyed by each position can be further modified by the length of a glance and its intensity.

In most cultures, good rapport is enhanced when one's gaze meets the other's 60% to 70% of the time. When we talk, we maintain eye contact about 40% of the time and 80% when listening. Ninety percent of the gaze will be in a triangular area between the eyes and the mouth (Pease and Pease, 2004). On meeting, two people will scan each other's face for about 3 seconds, then briefly gaze downward. An upward eye break may be disconcerting or convey a lack of interest (Lewis, 1989) (Figure 13-6).

The eyes can give more information for some emotions than others. Knapp (1978) found that the eyes were better than the brow, forehead, or lower face for the accurate portrayal of fear but were less accurate for anger and disgust. Even the lower eyelid alone can convey considerable information. In Figure 13-5, it is apparent that the person in B depicts more sadness than the one in A, but the pictures differ in only one respect: the lower eyelid.

It has long been known that pupils dilate when the person sees something pleasant and contract when something unpleasant is viewed. This involuntary signal can be a valuable indication of what is really going on. Asian jade dealers wore dark glasses so that no one could see their pupils dilate when they discovered an especially valuable piece of jade. Likewise, a magician doing card tricks can tell when a preselected card is seen by a subject because of the sudden pupil enlargement. In one experiment (Hess, 1975), the pupils of males dilated when the men were shown photographs of nude females and constricted for nude males. Homosexuals demonstrated the opposite. Dilated pupils also can indicate that listeners are interested, whereas constricted pupils suggest that they do not like what is being said (or viewed).

Sincerity is expressed with the eyes. The best method for conveying sincerity is frequent eye contact, a technique most appropriately used when listening to the other person. One trait of good listeners is that they constantly look at the speaker. A listener who does not maintain eye contact but continues to look down or away from the speaker may be shy, depressed, or indicating rejection of the speaker or the comments being made. One patient said, “I had one student doctor who looked at his toes instead of me. If he ever opens a practice, I don't believe I would trust him.” Conversely, speakers frequently may break eye contact when talking and are permitted a distant stare when formulating ideas and selecting phrases. However, they still should try to make frequent, although less prolonged and intense, eye contact.

A special form of human-to-human awareness is conveyed by eye contact. Prolonged eye contact, or staring, can be offensive. Monkeys can be provoked to combat by a person staring at them because it represents a threat of aggression. Under other circumstances, however, staring can be flirtatious, emphasizing that the meaning of eye behavior depends on other factors in the situation.

The acceptability of eye contact varies significantly among different cultures. In the United States, focusing the eyes on the speaker indicates respect and attention, regardless of the age of the individuals involved. However, Mexican Americans tend not to maintain as much eye contact while listening as do other Americans and may look away from the speaker more often. This is not a sign of disrespect or inattention. In Latin American countries, a younger person may be thought disrespectful if his or her eyes meet those of the adult who is speaking. A physician could be considered seductive in that culture if he or she maintained steady eye contact while talking to a patient. In the United States, it is impolite to maintain eye contact with a stranger for more than 3 seconds, but Europeans believe that longer periods of eye contact are normal. The physician needs to consider the patient's cultural background when interpreting the meaning of eye contact behavior. Looking away from the speaker from time to time may be a sign of respect and sensitivity rather than the opposite. At the same time, the physician's failure to look a patient in the eye can be dehumanizing and can cause the patient to feel more like an object than a person. Patients are most comfortable when the physician looks at them approximately 50% of the time and are uncomfortable when eye contact is avoided. Some feel that rapport is improved if a person's gaze is met 60% to 70% of the time (Kuhnke, 2007).

The frequency of eye contact also can provide clues to whether the patient is anxious or depressed. The eyes of anxious patients blink frequently or dart back and forth. They look at the interviewer as frequently as low-anxiety patients but maintain eye contact for less time on each gaze. Similarly, the patient may interpret the physician's lack of eye contact as indicative of anxiety or discomfort, even rejection.

Frequent blinking of the eyes can be a sign of pressure or stress. In a political debate between Senator Bob Dole and President Bill Clinton in 1996, Dole blinked an average of 105 times per minute, showing more pressure than Clinton's 48 times per minute.

Depressed patients maintain eye contact only one-fourth as long as nondepressed patients. Downward contraction of the mouth and a downward angling of the head are also cues to depression. As with the anxious patient, there is no difference in frequency of eye contact in the depressed patient; the difference is only in the duration of contact.

Patients with abdominal pain caused by organic disease are more likely to keep their eyes open during palpation of the abdomen than those with nonspecific pain (Gray et al., 1988). The patient with genuine abdominal tenderness may apprehensively watch the physician's hand as it approaches the tender area.

Hands

The hands will be droopy and flaccid with sadness, fidgety or grasping in anxiety, and clenched in anger. When a speaker joins her or his hands, with fingers extended and fingertips touching, it is called steepling and indicates confidence and assurance in the comments being made (Figure 13-7). It can be taken to extremes if held too high and convey arrogance instead of self-assurance (Kuhnke, 2007).

Palms usually are held in the palm-in position. Turning the palms outward can be a subtle courting behavior (usually used by women), but it more likely indicates a warm and friendly greeting (Davis, 1975).

The hands of an anxious patient can be observed to shake when holding a pen, to twitch, or to be braced unnaturally. The white-knuckle pose of tightly locked fingers can be an effort to mask anxiety.

Hands can be a subtle indicator of the urge to interrupt. Be alert for this sign in a patient so that important infor­mation will not be suppressed, and the patient can be given every opportunity to supply valuable information. Indications of this urge to interrupt are a slight raising of the hand or perhaps the index finger only, pulling at the earlobe, or raising the index finger to the lips. The latter gesture also may indicate an attempt to suppress a comment and should alert the physician to inquire further and elicit the hidden information. A patient listening in “The Thinker” position, with the index finger across the lips or extended along the cheek, or one sitting with elbows on the table and hands clenched in front of the mouth, although listening intently, may not believe or understand the physician's words (Figure 13-8). The physician should take additional time to amplify the issue or explain the diagnosis or treatment regimen further.

Arms

Although folded arms are found in all cultures, this is considered a discovered action rather than an inborn trait because it is a natural position of comfort that is as easily discovered by the African tribesman as the New York banker. It is the subtle ways in which the arms are held that can give clues to underlying emotions. Crossed arms can be a defensive posture, indicating disagreement with another's view, or it can be a sign of insecurity. It can also be nothing more than a position of comfort and should, as with all other signs, be considered in the context of the individual's total behavior.

Notice the manner in which the arms are crossed. Are they relaxed in the normal position of comfort, or are they in a self-hugging posture, reflecting insecurity or sadness and indicating a need for reassurance? Anger can be seen in clenched fists that are held tightly against the body in a holding-back manner, preventing them from hitting (Figure 13-9). If the patient has assumed a position of resistance or defensiveness, sitting with arms and legs crossed and perhaps with body turned away, search for the reason for this defensiveness and try to eliminate it. Perhaps a recommendation that the patient stop smoking is threatening and difficult to accept. In that case, it is important to make an additional effort to explain the rationale for the recommendation; do not hurry over it with a brief comment or admonition.

Men who are under stress will often cross their hands in front of them as if protecting their genitals, called the fig-leaf position or “protecting the precious.” Women may cross arms over their abdomen referred to as “egg protecting” (Hartley and Karinch, 2010).

Legs

Although crossing the legs is a common position of comfort, it can also indicate a shutting out of or protection against the outside world. If crossed legs in a patient confirm the total kinesic picture of resistance, including crossed arms and other signals discussed earlier (Figure 13-10), make every effort to identify the reason for the resistance and correct it before proceeding further. Likewise, locked ankles can indicate defensiveness. Diagnostic information obtained from a resistant patient is likely to be incomplete, and instructions are unlikely to be followed.

When seated, a person's legs are pointed in the direction of interest and if disinterested will point away. Similarly, when legs are crossed, the upper knee dictates the direction of interest.

Notice the position of the feet and their movement. As with fidgety hand movements, anxiety is associated with the fidgety, constantly moving foot. An anxious or scared person may sit forward in the chair with feet placed in the ready-to-run position, with one foot in front of the other. The angry person is more likely to place the feet widely apart in a position of stability, whereas the feet of a sad person tend to move in a slow, circular pattern.

Nose Rub

Another component of the respiratory avoidance response is the nose rub (Figure 13-11). This involves a light or subtle rub of the nose with the index finger and signals rejection of a statement being made by the subject or by another individual. The nose rub to relieve an itch is usually vigorous and involves a repeated series of rubs, whereas that of the respiratory avoidance response is soft and consists of one or two light strokes, often involving nothing more than a light flick of the nose. Morris (1977, p. 111) described the nose flick as “a reflection of the fact that a split is being forced between inner thoughts and outward action.” It can be associated with lying or with the struggle to appear calm while suppressing anger or discomfort. During Bill Clinton's testimony to the grand jury regarding his affair with Monica Lewinsky, he rarely touched his nose when telling the truth, but when he lied he gave a split-second frown, then touched his nose. During the testimony he touched it 26 times (Pease and Pease, 2004). Variations of the nose rub include pulling at the earlobe, scratching the side of the neck or rubbing one eye. Someone aware of the nose rub will often notice it in themselves and realize they are uncomfortable with what is being said by themselves or others. Watching for this during interviews on television may indicate the person being interviewed is uncomfortable with the question, or the person asking may realize it is a “testy” point.

This sign can be quite useful in patient interviewing. For example, the physician may ask a patient, “How are things at home?” The patient may answer, “Fine,” but then clears his or her throat and lightly rubs the nose with the index finger. He or she is actually saying, “I don't like what you are asking me,” or “I feel uncomfortable with my answer; things really aren't going very well at home.” If there is a cause to pursue the issue further, a simple comment such as “Really?” or “You mean not even an occasional argument?” may lead to a flood of information masked by the previous response.

Neurolinguistic Programming

Neurolinguistic programming (NLP) involves the eye movements performed while thinking and depends on whether a person is thinking visually, aurally, or kinesthetically. A right-handed person who is visually oriented will look up and to his or her left when recalling something visually, but up and to the right if creating something visually or, in other words, making it up or lying. Similarly, a right-handed person will look sideways to his or her left when recalling sounds and sideways to the right when imagining sounds (Ritch, 2004). A person who is looking up and to his or her right (i.e., your left) probably is imagining things he or she has never seen before. This technique is used by police investigators when interviewing suspects. A left-handed person will respond in opposite directions (Brooks, 1989; Zellmann, 2004) (Figure 13-12).

Detecting Lying

In addition to looking up and to the right to create an image or a fact, a person who is lying is also likely to do the following:

The liar will also rarely touch the other person or point a finger at them or others, and the story will not include negative details (Lieberman, 1998). The liar is not comfortable with silence and may speak more than normal to convince the other. Persons suspected of lying should be encouraged to talk because verbal and nonverbal clues will then be easier to detect (Vrij, 2005). Liars are also likely to slouch, unlike a confident person, who will sit upright. Remember that it takes a combination of verbal and nonverbal clues to detect lying, and no single action is likely to be dependable other than to raise doubt or suspicion.

Proxemics: Spatial Factors

Proxemics is the study of how people unconsciously structure the space around them. This structuring varies with every culture. North Americans, for example, maintain a protective “body bubble” of space about 2 feet in diameter around them when they interact with strangers or casual acquaintances. Violators of that space are considered intruders and cause the person to become defensive (Figure 13-13). In the Middle East, no such bubble exists, and it is proper to invade this area. In fact, not to do so may be interpreted as unfriendly and aloof. Arabs prefer to stand close enough to touch and smell the other person. Americans, however, if forced to stand close together, as on a crowded subway, will use their eyes (i.e., distant gaze) to maintain a more proper distance. An arm's length is a good measure of the appropriate personal distance for most people. A wife can stand inside her husband's bubble, but she will be unhappy if another woman invades this sphere of privacy, and vice versa.

Robert Frost said, “Good fences make good neighbors.” In suburbs and small towns, people are more likely to talk to each other while in their backyards if a fence indicates the boundary than if there is a communal yard (McCaskey, 1979). Marking the boundary helps maintain territoriality and actually brings the neighbors closer together than when there is no fence.

Intimate space has been classified as that ranging from close physical contact to 18 inches, personal space from 18 inches to 4 feet, social space from 4 feet to 12 feet, and public space from 12 feet and beyond (Lambert, 2008). Placing a desk between two people shifts personal space to social space. The office desk also can be a barrier to communication when it is placed between the physician and patient, thereby emphasizing the illusion of the physician's importance and power. There may be occasions when this is desired, but it usually is not necessary in a family physician's office. Office furniture should be arranged so that a minimum number of obstacles lie between physician and patient.

Automobiles magnify the size of one's personal space up to 10 times. Compare the relationship of two people having a conversation with that of “road rage” when one invades the other's space by cutting in front of them.

Hidden or Masked Communication and Patients' Expectations

Although the average person has a symptom about every 6 days, he or she visits a physician only once every 4 months. Some people visit a physician much more frequently than others for the same symptom. The group who visits more frequently tends to have a higher level of anxiety, fear, grief, or frustration. It is the physician's responsibility to search for, identify, and treat organic disease if it is present, but in about one half of cases, none will be found. It is equally important to identify the reason for these visits—the basis for the heightened concern or increased anxiety. A person may see a minor symptom as a potential catastrophe if she or he thinks it may be a sign of cancer similar to that causing a parent's death. Is the patient really there “just for a blood pressure check,” or because of concern about the condition of his or her coronary arteries since a friend recently had an acute myocardial infarction? If the physician deals only with the symptoms, the real concerns may go undetected, and the result will be a dissatisfied and noncompliant patient.

Barsky (1981, p. 492) cautioned, “Patients who express dissatisfaction with their medical care should be questioned about this, as they may be dissatisfied because their real motivation in seeking care has not been illuminated.” He also advised the physician to investigate the patient's current life stresses when visits are made if there is no change in clinical status.

Patients may come to a physician because of what they imagine is causing their symptoms rather than because of the symptoms themselves. Identifying what patients hope can be done for them—focusing on their expectations for the visit—often reveals hidden reasons for the visit. The physician should be sure to address the patient's expectations and make certain that the interpretation is correct. Rapport and satisfaction will be enhanced if the physician identifies and satisfies the patient's expectations for the visit. Dissatisfaction results when these expectations go unmet.

Listening Well

A good family physician must be a good listener. Of all the communication skills essential to rapport, the ability to listen well is probably the most important. All the information in the world about body language, vocal messages, and nonverbal cues is of limited value unless it helps the family physician be a better listener.

As Lown (1996) states, “In the brief time available to take a history, the aim is to obtain, in addition to essential facts, insight into the human being. This seems easy, but listening is the most complex and difficult of all the tools in a doctor's repertory. One must be an active listener to hear an unspoken problem” (p. 10). The appearance of readiness to listen is aided by bending forward and maintaining eye contact. The physician can discourage a patient from talking by looking away or writing in the medical record. Well-chosen questions can be rendered useless by inappropriate nonverbal behavior. Even great questions are of no value if you do not know how to listen.

For many people, the opposite of talking is not “listening” but rather “waiting to talk.” It is impossible to listen attentively when you are planning what to say next. Besides, learning to listen is more difficult than learning to ask good questions (Dimitrius and Mazzarella, 1999).

The average listening efficiency of most people is only 25% because we do not concentrate on what is being said. Effective listening requires focus on what is being said and on voice tone, facial expression, and body movements. Hearing what someone says and truly listening to what they are saying is quite different (Zellmann, 2004).

Analyses of physician-patient interviews reveal that, on average, the physician rather than the patient does most of the talking, although when questioned, physicians usually imagine the reverse. In general, the less the physician says during an interview, the more the patient will say.

Boredom is one of the most difficult states to conceal. It is very difficult to appear attentive and interested if you are bored, and it takes considerable effort to appear interested (Dimitrius and Mazzarella, 1999).

Silence

Silence can be as effective a means of eliciting further information as direct questions. The timing is important, however, and silence should be used as a technique only when the physician is relatively certain that there is more information to follow the last statement. A shift of position or a nod and a smile, properly timed and coupled with silence, can be more effective than an encouraging comment. Nonverbal encouragement to continue is less distracting and may be more facilitative than the verbal form.

Attorneys use silence in the courtroom to get witnesses to say more than they had intended. They wait silently as if the witness has not given a complete answer, and usually they do receive additional information. Silence can be effective as long as the patient feels more inclined to fill the void than the physician. This is of value, however, only when there is more information to be obtained. It is said that Charles DeGaulle thought that silence was the ultimate power tool, and in his speeches, he gained control by looking at the audience, never breaking eye contact, and saying nothing.

Interruption

The patient may be following a line of thought and may be about to open up more but must stop and refocus if the physician captures the patient's attention with a question. The physician should interrupt a patient's statement only if it is necessary to change the conversation to a new topic, clarify an issue, elicit information not produced spontaneously, offer reassurance, or reduce patient anxiety.

Physicians usually use closed-ended questions to interrupt the patient and thereby inappropriately control the interview. Beckman and Frankel (1984) found that 69% of patients (52 of 74) had only 18 seconds to complete their initial complaint before being interrupted by their physician. This usually occurred after the patient stated only a single concern, and it effectively halted the further flow of information from the patient. This prematurely terminates opportunities for patients to present their primary concerns. Only one of the 52 patients subsequently returned to and completed the opening statement. In these recorded office interviews, only 23% of the patients were permitted to complete their list of problems uninterrupted; when they were, the complete statements usually took less than 60 seconds, and none required more than 2.5 minutes.

Humor

The art of medicine consists of amusing the patient while nature cures the disease.

—VOLTAIRE

Humor can be helpful in establishing rapport and can strengthen the physician-patient relationship. It can be used to “break the ice” and is most useful if it communicates the feeling that “we are all in this together.” Humor is an effective way for physicians to appear human while supporting and empathizing with their patients. Physicians who score high in empathy also tend to have a good sense of humor (Hampes, 2001). Empathic humor can promote a stronger physician-patient relationship and enhance the effectiveness of other, more traditional as well as nontraditional forms of therapy (Berger et al., 2004).

Care must be taken, however, because humor can be a two-edged sword that can cut either way if used inappropriately. The least risk is when the humor is self-deprecating or focused on neutral topics such as the weather or parking. It can even alienate the patient if they feel the joking around is inappropriate at the very time they want serious attention paid to their problem.

More research is needed on the value of humor in medicine so that we will know when and how to use it effectively. Norman Cousins, former editor of the Saturday Review, had ankylosing spondylitis. He received 3 hours of pain relief after watching comedy videotapes of The Three Stooges and Abbott and Costello but obtained only one-half hour of pain relief from an oral analgesic. Some physicians write prescriptions for patients to laugh out loud three times each day. In India, more than 600 Laughter Clubs convene for 15 to 20 minutes at the beginning of each day to laugh out loud. Even a fake laugh makes one feel better throughout the day. Laughter boosts the immune system and even forced laughter leads to a good feeling and relieves stress and anger (Cleese, 2001).

Physicians who express interest in patient opinions and who use humor more often are sued less often. Tasteful humor can reduce anxiety and create a bond of friendship, but humor used inappropriately can magnify the distance between patient and physician, especially if it belittles the patient.

See eAppendix 13-1 online for interviewing effectively (including facilitating techniques) and eAppendix 13-2 for care with caring.