Non-Verbal Communication

Interpersonal Communication And Relationship Enhancement (I*CARE)
Communications Skills - Basic Principles
Non Verbal Communication
Time: 22:52

Robert A. Buckman, M.D., Ph.D.
Adjunct professor, Behavioral Science
The University of Texas M. D. Anderson Cancer Center

Dr. Buckman:
This part of the I*CARE Web site is rather unusual. We're going to offer you some relatively straightforward and practical guidelines for helping with something that we all know about but we don't often talk about, namely non-verbal communication. There are signals we may be sending to our patients, but we're not saying anything and often without even realizing that we are doing it. Now, why is this important? It's important because studies show that really seriously about 60 percent of the information we transmit in our communications with patients involves non-verbal aspects of communication.

So if we don't pay attention to those non-verbal messages, the tone of voice and the body language that this type of communication is transmitting to our patients, we may for example be sending them contradictory messages. For example, even if we are listening to our patients but we've actually got our arms folded, we might be telling them that actually we are closed to what they have to say. So those behaviors actually can be a code for our own attitudes and emotions. And we're going to see there are a few really simple tips and techniques that you can use which really do help that interaction and help you send the right message. And just in case you are feeling skeptical, I promise, this section is not going to be fringy or mystical or woo woo or mysterious.

What we'll be talking about are straightforward practical things, things that you can do as I do everyday in a busy clinical practice. Now, in many respects, non-verbal communication and body language, they are no more mysterious than any set of socialized rules. As for example table manners, that's a good example.

Without fully realizing it, when you're having a meal with someone who eats like this, subconsciously you get an impression of a normal orderly person that is very different for example from a situation like this. Now, of course, that's to say first but subconsciously without realizing it, you get a very different impression. Actually, you might be so distracted by the open mouth chewing and the waving of the taco and the spray of food particles that you can't listen with your full attention to what they are actually saying.

As with table manners, it's the same with our non-verbal communication. Without realizing when you do something like this, inadvertently you might be creating an impression which is actually the equivalent of this.

Actually that isn't just a theory. That is a proven observation. There are studies that show that patients are somewhat put off when the doctor doesn't look up from the chart when the patient comes in.

Now, that doctor there did a lot of things wrong, waved the patient in, barely acknowledged them. He kept on talking on the phone, didn't close the computer. All of those things will be perceived negatively by anyone and most certainly by our patients.

So next, let's have a look at just some of a few of the positive things that you can incorporate into your normal operating procedure, as it were, to optimize the interview even before you actually start talking.

First of all, stop what you're doing. Whatever you're doing, stop it and greet the patient. Perhaps the most important tip of all is that first impressions really count. As the old saying goes, you never have a second chance to make a first impression. So that initial contact with the patient, especially that crucial first time that you meet them, may make a genuinely lasting impression. In fact, there are specialized neurons in the brain. They are called mirror neurons, which actually help us interpret the intentions, the intentionality of the other person so that what we do at the beginning of the interview really helps to get a start in developing trust and rapport with the patient. And of course, trust and rapport are the cornerstones, the foundation of our relationship with our patient, particularly true in oncology. Because as we all know, our patients may be very anxious about the information they're getting and they're sometimes very observant, not to say hypercritical about our behavior.

So it really helps. It really helps when you greet the patient in a friendly manner and if it is culturally acceptable, shake hands. If you haven't met the patient before, introduce yourself properly. Make sure that they know who the others in the room are and very briefly just say who you are and very simply what you do. "I'm a medical oncologist," whatever it is.

Then, then sit down and get your eyes on the same level as the patient. That tells the patient that you are ready to listen and give your full attention to them for all important interviews. Therefore rule 1, sit down, and get your eyes on the same level as the other person. It seems terribly simple, it is. But it makes a huge difference.

I mean, seriously, just imagine for a moment how you would feel if you were the patient and the doctor was towering over you, 5 feet away, 4 feet above you, just a simple act of sitting down changes things considerably because maybe that's made a big difference.

There are 2 other useful tips. First, many of our interactions in the office look a bit like this with just the wide expanse of desk between the doctor and the patient. A better way is to sit across the corner of the desk. Really, imagine it makes a difference. It's less of a barrier.

Also, do make sure that you are actually closer to the patient than you are to the relative or friend. In other words, you're showing that the patient has primacy. A couple of very simple tips make a big difference. There's a tiny amount of evidence supporting that actually and showing that this actually improves the ease of communication. Rearrange the furniture, the corner of a desk, makes a difference.

And finally, the distance between you and the patient, the zone between people who don't know one another is--those socials zones --is apparently a minimum of 4 feet. But if we know a patient well and we're seeking to comfort them, this distance can shorten significantly, and of course obviously, when you're examining a patient that distance tends to decrease dramatically. If you are in a clinic or in the patient's room, make sure that there is no obstacle between you and the patient. On the ward you can, if you ask, sit on a patient's bed. Maybe it's not the best idea if there's a chair available, sure do that first. Because sitting down on the bed, psychologically you're invading the patient's space. You must ask before you sit down, otherwise you may actually cause them to be more anxious.

Also, be aware that there are some cultural rules that regulate the kind of greeting or the degree of distance between you and your patient and also to whom you principally direct the information. For example, in certain cultures and in certain religions, shaking hands with a female patient may actually be taboo. Now, here's an additional brief point, rare but important. Sometimes you've just got to hold a conversation in the hospital corridor; you're accosted by a relative or somebody very important. Of course, it's far from ideal but just occasionally it's unavoidable. And if there isn't a relative's room or a private room that you can sit down and have some privacy and it helps just to draw the person to the side of the corridor creating at least a message that you would like privacy and that you consider privacy important.

So now, as it were, we optimized the physical setting of the interaction, this--this walking in and sitting down in the right place, eyes on the same level invested in the beginning of the encounter and it just takes a few seconds and it really pays off. It gradually becomes automatic and it reaps big rewards.

Now, the important thing to see is this, can we do anything about our own non-verbal communication, our body language, and our facial expressions that will help. Well, of course the answer is yes. So here are another few simple tips. These tips also don't take up any time at all and basically you sort of get into the habit, the routine of doing these things. All that you will notice is that your interviews seem to be going a bit better and that your patients and their relatives find you more supportive and rightly so.

So, first of all try and look relaxed even if you don't feel it. No matter how long we've been in oncology practice, a lot of our interviews are emotionally laden and tough. Even if you're feeling anxious, you can still avoid sending those signals. Make a habit of sitting with your feet flat on the ground with your heels and your knees together, and then drop your shoulders down. Unless you're actually writing in the chart or something, put your hands flat on your lap. That position, as I'm doing now, is actually called a neutral body posture. It's what psychiatrists and psychotherapists have been using for decades. Now we can too. It really does help in facilitation.

On the other hand, crossing your legs or sort of hanging one leg over another, what somebody called the "open 4" may signal excessive casualness, maybe overly casual or over familiarity which may not be wanted. Then having got into your habit of sitting in a relaxed, neutral body posture, again, get into the habit of always making eye contact while the other person is talking. There are data that show that you will not be perceived as an effective listener if you are not looking at the patient, if you're looking down at the chart or at the computer screen. If you are permanently engrossed into those things, even if what you are engrossed in is actually relative to that, relevant to that particular patient, you've got to look at them for most of the time.

Now, here's something quite important. If the person you're talking to is crying, crying or very angry, at that point it is useful to break eye contact. If they are crying, move closer, touch the patient's forearm if you feel comfortable with it and offer them a Kleenex or tissue. Those simple actions are absolutely essential and are basically no more than human good skills. That's all, good people skills.

Then, don't underestimate the value of a smile. Of course, a smile is not a universal "fix it". It cannot possibly be so. It's not going to change the prognosis or the CEA level or the size of the nodes on the CT, but a smile, like good table manners, like all people skills, shows the person that you are not there to do them harm and that you want to be friendly to them. You're actually trying. And that you think that making that kind of effort is worth doing. In other words, by simply smiling, simply smiling, you are at least showing the person that you are aware of him or her as a person, as well of course as being aware of the abdominal lymph nodes or whatever it is on a CEA. It doesn't change what you are going to discuss together, but it certainly does change the way the discussion is going to go. It may even help the patient to become--to communicate more spontaneously and more accurately in what they are telling you about their concerns.

And as everybody knows nowadays, you have at least to think the smile. You can't simply bare your teeth as a snarl. There is good evidence that unless you actually think the smile, as I'm thinking now, you won't move the upper part of your face and the smile will be perceived as artificial and insincere. So, think the smile.

Okay, to summarize. We've come into the room. We've introduced ourselves, we've positioned ourselves, we've sat down eyes at the same level, we've adopted neutral body language and we've smiled. Well, maybe 5, 6 seconds into the interview, what next? Well, here's what's next.

You need to start the dialogue. What we're talking about here are things that you can do which help roll the dialogue along. The techniques, they're often called facilitation techniques. And the most useful of all facilitation techniques, the one that comes first in portraying you as an effective listener, is the simple act of listening consisting of being silent when the other person is talking so that you can concentrate on what they are saying. When they talk, you don't.

In addition, there are listening noises as well and those listening noises can help show that you are following along with what is being said. Listening noises are "uh-hmm," nodding, smiling, and repeating a word from their last sentence. But first and foremost, whether a total silence or where nodding an "uh-hmm" and acknowledging what we are not doing is talking, we are not interrupting, it's that simple. And there's, probably we all know, there is the famous Beckman and Frankel study in 1979 that showed that we doctors tend to interrupt our patients after a median time of 22 seconds. And it also showed that over 90 percent of the patients had stopped talking anyway by just over a minute. So clearly, it does require a bit of conscious effort not to talk, particularly after those first 22 seconds are up, but please make that effort.

And to do so, maybe it helps to keep your lips pressed together. I've actually trained myself to do that. Keep your lips pressed together while they're talking, and that shows the patient I'm listening, I'm not bursting to talk myself.

Meanwhile pay attention to how you are sitting while the patient talks. Seriously, data again. Frowns or folded arms or checking you're handheld, they all send the signal to the patient that you actually disagree with what they are saying or are not receptive to it. In fact, another useful hint before you go into an important interview, put your pager or your handheld on silent before you come into the room, or if you are expecting an important call, let the patient know ahead of time that you may need to interrupt the interaction for an important call.

Also, another tip and guideline lean slightly forward when the patient is making an important point. That sends a signal that you are being particularly attentive. And again, there are data to support that.

Next, the next most invaluable facilitation technique in my book anyway is the one I've mentioned already, repetition. Now, I do realize that we're moving on slightly from the non-verbal aspects of communication into the verbal ones, I mean the spoken word. But the next point is very brief. It's a footnote really, and it's part of the things that we should do all the time with all our patients. So it's really a part of the basic communication skill, a verbal technique that should really be automatic which we call, as I have said, repetition.

By repetition we simply mean repeating 1 or 2 of the keywords from the patient's last sentence in our first sentence. It really is as simple as that, 1 or 2 words from their last sentence in your first sentence. It makes a big difference to the way you are perceived as a listener and communicator. Here are a few examples of that.

Patient:
Tired?

Doctor:
Uh-hmm. Now, how bad is the tired and not feeling energetic?

Doctor:
What about energy levels, what are you actually doing during the day, James?

Patient:
Well, I don't feel sick. I guess I feel tired.

Doctor:
Tired?

Patient:
I've got 2 daughters and, you know, really I want to be--I want to dance at their weddings, you know.

Doctor:
You want to dance. I hear you clearly.

Patient:
I really do.

Doctor:
You want to dance at your daughter's--

Doctor:
How's your mood and how do you actually feel and your spirits?

Patient:
Really bad.

Doctor:
I'll just pass a Kleenex over to you.

Patient:
Thank you.

Doctor:
Tell me about really bad. Tell me what happened and why?

Patient:
There's nothing seems--nothing seems to be going right.

Doctor:
Yeah. In what way do you mean that, that nothing seems to be going right?

Patient:
It's just too stressful of a time. I know you probably hear that from all your patients. It's a bad time, but I mean it's just--

Doctor:
Tell me about stressful, what's stressful?

Patient:
Well, I'm a graduate student--

Doctor:
Yeah.

Patient:
--in civil engineering and it's just--it's a nightmare. It's so busy. There's so much reading and some new projects that have to be done. It's just--I would say it's just a really, really bad time to ask me to do that.

Dr. Buckman:
So, let's just sum up some of the important points that we've made.

For every patient encounter, remember to begin by introducing yourself if you don't already know the patient or family member.

Be seated. Sit down so that your eyes are on the patient's eye level.

Always sit nearest to the patient rather than the relative even if you have to ask people to swap seats.

Then, seat the patient across the corner of the desk. It's actually worth fiddling with the furniture and getting this right. Have them across the corner of the desk rather than across the width of the desk so there isn't a barrier.

The optimal distance between you and the patient is somewhat less than 4 feet.

Now, the best facilitation techniques are the neutral body posture that's a relaxed one, shoulders down, attentive to what is being said and attentiveness means maintaining eye contact most of the time while the other person is talking, leaning forward to emphasize the point that you are listening for important points.

Finally, these 3 things tell the other person, "I'm listening to you." Number 1, number 1, being silent and not interrupting, number 2, remember pausing attentively or nodding approval or saying "uh-hmm" is the best non-verbal facilitation technique that exists. And finally, repetition, using his or her last few words when you respond. The message that is delivered by this is, "I have been listening."

So, there you have it. Everything we've been talking about is really a matter of reflecting on and attending to a few simple behaviors. And these little things make a great big difference. For that reason, it's worth building these things into your usual habits so they become automatic. You do them even without, I mean to think about them, and in that way you are going to notice a very considerable improvement in your interactions with a relatively small amount of effort, and that is not a bad thing on difficult days.

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