Nonverbal Interpersonal Interactions in Clinical Encounters and Patient Perceptions of Empathy

Enid Montague; Ping-yu Chen; Jie Xu; Betty Chewning; Bruce Barrett


J Participat Med. 2013;5 

In This Article

Abstract and Introduction


Objective: The relationship between nonverbal behaviors and patient perceptions of clinicians has been underexplored. The aim of this study was to understand the relationship between nonverbal communication behaviors (eye contact and social touch) to patient assessments of clinician (empathy, connectedness, and liking).

Methods: Hypotheses were tested including clinician and patient nonverbal behaviors (eye contact, social touch) were coded temporally in 110 videotaped clinical encounters. Patient participants completed questionnaires to measure their perception of clinician empathy, connectedness with clinician, and how much they liked their clinician,

Results: Length of visit and eye contact between clinician and patient were positively related to the patient's assessment of the clinician's empathy. Eye contact was significantly related to patient perceptions of clinician attributes, such as connectedness and liking. Conclusion: Eye contact and social touch were significantly related to patient perceptions of clinician empathy. Future research in this area is warranted, particular with regards to health information technology and clinical system design.

Practice Implications: Clinical environments designed for patient and clinician interaction should be designed to facilitate positive nonverbal interactions such as eye contact and social touch. Specifically, health information technology should not restrict clinicians' ability to make eye contact with their patients.


The clinician-patient relationship has evolved from an autocratic relationship to a partnership between patient and clinician.[1–4] Training in teamwork might promote strategies for positive communication, such as adaptation to stress, group decision making, and coordinated task performance.[5] Communication plays an important role in each phase of teamwork; therefore, factors that affect clinician-patient communication and teamwork should be investigated in depth.[6]

Clinician-Patient Relationships

The relationship between clinician and patient in the clinical encounter is a fundamental aspect of the health care system.[7] Previous studies have indicated that there is a lack of high-quality research and evaluation regarding consultation dynamics.[8–10]

One metric of assessing the quality of the clinician-patient relationship is patient satisfaction.[11] Patient satisfaction is related to the clinician-patient relationship,[12] the quality of health care,[13] and adherence to medical treatment.[14] While many dimensions may contribute to patient satisfaction such as waiting time, hospital location, care delivery, and communication skills,[15 16] the quality of communication with clinicians can influence patient perceptions of their clinicians and the quality of care they are receiving. One report has suggested that 85% of patients changed or were considering changing their physician due to poor communication skills.[17]

Empathy, as it applies to clinicians, is defined as the socio-emotional competence of a physician to be able to understand the patient's situation (perspective, beliefs, and experiences), to communicate that understanding and check its accuracy, and to act on that understanding with the patient in a therapeutic way.[9 18 19] Empathy may be a core component of the medical relationship and has been linked to other important interpersonal interaction variables such as patient trust and satisfaction.[7] Health systems researchers have made connections between empathy and other outcomes, such as enhanced adherence, patient satisfaction, patient enablement, and information exchange.[20–4] Studies have illustrated the importance of these outcomes to patient assessments of their clinician's empathy.[24] Developing empathy is key to building a solid base for the clinician-patient relationship. Empathy has been investigated in clinical encounters,[25–27] but there is very little evidence that links empathy, satisfaction, and nonverbal behavior to health encounter outcomes. Investigating these linkages is important since such social processes and outcomes may relate to the effectiveness of clinical encounters regarding behavior changes. For example, emotional rapport may influence the effectiveness of behavior change counseling for overweight and obese patients.[28] The study described in this manuscript explores nonverbal interactions in the clinical encounter in relation to patient perceptions of the clinician's empathy.

Nonverbal Behavior in Clinician-patient Interaction

Nonverbal communication is defined as the aspect of communication that information is exchanged through nonverbal cues which are not purely linguistic in content,[29] such as gesture, touch, posture, facial expression, eye contact, clothing and hairstyle.[30] Investigating the clinician-patient relationship, there were significant amount of research focused on verbal communication between clinician and patient.[31 32] On the contrary, nonverbal behavior among clinician-patient relationship has been less studied.[30] Many studies focus on how the clinician's nonverbal behavior affects the patient's perspective, such as patient satisfaction.[6] However, there is a growing awareness of the value of nonverbal communication; more and more studies have focused on quantitatively evaluating nonverbal behavior. Coding systems for nonverbal interaction have been developed, such as Nonverbal Communication in Doctor-Elderly Patient Transactions (NDEPT),[33] Nonverbal Accommodation Analysis System (NAAS),[34] Relational Communication Scale for Observational Measurement (RCS-O),[35] and some instruments used in studies of the effects of physician gender on nonverbal behavior.[36] Developing validated methods and reliable analysis tools are still needed to evaluate nonverbal communication in clinician-patient relationship.[37]

Eye gaze is a particular point of interest in nonverbal cues related to understanding trust, empathy, and rapport. The role of directed gaze in clinician-patient interaction has been explored in previous studies. In one study 34 patient-physician visits at a family medical center were videotaped; after the session all patients completed a survey about their satisfaction with the clinician. Each tape was reviewed at 40-second intervals and coded for nonverbal behaviors. The results suggested that the clinician's gazing at the patient was not significantly related to the patient's satisfaction.[38] In addition, studies have explored eye contact with computers in clinical encounters. Margalit and colleagues[39] found that computers affected communication patterns between patients and clinicians, and they recommended using caution regarding the implementation of technologies in clinical encounters. In another study, Harrigan and colleagues[40] conducted an empirical study of 36 videotaped family medicine residents' interviews with patients. Nonverbal behavior was coded using a coding system, and each video was rated for rapport and connection between clinician and patient. Eye contact between the clinician and the patient significantly related to patient ratings of rapport and satisfaction.

Touch is another nonverbal interaction that is important for the development of empathy. For example, clinicians sometimes touch their patients to express caring and empathy.[41] Generally, there are two different types (see Table 1) of touch in the consultation: physical touch and therapeutic touch.[42] Others have described these types of touch as diagnostic touch and healing touch.][43] Although they have different names, the action and purpose of the touch are the same. In this study, task touch and social touch are used to distinguish the two forms of touch. Task touch is touch that has a clinical purpose, such as a clinician's touch during an examination, and social touch has specific social meaning, such as a handshake.

Table 1.

Type of Touch [a]

Goals and Hypotheses

The goal of this study was to explore the relationship between nonverbal behaviors and patient perceptions of clinician empathy in clinical encounters. The following three hypotheses were proposed:

  • HI: Eye contact between clinician and patient during the health encounter will be positively related to the patient's perception of the clinician's empathy.

  • HII: Social touch will be positively related to the patient's assessment of the care provider and to perception of the clinician's empathy.

  • HIII: Eye contact between clinician and patient will be positively related to patient ratings of liking and connectedness.