By Eileen S. Lenson, MSW, ACSW, BCC
Posted on September 5, 2021
Welcome to Q&A Today, a column designed to answer your questions regarding challenges and concerns in everyday life, from family to coping with current events. A popular topic today revolves around the coronavirus. All questions are fair game. Just send me an email with your questions or concerns, and watch for the answer in upcoming editions of the Tasmanian Times. Q&A Today is published on the first and third Sundays of the month. If your question is printed, only your first name will appear in this column.
Q: I am an internist in a busy urban practice. A large part of my job satisfaction comes from the trusting relationship I have established with my patients.
Last week an elderly patient I have known for years came in for her annual check-up. Only after she left did I learn that my patient had informed my front office receptionist that she was struggling with depression. My patient never mentioned this serious matter to me during her appointment.
The practice of medicine is changing and I can see it is affecting my work, and not in a good way. I’m spending more time sitting behind a computer monitor during patient appointments, documenting information with less opportunity to have face-to-face contact with my patients. The result is I’m probably missing the ability to pick up nonverbal cues from my patients, such as the one I just mentioned. To make matters worse, my daily patient load is packed with nonstop back-to-back appointments. Do you have any suggestions for me? – GWT, MD
A: The medical field is rapidly changing. Fortunately you are aware of the barrier computer screens can impose on your personal connection with patients. When that connection is lost, openness, honesty and transparency, which are vital to a healthy patient-physician relationship, can be lost. When patients withhold information from their physician, knowingly or unknowingly, the ramifications can be disastrous, even life-threatening.
There are ways to work within the burdens of time constraints and computer screens. Observing and understanding verbal as well as nonverbal communication from your patients will help you be more capable of understanding your patients’ feelings and help them feel understood and supported – all of which will enhance your ability to provide optimal medical care and positive outcomes for your patients.
Conscious and unconscious nonverbal changes in your patient’s body movements can indicate discomfort, fear, anxiety or anger resulting from part of your examination. On the other hand, patients who sit in your office with open palms, a relaxed posture and lean towards you when you speak are a few indicators of positive body language. These nonverbal behaviours occur in real time, can change quickly and even be barely noticeable. Training yourself to look for and recognize these behavioural changes will afford you the option to further explore your patients’ stated and unstated concerns.
Understanding what you’re seeing can help you to more effectively enhance trust and honesty in your physician-patient relationship. Below, starting at the top of the body and working downwards are a few examples of non-verbal behaviours your patients may exhibit in your office.
Head: Heads don’t stay put for long, which means your patients are consistently emitting subconscious information about their stress and compliance level. A patient sitting in your office with a slightly tilted head is interested, comfortable. But if that same head is tilted back, it may be a sign of defensiveness or uncertainty. If the head dissolves into the shoulders like a turtle into its shell, your patient may be experiencing discomfort or trying to avoid hearing what you have to say.
Nods carry a vast amount of meaning. Heads that nod slowly while you’re talking likely convey interest or at least cautious agreement in what you’re saying. A patient’s fast nodding head is less clear, signalling either full agreement or impatiently wanting you to be done talking.
Face: We grow up teaching our faces to mask our true feelings. To an extent this is beneficial. It would not be good for business if the dentists’ distain for her patient’s oral hygiene showed on her face. Nor would it be helpful for a son-in-law to show his true feelings to his mother-in-law about her excessive spontaneous dinner-time visits. While we attempt to develop a poker face and present our face as a mask, we cannot conceal all of our honest feelings.
When you share distressful information your patient may purse his lips. Your patient may also purse his lips as an indicator of deep thinking, or it may be a subconscious effort to hold back words from being spoken. In some cases it may reflect disagreement, resentment or worry. These varied reactions indicate the value in probing the patient’s feelings or concerns when you see these reactions.
Another area of communication is rubbing of the eyes, forehead or cheek. Body language experts view this behaviour as an attempt to block oneself from information or thoughts. If the nose becomes crinkled, even momentarily, the patient is likely expressing distaste for what has been said immediately prior to the behaviour being exhibited. The nose and chin typically work as a team, conveying confidence when held high, and a lack of confidence when lowered.
We can’t very well leave our discussion about the face without commenting on what is frequently referred to as the ‘windows to the soul’ – the eyes. Blinking is normal, but excessive blinking may reflect feelings of upset or anxiety.
Neck: A behaviour that physicians may observe in the office is patients touching their necks. Our neck is a vulnerable part of our body, and we instinctively want to protect it, if not from an axe-wielding predator then from the attack of bad medical news. Nervous patients will unknowingly touch their necks or fiddle around with their necklace or collar as a self-comforting measure. It is possible that they are responding to something that was said or done that made them feel threatened, and neck touching reduces feelings of tension.
Hands: When nervous or excited, many people absentmindedly rub the inside of their palms. This is another self-comforting behaviour and an indicator that an immediately preceding event or comment created anxiety.
Torso: Our torso contains vital organs that sustain life, and as such we are hard wired to protect it. When threatened by the words another has spoken, people will often put up barriers. A woman may move her purse onto her lap, providing a protective barrier.
Legs: Joe Navaro, a former FBI agent, and author of the book What Every Body Is Saying, once told me that legs are a lot more honest than our faces in conveying emotions, and that if poker tables had clear table tops the movement of player’s legs would provide truthful information, influencing bets. For instance, people tend to turn their bodies towards the person with whom they are speaking because they know they should, but their legs may not follow. Their legs might be turned at an angle, indicating they secretly wish to be elsewhere. Crossing legs towards you indicates interest, whereas the opposite reflects a patient who wants to be elsewhere, or is rejecting what you are saying, or was dealt bad cards.
Legs can also communicate a sense of security. Our legs are hard wired to protect us from danger. When standing, two legs planted firmly on the ground provide security by enabling the person to flee quickly if need be. Standing with one leg bent and crossed over the other inhibits a quick escape. The person assuming this relaxed position is conveying feelings of confidence.
It is quite satisfying to know that even small behavioural changes can do so much. Patients often interpret physicians who sit rather than stand to show more interest and to have spent more time with them. Remember to make eye contact while you are multitasking, focusing on the computer, patient’s chart or medical equipment. When that isn’t possible, nodding when they speak conveys empathy and validates that their message has been heard. This helps them feel respected and heard, which will increase the likelihood of your patients taking a risk and sharing information they would otherwise be hesitant to disclose.
I’ve pointed out only a few of the many valuable non-verbal signals that represent attitudes and emotions that may take place in your office. Understanding non-verbal cues you’re sending, along with observing those you are receiving, will aide you in obtaining meaningful information and reduce those times when you’ve felt blindsided after a patient’s appointment. You’ll find yourself to be more capable of understanding your patient’s true thoughts and feelings and able to help them feel understood and satisfied – all which will enhance your ability to deliver optimal medical care for your patients.
– Best wishes, Eileen
Eileen S. Lenson, MSW, ACSW, BCC is author of Overcoming Adversity: Conquering Life’s Challenges, by Australian Academic Press. Eileen is a life and business coach and public speaker residing in the United States. She has spent her professional career working in medical and psychiatric hospitals and in her private practice, counselling people experiencing emotionally traumatic events.
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