Non-verbal clues guide doctor-patient relationships and clinical judgments, U-M study finds

Stephen G. Henry, M.D., lead study author, research fellow at the VA Ann Arbor Healthcare System and the U-M Medical School's Department of Internal Medicine

Some doctors are more conscious than others of the messages they tacitly send.

Most physicians intuitively understand that they exchange subtle and unspoken clues with patients in the exam room through body language, eye contact, physical appearance, and tone of voice. However, such clues are difficult to observe and evaluate. A new study by researchers at the University of Michigan Health System sought to help elucidate signals sent and received on both sides of the examination table by analyzing video recordings of routine checkups and conducting follow-up interviews with participants.

The method shows promise for improving medical decision making by allowing doctors to better understand how they make judgments and what messages they may be unwittingly conveying to or receiving from patients, says lead author Stephen G. Henry, M.D.,lead author Stephen G. Henry, M.D., a research fellow at the VA Ann Arbor Healthcare System and the U-M Medical School's Department of Internal Medicine. The results were recently published in the Journal of Evaluation in Clinical Practice.

"Our findings show that both doctors and patients identified tacit clues involving the behavior or appearance of the other, but they were not always able to articulate precisely how these clues informed their medical judgments and assessments," Henry says.

"Not surprisingly, patients and doctors discussed these clues very differently," he adds, noting that the study is exploratory and did not examine whether the clues led to better or worse judgments. It is hoped future research will help show how such clues can affect care and medical judgments.

One important study finding was that some physicians appeared to be far more conscious than others of the non-verbal messages they send to patients, says Henry. Just five of the 18 southeast Michigan doctors who participated in the study contributed 64 percent of all the comments, which were given while reviewing a recording of the interaction.

One physician was particularly attuned to how non-verbal communication spoke to patients, the authors note. "I use my body a lot," the doctor reported. "It's nice to see that I don't look rushed in the room. Although in my mind, I'm whirling. Okay, so I sit down, I try to relax and look relaxed."

Physicians also reported using these tacit clues to aid in diagnosing a patient, says Henry, a researcher in U-M's Robert Wood Johnson Foundation Clinical Scholars program. They discussed observing the patient in a general way for signs that they might be depressed or that they were not revealing the whole of their concerns. "It's mostly looking at the patient. Do they
look healthy?" one doctor said.

Another doctor noted this ability to put together the puzzle pieces of a patient's verbal and non-verbal communication becomes intuitive: "How do you know what Aunt Martha looks like? Because you know what she looks like, you've seen her lots of times. I can't detail as to why I know that, but I've been down the road long enough to know."

The way a patient comports himself may give a physician clues as to whether nonspecific symptoms like weight gain, fatigue and high blood pressure are signals of depression - or whether something else may be responsible, such as Cushing syndrome, which may indicate an adrenal tumor, the authors note.

Patients in the study, on the other hand, were mainly concerned with clues that indicated their place within the doctor-patient relationship: Did the doctor make the patient feel comfortable? Did the doctor seem like she was in a hurry? Did she put the patient at ease? Was the doctor a good listener? Did he make eye contact? While doctors and patients keyed in on particular tacit clues in many of the examinations, sometimes they were unsure of precisely how they arrived at an opinion.

"Our findings are consistent with research from the social sciences suggesting that doctors' and patients' judgments in the examining room are often complicated and take into account many subtle, unspoken clues," says senior author Michael Fetters, M.D., M.P.H., M.A., associate professor of family medicine at the U-M Medical School. "In the future, we hope this method of recording and reviewing these types of interactions can inform interventions designed to improve medical decision making and doctor-patient interaction by providing a more complete understanding of the kind of signals upon which doctors and patients rely."

Additional Author: Jane H. Forman, Sc.D., M.H.S., of VAAAHS

Funding: The research was supported by the U.S. Department of Veterans Affairs and the Robert Wood Johnson Foundation.

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Citation: "'How do you know what Aunt Martha looks like?' A video elicitation study exploring tacit clues in doctor-patient interactions," Journal of Evaluation in Clinical Practice, DOI: 10.1111/j.1365-2753.2010.01628.x