Download Nonverbal Communication and Physician

23-Manusov.qxd
6/19/2006
7:54 PM
Page 437
23
NONVERBAL COMMUNICATION
AND PHYSICIAN-PATIENT
INTERACTION
Review and New Directions
Jeffrey D. Robinson
Rutgers University
O
nce considered to be an intangible aspect of “bedside manner,”
the scientific study of nonverbal communication during visits
between patients and medical physicians is now well documented.
Research suggests that physicians’ nonverbal behavior shapes participants’ visit communication (e.g., patients’ self-disclosure); ratings of
physicians’ rapport, dominance, and medical-technical skills; patients’
satisfaction with physicians; patients’ understanding and recall of visit
information; and patients’ adherence to physicians’ medical recommendations. Physicians’ nonverbal behavior is consequential in other ways
as well. For example, both the accreditation of residency programs and
the certification of physicians require assessment of physicians’ competence in “interpersonal skills,” which involve “inherently relational”
Author’s Note: The author thanks James Dillard, Jenny Mandelbaum, Valerie
Manusov, and Richard Street for comments on earlier drafts.
◆
437
23-Manusov.qxd
6/19/2006
7:54 PM
Page 438
438–––◆–––Contexts and Consequences
and “humanistic” aspects of nonverbal
and verbal communication (Duffy, Gordon,
Whelan, Cole-Kelly, & Frankel, 2004).
There is also some evidence that training
in nonverbal communication skills aids success in the American Board of Surgery’s
oral-certification exam, which is designed
primarily to test candidates’ medical-technical
skills or their “clinical reasoning, problem
solving ability, and clinical judgment”
(Rowland-Morin, Burchard, Garb, & Coe,
1991, p. 655).
This chapter begins by providing a rationale for studying nonverbal communication
between medical physicians and their
patients,1 reviews findings related to individual nonverbal behaviors or variables, and
discusses new directions for nonverbal
research. The premise of the final section is
that the social meaning of individual nonverbal behaviors—and thus their production, understanding, and effects—is shaped
fundamentally and irremediably by, and
must be studied relative to, their situation
within a variety of aspects of interactional
context. This context includes other modalities of communication (e.g., other nonverbal and verbal behaviors), as well as norms
and rules that structure the interaction itself,
such as those dealing with turn taking,
social action, and sequences of action.
♦ Rationale for Studying
Nonverbal Communication
Patients do not abide strictly by a rationalconsumer model of medicine. That is, they
seldom select and retain physicians, nor
do they evaluate physicians and their medical care or competence, based solely on
physicians’ medical-technical skills and
patients’ health outcomes (Glassman &
Glassman, 1981). Akin to organizational
communication generally (Farace, Monge,
& Russell, 1977), physicians’ and patients’
communication has at least two underlying
dimensions: medical-technical (i.e., instrumental) and affective-relational. The affective-relational dimension appears to be
particularly salient to patients. At the point
when physical medical problems drive
patients to seek professional medical help,
such problems may create uncertainty, anxiety, and feelings of fear, frustration, and
vulnerability in patients, who (1) must disclose private (and sometimes socially delicate, embarrassing, illegal, etc.) information
(e.g., sexual history, drug use) to physicians
who are relative strangers and (2) are
largely dependent on physicians, who are
relatively knowledgeable experts and legitimate brokers of treatment (Mishel, 1988).
Patients can discriminate between
medical-technical and affective-relational
dimensions of physicians’ communication
(Bensing & Dronkers, 1992) and, within the
latter set of messages, they are able to distinguish between “positive” and “negative”
nonverbal affective-relational styles, such
as those communicating “attention or concern” rather than “inattention or distance”
(Aruguete & Roberts, 2002). Whereas
patients base their evaluations of physicians’
communicative competence on both dimensions (Cegala, McNeilis, McGee, & Jonas,
1995), and although patients’ evaluations of
these dimensions are positively correlated
such that an increase in one tends to result
in an increase in the other (Ben-Sira, 1982;
Street & Buller, 1987), there is an accumulation of evidence suggesting that patients’
evaluations of the quality of physicians
and their medical care are influenced
more heavily by the affective-relational
(vs. medical-technical) dimension of physicians’ communication (Ben-Sira, 1982;
Griffith, Wilson, Langer, & Haist, 2003;
Mechanic & Meyer, 2000).
This evidence leads to the conclusion
that successful medical treatment involves
physicians’ competent management of the
23-Manusov.qxd
6/19/2006
7:54 PM
Page 439
Nonverbal Communication and Physician-Patient Interaction–––◆–––439
affective-relational dimension of communicative action. For example, practices of
interaction that address the affectiverelational dimension “positively” (e.g.,
reassurance) have been associated with
decreases in patients’ requests for postoperative narcotics (Egbert, Battit, Welch,
& Bartlett, 1964; Langer, Janis, & Wolfer,
1975) and increases in patients’ levels of
physical functioning, such as their levels of
blood glucose and diastolic blood pressure (Kaplan, Greenfield, & Ware, 1989).
Although the affective-relational dimension
of communication (including empathy and
rapport) is managed partially through verbal
behavior, such management involves nonverbal behavior primarily (Ekman & Friesen,
1969; Harrigan & Rosenthal, 1986).
The next section reviews associations
between a variety of communicative, social,
and psychological outcomes and the following nonverbal behaviors: gaze orientation,
head nodding, and body orientation (including proximity). Space prevents an exhaustive
review of all nonverbal variables, including smiling, touch, tone of voice, physical
appearance, and skill at encoding and decoding emotion (for more on the latter, see
Riggio, this volume). Given the concern in
this section of the Handbook with the implications of our work, the variables reviewed
here are relatively more “controllable” by,
and thus “teachable” to, physicians.
♦ Findings Related to Individual
Nonverbal Behaviors
PHYSICIANS’ GAZE ORIENTATION
Gaze orientation communicates one’s
current attention to, availability for, and participation with others’ actions (or lack
thereof; Goodwin, 1981; Kendon, 1990)
as well as who one is addressing when
speaking (Goodwin, 1981; Sacks, Schegloff,
& Jefferson, 1974). Research on gaze in
physician-patient interaction has focused on
its effects on both verbal communication and
visit or medical outcomes. Concerning verbal communication, Verhaak (1988) and
Bensing, Kerrsens, and van der Pasch (1995)
examined physicians’ gaze toward patients,
and Van Dulmen, Verhaak, and Bilo (1997)
examined the amount of time physicians
gazed directly at patients’ faces, and these
studies showed that physicians’ gaze orientation was associated positively with the
amount of psychosocial (rather than
somatic) information given by patients.
Along similar lines, Duggan and Parrott
(2001) found physicians’ lack of direct facial
orientation toward patients to be negatively
associated with patients’ self-disclosure (e.g.,
about life beyond symptoms). Some results
are non-intuitive and beg further investigation. For example, Van Dulmen et al.
(1997), found the amount of time that physicians gazed directly at patients’ faces
was negatively associated with the amount
of agreements given by patients and the
amount of reassurance, orientation, and
medical counseling given by physicians.
A somewhat inconsistent picture
emerges when the research focus concerns
visits or medical outcomes. For instance,
Larsen and Smith (1981) discerned that
physicians’ direct facial orientation toward
patients was negatively associated with
patients’ post-visit satisfaction with medical
care. Relatedly, Harrigan, Oxman, and
Rosenthal (1985) found physicians’ increased
and decreased mutual gaze with patients to
be negatively and positively associated with
external raters’ evaluations of physicians’
rapport, respectively.2 These research studies suggest that gaze and face orientation
toward patients may increase disclosure but
decrease patients’ satisfaction. In possible
contradiction to these findings, however,
Smith, Polis, and Hadac (1981) showed
23-Manusov.qxd
6/19/2006
7:54 PM
Page 440
440–––◆–––Contexts and Consequences
that physicians’ time spent reading patients’
medical records, which was also physicians’
time spent gazing away from patients, was
negatively associated with patients’ postvisit satisfaction and understanding of
medical information. Furthermore, Bensing
(1991) showed that physicians’ gaze toward
patients was positively associated with
external physician-raters’ evaluations of the
quality of participant-physicians’ psychosocial care.
One explanation of this possible contradiction lies in an analysis of where physicians are gazing—and what physicians are
doing—while patients are talking. For
example, Harrigan et al. (1985) also found
that, compared with low-rapport physicians,
high-rapport physicians gazed at (i.e., read)
patients’ medical records more often when
not gazing at patients, but they were more
likely to continue to gaze at patients when
patients were talking. In support of this, Giron,
Manjon-Arce, Puerto-Barber, Sanchez-Garcia,
and Gomez-Beneyto (1998) revealed that
physicians’ eye contact while patients spoke
was positively associated with physicians’
psychodiagnostic abilities.
In sum, physicians’ gaze toward (rather
than away from) patients appears to be
positively associated with patients’ giving
of psychosocial information, which may
explain the concomitant positive associations with physicians’ psychodiagnostic
abilities and patients’ positive evaluations
of at least the affective-relational dimension
of physicians’ communication. These findings are confounded by a lack of control
for what physicians and patients are doing
while gazing, however, as well as where
patients are gazing (e.g., toward or away
from physicians). A particularly salient
issue seems to be whether physicians and
patients are talking generally and, specifically, what social actions are getting accomplished through such talk (e.g., instructing
patients to sit on the examination table vs.
delivering bad medical news). The analytic
“payoff” of looking at the larger interaction, rather than discrete variables, will be
discussed later in this chapter.
PHYSICIANS’ HEAD NODDING
When people gaze at speakers, especially
when speakers are producing multi-unit
turns (e.g., when patients produce illness
narratives or when physicians explain treatments), gazers nod their head frequently,
which, at a minimum, communicates attention (Schegloff, 1982). Hall, Irish, Roter,
Ehrlich, and Miller (1994) found that, compared with male physicians, female physicians nod more overall and they nod more to
female patients. Harrigan and Rosenthal
(1983) discovered external raters’ evaluations of physicians’ nodding to be positively
associated with raters’ perceptions of physicians’ rapport. In a later study, however,
Harrigan et al. (1985) found no association
between nodding and rapport. Nodding is,
however, more commonly studied in association with other variables than as an isolated
cue, and the findings when nodding is viewed
as part of a larger communicative function are
more robust. For example, Weinberger,
Greene, and Mamlin (1981) found physicians’
nonverbal encouragement—operationalized
in terms of nodding and gesture—was positively associated with patients’ post-visit satisfaction. Duggan and Parrott (2001)
showed likewise that physicians’ facial reinforcement—operationalized in terms of nodding and facial animation—was positively
associated with patients’ self-disclosure (e.g.,
about life beyond symptoms).
PHYSICIANS’ BODY ORIENTATION
Although head movement and gaze
orientation communicate persons’ current
23-Manusov.qxd
6/19/2006
7:54 PM
Page 441
Nonverbal Communication and Physician-Patient Interaction–––◆–––441
engagement, the front of a person’s body
communicates a frame of dominant orientation: a frame of space wherein long-term and
dominant social actions are most likely
to be focused (Goodwin, 1981; Kendon,
1990; Schegloff, 1998). The orientation of
persons’ bodies communicates their availability or nonavailability for collaborative action.
When two persons bring each other into (or
remove the other from) their frame of dominant orientation, they establish (or dismantle)
a participation framework (Goodwin, 1981).
This orientation appears to have a
number of outcomes. Larsen and Smith
(1981) found that the amount of time
physicians spend with their bodies oriented
toward patients was positively associated
with patients’ post-visit satisfaction and
understanding. Street and Buller (1987)
showed that physicians’ indirect body orientation (i.e., away from patients) was positively associated with patients’ perceptions
of physicians’ dominance. Harrigan et al.
(1985) reported that physicians’ body orientation away from patients was negatively
associated with external raters’ evaluations
of physicians’ rapport. In a different vein,
Giron et al. (1998) found physicians’ open
face-to-face posture while patients spoke
to be positively associated with physicians’
psychodiagnostic abilities. A range of studies has also found positive relationships
between physicians’ proximity to and lean
toward patients and outcomes such as
patients’ post-visit understanding (Larsen &
Smith, 1981; Smith, Polis, & Hadac, 1981)
and external raters’ evaluations of physicians’ rapport (Harrigan & Rosenthal, 1983;
Harrigan et al., 1985).
Overall, this work shows that physicians’
body orientation toward (and physical
proximity to) patients appears to be positively and negatively associated with ratings
of physicians’ rapport and dominance,
respectively, and this may partially explain
the positive association between physicians’
body orientation and patients’ satisfaction
with physicians. As with gaze, however,
these findings may be confounded by a lack
of control for what physicians and patients
are doing.
SUMMARY
A variety of individual nonverbal behaviors have been associated with communicative, social, and psychological outcomes. The
majority of these outcomes relate to the affective-relational (vs. medical-technical) dimension of communication, such as ratings of
physicians’ dominance, rapport, and likeability, and to psychosocial (vs. somatic) aspects
of care, such as patients’ self-disclosure of
lifeworld events and physicians’ psychodiagnostic abilities. Together, they suggest the
important role that nonverbal cues may play
in physician-patient interactions.
Despite the overall strength of their conclusions, the findings just reviewed can be
extended in a number of ways that highlight
new directions for research on nonverbal
communication. Put generally, to understand the process more completely—that is,
how these behaviors come to have the consequences that they do—research needs to
be situated within a larger framework
for understanding communication per se.
Whereas communication simultaneously
involves multiple, mutually influential
modalities of meaning (nonverbal, verbal,
artifactual) and is interactive inherently,
much of the research done in the medical
context focuses in isolation on one modality of behavior (i.e., nonverbal) produced
by one participant (i.e., the physician). To
make its largest contribution—to help
understand how communication in the
medical context comes to work as it does—
research on physician-patient communication needs to be situated within (i.e., needs
to control for) aspects of interactional
23-Manusov.qxd
6/19/2006
7:54 PM
Page 442
442–––◆–––Contexts and Consequences
context that have been shown to shape how
nonverbal behavior is produced and understood. The following section suggests how
this may be done.
♦ New Directions for
Research Dealing With
Interactional Context
Street (2003) proposed an ecological model
of communication that recognizes that “visit
communication” and its outcomes are organized by reference to organizational, political, media, cultural, and interpersonal
contexts. This section of the chapter extends
Street’s model generally, and his interpersonal context specifically (which includes
verbal and nonverbal communication), by
recognizing the organizing effects of interactional context. That is, in addition to traditional conceptions of context, interaction has
its own, independent orders of social organization (Goffman, 1983) that can affect both
the production and the understanding of
nonverbal communication. Over the past 30
years, three of the most robust “interaction
orders” involve turn taking, social action,
and sequences of talk and action. Before
addressing these issues, however, this section
begins with a discussion of the inseparability
of nonverbal and verbal behavior.
THE INSEPARABILITY
OF NONVERBAL AND
VERBAL BEHAVIOR
Almost 15 years ago, Streeck and Knapp
(1992) asserted that “the classification of
communicative behavior as either ‘verbal’
or ‘nonverbal’ is misleading and obsolete”
(p. 3). Although this position is not new,
and has continued to be a mantra of
research reform (see Bavelas & Chovil, this
volume), its implications often go ignored.
There are at least two different ways of
conceptualizing the relationship between
verbal and nonverbal behavior that focus
on their co-occurrence in social meaning.
The first conceptualization is that verbal
behavior and nonverbal behavior constitute two distinct channels of communication that are attended to and processed
separately by receivers (e.g., Ekman &
Friesen, 1969). Researchers adopt this position tacitly whenever they examine phenomena whose functions entail both verbal
and nonverbal communication (e.g., dominance) yet analyze such phenomena exclusively in terms of one channel, or modality,
of meaning.
The second, alternative, conceptualization (which this chapter adopts) is that the
meaning of communicative events is shaped
by, and thus depends on, the “context” in
which it is situated and that verbal and nonverbal behavior are each forms of context
(Goodwin, 1995; Sanders, 1987). From this
perspective, the relationship between verbal
and nonverbal behavior is neither additive
nor multiplicative, in the sense that each
constitutes a separate yet combinable factor
of meaning. Rather, their relationship is
holistic and metamorphic, with a multitude
of modalities (e.g., verbal, nonverbal, artifactual) working together to convey a single
meaning (for more on this, see McNeill,
Cassell, & McCullough, 1994).
This second conceptualization shifts
analytic attention away from the function
of individual nonverbal behaviors to how
they achieve their social meanings in and
through interaction—that is, to the multimodal array of communication practices
that participants rely on to accomplish certain meanings (Sanders, 1987). This conceptualization is in line with Burgoon’s
(1994) message perspective and Stamp and
Knapp’s (1990) interaction perspective on
the nature of nonverbal communication,
and Robinson and Stivers (2001) supported
the validity of a multimodal perspective in
physician-patient interaction specifically.
23-Manusov.qxd
6/19/2006
7:54 PM
Page 443
Nonverbal Communication and Physician-Patient Interaction–––◆–––443
From this multimodal perspective, the first
conceptualization (stated above) is statistically reified (rather than supported) by
physician-patient studies showing that,
when controlling for verbal variables, nonverbal variables retain independent significance (e.g., Bensing, 1991; Griffith, Wilson,
Langer, & Haist, 2003).
THREE ASPECTS OF
INTERACTIONAL CONTEXT
Taking into account the multimodal conceptualization, and because in face-to-face
interaction, nonverbal behavior is produced
and understood largely by reference to talk,
researchers studying nonverbal communication need to account for the organizing
effects of at least three aspects of interactional context: (1) turn taking, (2) social
action, and (3) sequences of talk and action.
Furthermore, researchers need to account
for the fact that (4) individual nonverbal
behaviors are (almost always) produced and
understood by reference to each other.
These four issues are discussed in order.
Turn Taking
Buller and Street (1992) noted that traditional measures of nonverbal behavior
“do not account for how communicators
qualitatively interpret the behaviors being
quantified” (p. 135, emphasis in original).
The underlying issue in their statement is
whether operationalizations of nonverbal
behavior are ecologically valid (i.e., relevant
to participants). An integral component of
operationalizing talk is unitization. In studies of physician-patient communication,
nonverbal behavior has been unitized historically in terms of its duration and frequency (e.g., in seconds) across (sometimes
randomly selected) segments of (or entire)
visits. Contrary to this, physicians and
patients organize much of their nonverbal
behavior relative to talk, and organize their
talk according to turn-taking rules for
ordinary conversation (Sacks, Schegloff, &
Jefferson, 1974; for a review, see Robinson,
2001a).3
One example occurs with gaze orientation. Because gaze can communicate that
one is “listening,” interactants orient to the
general rule that recipients (e.g., physicians)
should gaze at speakers (e.g., patients)
when being spoken to (Goodwin, 1981).
Turns of talk have consequential “positions,” such as beginnings, middles, and
endings (Schegloff, 1996), and Goodwin
(1981) showed that recipients’ gaze toward
speakers is particularly salient at turn
beginnings. For instance, in Extract 1, when
the physician begins to ask his question
(Line 1), he is gazing at the computer screen
(see Figure 23.1, which corresponds positionally to the “1” in the transcript).
Precisely at the completion of his question—that is, just as he is about to become
a recipient of the patient’s talk—the physician shifts his gaze to the patient (Figure
23.2; commas “,” symbolize movement of
the physician’s head, the “X” symbolizes
the point at which the physician’s gaze
reaches the patient, and brackets “[ ]” symbolize simultaneous behavior).
Extract 1 [MC:12:03]
1
2
01
DOC:
What’s wrong=with your ea:r[s. (.)]
02
DOC:
[,,,,,X]
03
PAT:
I think they’re both infected.
23-Manusov.qxd
6/19/2006
7:54 PM
Page 444
444–––◆–––Contexts and Consequences
Figure 23.1
Figure 23.2
23-Manusov.qxd
6/19/2006
7:54 PM
Page 445
Nonverbal Communication and Physician-Patient Interaction–––◆–––445
Figure 23.3
Due to the rules of gaze orientation in
ordinary conversation (Goodwin, 1981), if
speakers (e.g., patients) do not secure recipients’ (e.g., physicians’) gaze at the beginning of their turns, speakers use vocal
hitches and perturbations—such as pauses,
cutoffs, and other marked prosodic patterns—to secure recipients’ gaze prior to
beginning or completing their turns. This is
equally true in physician-patient interaction
(Heath, 1986; Ruusuvuori, 2001). In
Extract 1, the patient does secure the
physician’s gaze prior to beginning her
turn, and she produces a fluent response
(Line 3). This, however, is not the case in
Extract 2. When the physician completes
his question “What’s up.” (Line 1), he is
gazing down at the computer keyboard
(Figure 23.3).
At the outset of her response (Line 2), the
patient attempts to secure the physician’s
gaze by pausing briefly (i.e., breathing in,
symbolized by “.h”) and further delaying
her answer with “Uh:m.” In this case, the
patient does not succeed in securing the
physician’s gaze, and she continues to produce a self-diagnosis: “I believe I have a
sinus infection.” (Line 2).4 Research shows,
however, that although recipients’ gaze is
particularly salient at the beginning of
speakers’ turns, it is relevant throughout
speakers’ turns, and speakers continue frequently to work to secure recipients’ gaze
(e.g., Goodwin, 1981; Heath, 1986). When
the patient in Extract 2 continues to produce
more talk (Line 3), she again attempts to
secure the physician’s gaze by cutting herself
off (symbolized by the hyphen, “a-”) and
pausing for three tenths of a second (each
tenth is symbolized by a dash, “(—)”). This
time, she succeeds—that is, immediately
after her cutoff and two tenths of a second
of silence, the physician shifts his gaze
toward the patient (Figure 23.4). The
patient begins to speak again precisely as the
physician’s gaze arrives.
23-Manusov.qxd
6/19/2006
7:54 PM
Page 446
446–––◆–––Contexts and Consequences
Extract 2 [MC:20:02]
3
01
DOC:
What's up.
02
PAT:
.h Uh:m I believe I have a sinus infection.
03
04
I’ve had=a- (— [-) c]o:ld yyou know [stuf]fy nose fer
about a week
DOC:
[,,,X]
[,,,O]
4
05
PAT: an’ then Saturday (0.2) it’s: kinda stayed
06
07
5
ri:ght, (- [—)] in thee
DOC:
[,,X]
e:ye e:a[r ]
[Y:]eah.
6
Recipients’ gaze is relevant not merely
once (i.e., fleetingly) but throughout speakers’ turns (Goodwin, 1981), and speakers
may work to recover recipients’ lost gaze.
For example, in Extract 2, as the patient
describes her “stuffy nose” (Line 3), the
physician removes his gaze back to the
computer screen (Figure 23.5). The patient,
however, is not finished speaking. Instead,
as the patient describes (and gestures with
her right hand toward) the location of
her problem (Lines 5–6), she markedly
stretches and inflects “ri:ght,” (symbolized
by the colon and the comma, respectively)
and pauses for three tenths of a second,
which succeeds in resecuring the physician’s
gaze (Figure 23.6).
Extract 2 raises an additional issue dealing with unitization. Physician-patient talk
has been coded historically in terms of
vaguely operationalized “thought units” or
“utterances.” However, turns (1) are constructed from particular types of turn-constructional units, (2) can contain more than
one turn-constructional unit, and (3) are
produced and understood in terms of
turn-constructional units (Sacks et al.,
1974). In Extract 2, it can be argued that
the patient’s turn includes three turn-constructional units (“I believe I have a sinus
infection.”, “I’ve had a cold you know
stuffy nose fer about a week”, and “an’
then Saturday it’s kinda stayed right in the
eye ear”) and that the patient orients to the
relevance of the physician’s gaze in (and
before the completion of) each unit.
In sum, gaze orientation is organized
largely by reference to turn construction.
Not only have there been specific calls for
understanding physicians’ and patients’
gaze orientation in terms of turn taking
(Irish, 1997), but there is preliminary evidence that doing so can produce analytic
payoff. For example, Harrigan et al. (1985)
found that high (vs. low) rapport physicians
are more likely to gaze at patients when
patients are speaking. Giron et al. (1998)
measured both physicians’ gaze and body
orientation toward patients separately
depending on whether physicians or
patients were speaking and found these
variables to be positively associated with
23-Manusov.qxd
6/19/2006
7:54 PM
Page 447
Nonverbal Communication and Physician-Patient Interaction–––◆–––447
Figure 23.4
Figure 23.5
23-Manusov.qxd
6/19/2006
7:54 PM
Page 448
448–––◆–––Contexts and Consequences
Figure 23.6
Figure 23.7
23-Manusov.qxd
6/19/2006
7:54 PM
Page 449
Nonverbal Communication and Physician-Patient Interaction–––◆–––449
physicians’ psychodiagnostic abilities only
when patients were speaking.
Other nonverbal behaviors, such as head
nodding, also appear to be organized by reference to turn construction. For example,
across Extract 3, the physician maintains his
gaze and body orientation toward the patient
(Figure 23.7). In the transcript, “/” and “\”
symbolize the upward and downward nodding of the physician’s head, respectively.
Extract 3 [MC:11:02]
01
DOC: When=did that sta:rt. (.) la- °°e-=uh-°° beginning
02
03
a last week? .hhhhhhhh thuh co[:ld? ]
[Y:eah] might even
PAT:
04
sta:rted duh week be[fore a little bit. an’ the:n] (.)
05
DOC:
06
PAT: la:st week w’s- thuh sore throat [ca:me an’- (.)] no:w
07
DOC:
08
[
/\/
[
]
/\
]
thuh si:nus. [(--)]
09
DOC:
10
DOC: °Okay.°
[ \/ ]
The physician’s three instances of
nodding (Lines 5, 7, and 9) map finely onto
places where the patient’s turn-constructional
units (in this case, sentences) are possibly (or
projectably) complete. The first nod begins as
the patient is saying “before” (Line 4), which
is a possible sentence ending (i.e., “might even
started duh week before”); the second nod
begins after “throat” (Line 6), which is a possible sentence ending (i.e., “An’ then last week
w’s thuh sore throat”); and the third nod
occurs in the two tenths of a second of silence
after “si:nus.” (Line 8), which is a possible
sentence ending (i.e., “An’ now thuh sinus.”).
Like gaze, nodding has been coded
historically in terms of gross frequency.
If nodding is organized relative to turnconstructional units, however, then it may
have different meanings depending on its
position within turn-constructional units,
such as being positioned before or after they
are possibly complete. Importantly, the relationship between nonverbal behavior and
turn taking does not stop at gaze orientation
and head nodding. For example, Harrigan
(1985) found that physicians and patients
self-touched more at the beginning and middle (vs. the end) of utterances. In line with
evidence from ordinary conversation (e.g.,
Streeck, 1993), a variety of physicians’ and
patients’ nonverbal behaviors are organized
by reference to turn construction, such as
23-Manusov.qxd
6/19/2006
7:54 PM
Page 450
450–––◆–––Contexts and Consequences
touching, gesturing, and smiling (Beach &
LeBaron, 2002; Haakana, 2002).
Social Action
Once nonverbal and verbal communication are reunited, researchers must recognize
that (1) persons produce and understand
all communication primarily in terms of the
action(s) it performs (e.g., explaining, advising, informing; Schegloff, 1995); (2) actions
are organized by social rules that transcend
individual actors (Heritage, 1984); and (3)
different social rules—for example, the rules
for (or practices of) providing good (vs. bad)
diagnostic news (e.g., Maynard, 2003)—
shape at least verbal behavior differentially
(Heritage, 1984).
Although the claim that the social
organization of action structures nonverbal
behavior is in need of further support, it is
buttressed by a variety of findings. Harrigan
(1985) found that patients self-touched more
when answering questions than when being
asked questions and concluded that “the
semantic context of an utterance may be
expected to exert the strongest influence on
the expression of self touching” (p. 1164),
which “is more complex than a simple cue
of anxiety” (p. 1167). Certain actions, such
as apologizing for causing emotional pain
(Beach & LeBaron, 2002), may make physicians’ touching of patients more normative
relative to other actions and thus affect
patients’ evaluations of physicians’ touch.
In line with Goffman’s (1963) notion of
civil inattention, while patients engage in a
variety of private actions such as undressing (Heath, 1986), it may be more normative for physicians to avert their gaze, even
if engaged in conversation. The action of
“remembering” publicly is associated commonly with gazing away from interlocutors
(Beach & LeBaron, 2002; Goodwin,
1987). When patients discuss personally
sensitive or embarrassing events (Beach &
LeBaron, 2002; Heath, 1986, 1988), or
when they receive bad medical news (e.g.,
cancer diagnoses; Maynard, 2003), they
sometimes look away from their interlocutors or cover their faces. One systematic
finding, then, is that while physicians
engage in physical examination, patients
tend to adopt a middle distance gaze orientation “away from the doctor yet at no
particular object within the local environment” (Heath, 1988, p. 149).
The possibility that the social organization of different verbal actions structures
nonverbal behavior differently has direct
implications for the types of outcomes discussed earlier. For example, it has already
been documented that physicians’ nonverbal
behavior affects raters’ evaluations of the
affective-relational dimension of communication. Such evaluations are, however, also
affected by physicians’ verbal behaviors,
which shape outcomes. For example, when
physicians are more verbally empathetic
(e.g., provide more reassurance), patients are
more satisfied and adherent to medical recommendations and less willing to sue for
malpractice (for a review, see Frankel,
1995). When providers are less verbally
domineering or controlling (e.g., less directive), patients are more assertive, expressive,
and disclose more information (Street,
1992b); are more satisfied (Street, 1992a);
and experience better physical-health outcomes (e.g., metabolic control; Street et al.,
1993). Researchers need to determine if
these types of verbal behaviors structure
nonverbal behavior in particular ways, and
they need to analyze nonverbal behaviors in
conjunction with them.
If researchers are going to link nonverbal
behavior to talk in interaction, in this case
physical-patient interaction, and if different
social organizations of verbal action structure nonverbal behavior differentially, then,
23-Manusov.qxd
6/19/2006
7:54 PM
Page 451
Nonverbal Communication and Physician-Patient Interaction–––◆–––451
at the very least, researchers need to refine
extant coding schemata to better control
for social action. The bulk of most coding
schemata categorize talk not in terms of
social action but rather in terms of a combination of grammatical form and topical
content. These limitations have been
addressed partially by narrowing analyses
to, and developing new coding schemata
around, particular (classes of) social actions,
such as patients’ requests for medical
services (Kravitz, Bell, & Franz, 1999).5
Sequencing
One of the most fundamental interactional contexts organizing social action is the
adjacency-pair sequence (Schegloff & Sacks
1973). In its basic form, the adjacency-pair
sequence is composed of two turns of talk: a
first-pair part, produced by one speaker,
which initiates a course of action, and a second-pair part, produced by a different
speaker, which responds to the initiated
action. Space limitations prohibit full explication of the adjacency-pair sequence, and
only two points are made here.
First, first-pair parts affect second-pair
parts by normatively obligating, and
constraining what counts as, relevant
responses. For example, “Yes”/“No”-formatted questions constrain initial responses
to versions of “Yes” or “No” (Raymond,
2003), and such constraints can have implications for patient participation (Heritage
& Robinson, 2006; Robinson, 2001a).
Second, first-pair parts establish frameworks for understanding second-pair parts,
and thus the meaning of communicative
behavior is heavily influenced by its sequential positioning (Schegloff & Sacks, 1973).
For example, in Extract 3, the physicians’
first two head nods (Lines 5 and 7) are produced after the patient’s response and are
understood as acknowledging the patient’s
talk and as encouragement to continue
(Schegloff, 1982). Evidence for this claim is
that in each case, the patient continues to
produce a new turn-constructional unit. In
contrast, in Extract 4, the physician’s head
nod (Line 4) is produced as a response to the
patient’s request for confirmation (Line 1);
because of its sequential positioning, it gets
understood differently as a confirmation.
Extract 4 [MC:14:02]
01
PAT: That takes effect right away? ((gazing at doctor))
02
(1.2)
03
PAT: Thuh [flu shot.]
04
DOC:
05
DOC:
06
PAT: ((Shifts gaze from doctor to computer))
[
/\[/
[°Mm hm,°
Research attempting to discover variables that affect physicians’ and patients’
communication has been criticized for (1)
not accounting for “the two-way and contingent (i.e., sequential) nature of physicianpatient interaction” (Hall, Harrigan, &
23-Manusov.qxd
6/19/2006
7:54 PM
Page 452
452–––◆–––Contexts and Consequences
Rosenthal, 1995, p. 25) and (2) implying
claims about causation while using the correlation statistic (for other critiques, see
Buller & Street, 1992; Street & Buller,
1987). Because correlations do not reveal
the direction of causality, because much of
social action is organized by the adjacencypair sequence, and because first-pair parts
affect second-pair parts, if sequencing is not
accounted for, then significant correlations
are constantly in danger of being sequentially spurious.
It also appears that nonverbal behavior
can be sequenced independent of verbal
adjacency-pair sequences (although nonverbal sequences are still often organized by
reference to talk). That is, there is preliminary evidence that physicians’ and patients’
nonverbal behaviors are nonrandom, patterned, and synchronized. For instance,
Street and Buller (1987) provided evidence
that physicians and patients “matched”
gaze orientation, body orientation, and
illustrative gestures, and Street and Buller
(1988) demonstrated physician-patient reciprocation or convergence regarding body
orientation. Koss and Rosenthal (1997)
found external raters’ evaluations of physician-patient nonverbal synchrony to be
positively associated with raters’ evaluations of physician-patient rapport. Several
reviews (Kiesler & Auerbach, 2003; Lepper,
Martin, & DiMatteo, 1995) have suggested
that the presence or absence of physicians’
and patients’ nonverbal synchrony (or
exchange) plays a role in a variety of participants’ affective-relational attributions,
such as affiliation and dominance, respectively (for more on synchrony, see TickleDegnen, this volume).
The above correlational research is supported by focused studies of interaction. For
example, in line with the observation that
gaze communicates persons’ current focus
of attention, Heath (1988) showed that a
physician’s gaze shift to a female patient’s
chest can lead directly to the patient gazing
at her own chest. Similarly, Heath (1986)
showed that physicians’ gaze shifts to
objects of discussion, such as X rays, can
lead directly to patients’ gazing at the same
objects. In the same way that patients can
use vocal hitches and perturbations to solicit
physicians’ gaze (see above), patients can
use nonverbal behaviors—such as gaze
shifts toward physicians, hand gestures,
torso shifts, and leg movements—to solicit
both physicians’ gaze and talk (Heath,
1986). For example, patients sometimes
seek physicians’ gaze nonvocally for purposes of exhibiting embodied characteristics
of their suffering (Beach & LeBaron, 2002;
Heath, 1986, 2002). In Figure 23.6, in addition to using vocal hitches and perturbations
to solicit the physician’s gaze, the patient
additionally gestures with her right hand to
locate the position of her symptoms (i.e.,
her “e:ye e:ar”). Although more research is
necessary, Heath (1986) noted that some
of these nonverbal sequences operate in a
fashion similar to verbal summons-answer
sequences (Schegloff, 1968).
The Inseparability of Nonverbal
Behaviors From Themselves
In addition to turn taking, social action,
and sequences, nonverbal behavior embodies its own interactional context. That is,
the social meaning of individual nonverbal
behaviors can be altered when they are
employed simultaneously. For example,
Harrigan and Rosenthal (1983) found
external raters’ evaluations of physicians’
rapport to be associated with interactions
between physicians’ torso position (i.e.,
forward or backward lean), head nodding,
and leg position (i.e., crossed or uncrossed).
Based on these types of findings, Harrigan
and Rosenthal (1986) later asserted,
23-Manusov.qxd
6/19/2006
7:54 PM
Page 453
Nonverbal Communication and Physician-Patient Interaction–––◆–––453
Nonverbal units of behavior are difficult, if not impossible, to study in total
isolation from one another. While the
head is nodding, the trunk may be
angled forward or back, the limbs may
be still or moving, the face expressionless or animated, and the gaze steady,
averted, or darting. Each unit of nonverbal behavior is interrelated in that each is
capable of influencing the evaluation of
another behavior. (p. 45)
Studies have not often tested for interaction effects between individual nonverbal
behaviors. In fact, such interactions are
obscured when individual nonverbal behaviors are collapsed into larger-order variables, such as immediacy, which has been
operationalized in terms of decreased physical proximity and increased touch, forward lean, gaze, and body orientation
(Larsen & Smith, 1981; see also the section
on head nodding). This is not to suggest
that the aggregation of individual nonverbal behaviors is completely unprincipled.
For instance, researchers often evaluate
their coherence with statistical techniques,
such as factor analysis. Aggregation is less
principled, however, when it is motivated
by professional demands involving acceptable levels of interrater reliability or significance, statistical demands involving cell
size, and so on. Aggregation does, however,
obscure the effects of individual nonverbal
behaviors, as well as the fact that individual
nonverbal behaviors do interact.
One of the most well-documented interrelationships is between gaze and body
orientation (Mehrabian, 1967). Although
different segments of the body (e.g., the
head, torso, and legs) can be oriented in
different directions (Kendon, 1990), there
remains a socially understood body-segment
hierarchy in terms of persons’ levels of
attention and engagement. Specifically, even
though gaze orientation communicates
persons’ current foci of attention, relative to
upper-body segments (e.g., the head), lowerbody segments (e.g., the legs) more strongly
communicate persons’ frames of dominant
orientation (Kendon, 1990).
For example, in Figure 23.5, the physician’s head, torso, and legs are in alignment
and face the desk or computer; the patient
is gazing at the physician. When physicians
arrange their body segments to have divergent orientations—for example, in Figure
23.6 (compared with Figure 23.5), when
the physician keeps his torso and legs oriented toward the desk or computer yet
rotates his head 30° to the right of his body
to gaze at the patient—they may communicate (1) postural instability (e.g., of their
head relative to their body); (2) potential
resolutions to such instability by reference
to the more stable segments of the body
(e.g., returning their head into alignment
with their body); (3) an orientation to multiple courses of action (e.g., one by their
head, such as engaging the patient to ask
them a question, and another by their body,
such as documenting the patient’s answer in
the medical records); and (4) a ranking of
these multiple courses of action in terms of
level of orientation (e.g., the action of documenting is more primary and long term
than that of engaging the patient in talk;
Robinson, 1998).
The interrelated social organizations of
gaze and body orientation can affect raters’
attributions. For example, in a nonmedical context, Mehrabian (1967) found the
amount of time senders maintained head
orientation toward receivers to be positively associated with external raters’ evaluations of senders’ positive attitudes toward
receivers, but only when senders’ bodies
were also oriented toward receivers. In a
medical context, Ruusuvuori (2001) examined patients’ responses to physicians’
23-Manusov.qxd
6/19/2006
7:54 PM
Page 454
454–––◆–––Contexts and Consequences
opening questions (e.g., “What can I do for
you today?”) and showed that when physicians removed their gaze from patients
prior to patients having completed their
responses, patients tended to produce disfluencies to (re)solicit physicians’ gaze.
Ruusuvuori found that patients produced
fewer disfluencies when physicians’ bodies
were oriented toward (vs. away) from
patients (e.g., Figure 23.7 compared with
Figure 23.6). Ruusuvuori’s findings suggest
that in terms of physicians’ levels of
engagement with patients (i.e., attention
to patient’s responses), patients understand
the absence or removal of physicians’ gaze
differently depending on the orientation of
physicians’ bodies.
The interrelationship between gaze and
body orientation can be complicated by
other nonverbal behaviors. For example, in
a nonmedical context, Goodwin (1981) suggested that recipients’ lack of attention communicated by shifting their gaze away from
speakers can be partially offset by recipients
nodding during and after their gaze
removal. To further complicate matters,
because gaze and body orientation are used
primarily to communicate (dis)engagement,
their understanding cannot be separated
from that of the objects being (dis)engaged.
Patients can differentiate between physicians’ gaze at patients’ eyes versus other
body parts (e.g., legs, breasts, backs), versus
medical records, with different interactional
and attributional implications (Heath,
1986, 1988; Robinson, 1998).
♦ Conclusion
This chapter reviews findings related to
nonverbal behavior and physician-patient
interaction and shows that physicians’
nonverbal behavior—which is integral to
the construction and management of
empathy, rapport, and generally a “positive”
affective-relational communication style—
has wide-ranging effects (direct and indirect)
on patients’ communicative, social, psychological, and physiological health outcomes.
Despite these empirical strides, research on
nonverbal communication can be improved.
The bulk of prior research has focused
exclusively on individual nonverbal behaviors (e.g., body orientation) or coherent
aggregates of nonverbal behaviors (e.g.,
reinforcement). This chapter argues that the
social meaning of nonverbal behavior—and
thus its production, understanding, and
effects—is fundamentally and irremediably
shaped by, and thus must be studied relative to, its situation within a variety of
aspects of interactional context. This is not
to say that the effects of nonverbal behavior
are relative. Rather, nonverbal behavior is
organized systematically and finely by reference to both talk and other nonverbal
behavior.
This chapter demonstrates that physicians’ production of individual nonverbal
cues (e.g., gaze, body orientation, head
nodding), and patients’ understandings of
such cues, is organized by rules associated
with turn taking, the construction of particular social actions, the sequencing of
actions, and the organization of other nonverbal behaviors (e.g., the interorganization
of gaze and body orientation). Not taking
these aspects of interactional context into
account obscures our understanding of the
cause-effect relationships between nonverbal (as well as verbal) communication variables and their outcomes.
Relative to research on nonverbal communication between 1965 and 1995,
research over the last 10 years has
languished. New directions in research
point toward developing new ways of
classifying—that is, conceptualizing and
measuring—nonverbal communication. On
the one hand, “without classification, there
23-Manusov.qxd
6/19/2006
7:54 PM
Page 455
Nonverbal Communication and Physician-Patient Interaction–––◆–––455
could be no advanced conceptualization,
reasoning, language, data analysis or, for
that matter, social science research” (Bailey,
1994, p. 1). Traditional methodologies for
coding interaction will always (for a variety
of statistical and other reasons) be blunt
to the ecological validity of interaction
(Mishler, 1984). As such, advances in
research will require large-scale partnerships between multiple teams of researchers
representing multiple methodological and
ontological perspectives. Largely qualitative research on the interorganizational
relationships between multiple modes of
communication (e.g., verbal, nonverbal,
artifactual) must proceed both simultaneously and in conjunction with largely quantitative, effects-based research, preferably
without too many analytic compromises on
either side.
♦ Notes
1. Because of space limitations, this
chapter excludes research on patient-nurse
and patient-psychotherapist interaction (for
a review, see Caris-Verhallen, Kerkstra, &
Bensing, 1999, and Hall, Harrigan, &
Rosenthal, 1995, respectively).
2. Compared with self-report measures of
emotional expressiveness, those that are based
on external raters’ observations of concrete
behaviors are more conservative and thus more
appropriate for isolating nonverbal “predictors”
of behavior (Riggio & Riggio, 2002).
3. Overall, researchers seldom measure
physicians’ and patients’ turns. For an exception, see Street and Buller (1988), who found
physicians’ turns to be longer than those of
patients and older patients’ turns to be longer
than those of younger patients.
4. The fact that the patient’s “.h Uh:m” does
not secure the physician’s gaze in this particular
instance does not invalidate it as being a member
of a class of practices designed to do so
(Goodwin, 1981; Heath, 1986; Ruusuvuori,
2001). As this section goes on to discuss, this
extract demonstrates both the interrelated and
the negotiated character of verbal and nonverbal
communication.
5. The argument concerning social action
can be extended to social activity. In physicianpatient communication, medical action is frequently produced within specific medical phases
or activities. For instance, primary-care acute
visits have roughly six phases: opening, problem
presentation, information gathering such as history taking and physical examination, diagnosis,
treatment, and closing (Robinson, 2003). These
phases can have their own forms of social organization that can shape the production and
understanding of their constituent actions, as
does opening (Robinson, 1998), problempresentation (Robinson & Heritage, 2005), and
closing (Robinson, 2001b). Along these lines, a
number of studies of nonverbal communication
have controlled for medical phase (e.g., Duggan
& Parrott, 2001; Harrigan, Oxman, &
Rosenthal, 1985; Larsen & Smith, 1981; Street
& Buller, 1987).
♦ References
Aruguete, M. S., & Roberts, C. A. (2002).
Participants’ ratings of male physicians
who vary in race and communication style.
Psychological Reports, 91, 793–806.
Bailey, K. D. (1994). Typologies and taxonomies: An introduction to classification
techniques. Thousand Oaks, CA: Sage.
Beach, W. A., & LeBaron, C. D. (2002). Body
disclosures: Attending to personal problems
and reported sexual abuse during a medical
encounter. Journal of Communication, 52,
617–639.
Bensing, J. M. (1991). Doctor-patient communication and the quality of care. Social
Science & Medicine, 32, 1301–1310.
Bensing, J. M., & Dronkers, J. (1992).
Instrumental and affective aspects of physician behavior. Medical Care, 30, 283–298.
Bensing, J. M., Kerssens, J. J., & van der Pasch,
M. (1995). Patient-directed gaze as a tool
for discovering and handling psychosocial
23-Manusov.qxd
6/19/2006
7:54 PM
Page 456
456–––◆–––Contexts and Consequences
problems in general practice. Journal of
Nonverbal Behavior, 19, 223–242.
Ben-Sira, Z. (1982). Stress potential and esotericity of health problems: The significance of the physician’s affective behavior.
Medical Care, 20, 414–424.
Buller, D. B., & Street, R. L., Jr. (1992).
Physician-patient relationships. In R. S.
Feldman (Ed.), Applications of nonverbal
behavior theories and research (pp. 119–
141). Hillsdale, NJ: Erlbaum.
Burgoon, J. K. (1994). Nonverbal signals. In
M. L. Knapp & G. R. Miller (Eds.),
Handbook of interpersonal communication
(2nd ed., pp. 229–285). Thousand Oaks,
CA: Sage.
Caris-Verhallen, W. M., Kerkstra, A., &
Bensing, J. M. (1999). Non-verbal behaviour in nurse-elderly patient communication. Journal of Advanced Nursing, 29,
808–818.
Cegala, D. J., McNeilis, K. S., McGee, D. S.,
& Jonas, A. P. (1995). A study of doctors’
and patients’ perceptions of information
processing and communication competence
during the medical interview. Health
Communication, 7, 179–203.
Duffy, F. D., Gordon, G. H., Whelan, G., ColeKelly, K., & Frankel, R. (2004). Assessing
competence in communication and interpersonal skills: The Kalamazoo II Report.
Academic Medicine, 79, 495–507.
Duggan, A. P., & Parrott, R. L. (2001).
Physicians’ nonverbal rapport building and
patients’ talk about the subjective component of illness. Human Communication
Research, 27, 299–311.
Egbert, L. D., Battit, G. E., Welch, C. E., &
Bartlett, M. K. (1964). Reduction of postoperative pain by encouragement and
instruction of patients: A study of doctorpatient rapport. New England Journal of
Medicine, 270, 825.
Ekman, P., & Friesen, W. V. (1969). The repertoire of nonverbal behavior: Categories, origins, usage, and coding. Semiotica, 1, 49–98.
Farace, R. V., Monge, P. R., & Russell,
M. (1977). Communicating in organizations. Reading, MA: Addison-Wesley.
Frankel, R. M. (1995). Emotion and the physician-patient relationship. Motivation &
Emotion, 19, 163–173.
Giron, M., Manjon-Arce, P., Puerto-Barber, J.,
Sanchez-Garcia, E., & Gomez-Beneyto
(1998). Clinical interview skills and identification of emotional disorders in primary
care. American Journal of Psychiatry, 155,
530–535.
Glassman, M., & Glassman, N. (1981). A marketing analysis of physician selection and
patient satisfaction. Journal of Health Care
Marketing, 1, 25–31.
Goffman, E. (1963). Behavior in public places.
New York: Free Press.
Goffman, E. (1983). The interaction order.
American Sociological Review, 48, 1–17.
Goodwin, C. (1981). Conversational organization: Interaction between speakers and
hearers. New York: Academic Press.
Goodwin, C. (1987). Forgetfulness as an interactive resource. Social Psychology Quarterly,
50, 115–131.
Goodwin, C. (1995). Seeing in depth. Social
Studies of Science, 25, 237–274.
Griffith, C. H., Wilson, J. F., Langer, S., &
Haist, S. A. (2003). House staff nonverbal
communication skills and standardized
patient satisfaction. Journal of General
Internal Medicine, 18, 170–174.
Haakana, M. (2002). Laughter in medical
interaction: From quantification to analysis, and back. Journal of Sociolinguistics,
6, 207–235.
Hall, J. A., Harrigan, J. A., & Rosenthal, R.
(1995). Nonverbal behavior in clinicianpatient interaction. Applied and Preventive
Psychology, 4, 21–37.
Hall, J. A., Irish, J. T., Roter, D. L., Ehrlich,
C. M., & Miller, L. H. (1994). Gender in
medical encounters: An analysis of physician
and patient communication in a primary care
setting. Health Psychology, 13, 384–392.
Harrigan, J. A. (1985). Self-touching as an indicator of underlying affect and language
processes. Social Science & Medicine, 20,
1161–1168.
Harrigan, J. A., Oxman, T. E., & Rosenthal, R.
(1985). Rapport expressed through nonverbal
23-Manusov.qxd
6/19/2006
7:54 PM
Page 457
Nonverbal Communication and Physician-Patient Interaction–––◆–––457
behavior. Journal of Nonverbal Behavior,
9, 95–110.
Harrigan, J. A., & Rosenthal, R. (1983).
Physicians’ head and body positions as
determinants of perceived rapport. Journal
of Applied Social Psychology, 13,
496–509.
Harrigan, J. A., & Rosenthal, R. (1986).
Nonverbal aspects of empathy and rapport
in physician-patient interaction. In P. D.
Blanck, R. Buck, & R. Rosenthal (Eds.),
Nonverbal communication in the clinical
context (pp. 36–73). University Park: The
Pennsylvania State University Press.
Heath, C. (1986). Body movement and speech
in medical interaction. Cambridge, UK:
Cambridge University Press.
Heath, C. (1988). Embarrassment and interactional organization. In P. Drew &
A. Wootton (Eds.), Erving Goffman:
Exploring the interaction order (pp. 136–
160). Boston, MA: Northeastern University
Press.
Heath, C. (2002). Demonstrative suffering:
The gestural (re)embodiment of symptoms.
Journal of Communication, 52, 597–616.
Heritage, J. C. (1984). Garfinkel and ethnomethodology. New York: Polity Press.
Heritage, J., & Robinson, J. D. (2006). The
structure of patients’ presenting concerns:
Physicians’ opening questions. Health
Communication, 19, 89–102.
Irish, J. T. (1997). Deciphering the physicianolder patient interaction. International
Journal of Psychiatry in Medicine, 27,
251–267.
Kaplan, S. H., Greenfield, S., & Ware, J. E.
(1989). Impact of the doctor-patient relationship on the outcomes of chronic disease. In M. Stewart & D. Roter (Eds.),
Communicating with medical patients
(pp. 228–245). Newbury Park, CA: Sage.
Kendon, A. (1990). Conducting interaction:
Patterns of behavior in focused encounters.
Cambridge, UK: Cambridge University
Press.
Kiesler, D. J., & Auerbach, S. M. (2003).
Integrating measurement of control and
affiliation in studies of physician-patient
interaction: The interpersonal circumplex.
Social Science & Medicine, 57, 1707–1722.
Koss, T., & Rosenthal, R. (1997). Interactional
synchrony, positivity, and patient satisfaction in the physician-patient relationship.
Medical Care, 35, 1158–1163.
Kravitz, R. L., Bell, R. A., & Franz, C. E.
(1999). A taxonomy of requests by
patients (TORP): A new system for understanding clinical negotiation in office
practice. Journal of Family Practice, 48,
872–878.
Langer, E. J., Janis, I. L., & Wolfer, J. A. (1975).
Reduction of psychological stress in surgical patients. Journal of Experimental Social
Psychology, 11, 155.
Larsen, K. M., & Smith, C. K. (1981).
Assessment of nonverbal communication
in the patient-physician interview. The
Journal of Family Practice, 12, 481–488.
Lepper, H. S., Martin, L. R., & DiMatteo, M. R.
(1995). A model of nonverbal exchange
in physician-patient expectations for
patient involvement. Journal of Nonverbal
Behavior, 19, 207–222.
Maynard, D. W. (2003). Bad news, good news:
Conversational order in everyday talk
and clinical settings. Chicago: University of
Chicago Press.
McNeill, D., Cassell, J., & McCullough, K.
(1994). Communicative effects of speechmismatched gestures. Research on Language
and Social Interaction, 27, 223–237.
Mechanic, D., & Meyer, S. (2000). Concepts of
trust among patients with serious illness.
Social Science & Medicine, 51, 657–668.
Mehrabian, A. (1967). Orientation behaviors
and nonverbal attitude communication.
Journal of Communication, 17, 324–332.
Mishel, M. H. (1988). Uncertainty in illness.
Image: Journal of Nursing Scholarship,
20, 225–232.
Mishler, E. (1984). The discourse of medicine:
Dialectics of medical interviews. Norwood,
NJ: Ablex.
Raymond, G. (2003). Grammar and social organization: Yes/no interrogatives and the structure of responding. American Sociological
Review, 68, 939–967.
23-Manusov.qxd
6/19/2006
7:54 PM
Page 458
458–––◆–––Contexts and Consequences
Riggio, H. R., & Riggio, R. E. (2002).
Emotional expressiveness, extraversion,
and neuroticism: A meta-analysis. Journal
of Nonverbal Behavior, 26, 195–218.
Robinson, J. D. (1998). Getting down to business:
Talk, gaze, and body orientation during
openings of doctor-patient consultations.
Human Communication Research, 25,
98–124.
Robinson, J. D. (2001a). Asymmetry in action:
Sequential resources in the negotiation of a
prescription request. Text, 21, 19–54.
Robinson, J. D. (2001b). Closing medical
encounters: Two physician practices and
their implications for the expression of
patients’ unstated concerns. Social Science
& Medicine, 53, 639–656.
Robinson, J. D. (2003). An interactional structure of medical activities during acute visits
and its implications for patients’ participation. Health Communication, 15, 27–59.
Robinson, J. D., & Heritage, J. (2005). The
structure of patients’ presenting concerns:
The completion relevance of current symptoms. Social Science and Medicine, 61,
481–493.
Robinson, J. D., & Stivers, T. (2001). Achieving
activity transitions in primary-care consultations: From history taking to physical examination. Human Communication Research,
27, 253–298.
Rowland-Morin, P. A., Burchard, K. W., Garb,
J. L., & Coe, N. P. W. (2002). Influence
of effective communication by surgery
students on their oral examination scores.
Academic Medicine, 66, 169–171.
Ruusuvuori, J. (2001). Looking means listening:
Coordinating displays of engagement in
doctor-patient interaction. Social Science &
Medicine, 52, 1093–1108.
Sacks, H., Schegloff, E. A., & Jefferson, G.
(1974). A simplest systematics for the organization of turn-taking for conversation.
Language, 50, 696–735.
Sanders, R. E. (1987). The interconnection of
utterances and nonverbal displays. Research
on Language and Social Interaction, 20,
141–170.
Schegloff, E. A. (1968). Sequencing in conversational openings. American Anthropologist,
70, 1075–1095.
Schegloff, E. A. (1982). Discourse as an interactional achievement: Some uses of “uh-huh”
and other things that come between sentences.
In D. Tannen (Ed.), Analyzing discourse: Text
and talk (pp. 71–93). Washington, DC:
Georgetown University Press.
Schegloff, E. A. (1995). Discourse as an interactional achievement III: The omnirelevance
of action. Research on Language and Social
Interaction, 28, 185–211.
Schegloff, E. A. (1996). Turn organization: One
intersection of grammar and interaction. In
E. Ochs, E. Schegloff, & S. Thompson (Eds.),
Interaction and grammar (pp. 52–133).
Cambridge, UK: Cambridge University Press.
Schegloff, E. A. (1998). Body torque. Social
Research, 65, 535–596.
Schegloff, E. A., & Sacks, H. (1973). Opening
up closings. Semiotica, 7, 289–327.
Smith, C. K., Polis, E., & Hadac, R. R. (1981).
Characteristics of the initial medical interview associated with patient satisfaction
and understanding. Journal of Family
Practice, 12, 283–288.
Stamp, G. H., & Knapp, M. L. (1990). The
construct of intent in interpersonal communication. Quarterly Journal of Speech, 76,
282–299.
Streeck, J. (1993). Gesture as communication I:
Its coordination with gaze and speech.
Communication Monographs, 60, 275–299.
Streeck, J., & Knapp, M. (2002). Culture,
meaning, and interpersonal communication. In M. L. Knapp & J. A. Daly (Eds.),
Handbook of interpersonal communication (pp. 286–319). Thousand Oaks, CA:
Sage.
Street, R. L., Jr. (1992a). Analyzing communication in medical consultations: Do behavioral measures correspond to patients’
perceptions? Medical Care, 30, 976–988.
Street, R. L., Jr. (1992b). Communicative styles
and adaptations in physician-parent consultations. Social Science & Medicine, 34,
1155–1163.
Street, R. L. Jr. (2003). Communication in medical encounters: An ecological perspective.
In T. Thompson, A. M. Dorsey, K. I.
Miller, & R. Parrott (Eds.), Handbook
of health communication (pp. 63–89).
Mahwah, NJ: Erlbaum.
23-Manusov.qxd
6/19/2006
7:54 PM
Page 459
Nonverbal Communication and Physician-Patient Interaction–––◆–––459
Street, R. L., Jr., & Buller, D. B. (1987). Nonverbal
response patterns in physician-patient interactions: A functional analysis. Journal of
Nonverbal Behavior, 11, 234–253.
Street, R. L., Jr., & Buller, D. B. (1988). Patients’
characteristics affecting physician-patient
nonverbal communication. Human Communication Research, 15, 60–90.
Street, R. L., Jr., Piziak, V. K., Carpentier, W. S.,
Herzog, J., Hejl, J., Skinnner, G., et al.
(1993). Provider-patient communication
and metabolic control. Diabetes Care, 16,
714–721.
Van Dulmen, A. M., Verhaak, P. F. M., & Bilo,
H. J. G. (1997). Shifts in doctor-patient
communication during a series of outpatient consultations in non-insulin-dependent
diabetes mellitus. Patient Education &
Counselling, 30, 227–237.
Verhaak, P. F. M. (1988). Detection of psychological complaints by general practitioners.
Medical Care, 26, 1009–1020.
Weinberger, M., Greene, J. Y., & Mamlin, J. J.
(1981). The impact of clinical encounter
events on patient and physician satisfaction.
Social Science & Medicine, 15E, 239–244.
23-Manusov.qxd
6/19/2006
7:54 PM
Page 460