How much time do you spend gazing into your patients' eyes during a consultation? The time you spend looking at their eyes during a technical examination or procedure doesn't count. Did you know that the amount of time (both actual and as a proportion of the visit) that physicians spend gazing at the patient predicts the latter's satisfaction?¹ In addition, a study showed that physicians who gazed at patients more frequently were more successful at recognizing their psychological distress as measured by a standard screening instrument.²

When they look at patients while they talk, doctors also have more opportunities to accurately recognize patients' nonverbal expression of emotions. This ability, referred to as decoding, has been associated with greater satisfaction among patients. The reverse is also true. The patients of physicians who are more skilled in terms of encoding (the ability to convey emotional messages accurately as intended) rate their physicians as listening more and being more caring and sensitive than other doctors.^3,4 When they rate their health care experiences, patients place a very high value on physicians' listening skills.

NONVERBAL BEHAVIOR
Vocal tone is an important part of doctor-patient communication. Malpractice litigation is associated with multiple factors, including not only physician negligence and error, but also the quality of communication between physicians and patients. A unique study specifically looked at the role of the surgeon's tone of voice in malpractice claims through analysis of brief audio clips of surgeons' voices taken from routine surgical visits.⁵ Half of the surgeons had had at least two malpractice claims against them, and half had no malpractice claim history. Controlling for content, ratings of higher dominance and lower concern/anxiety in their voice tones significantly identified surgeons with previous claims compared with those who had no claims. In other words,

40 seconds of surgeons' speech distinguished between surgeons with and without claims. This study is interesting because it suggests that tone of voice rather than just content of communication may be related to a patient's decision to sue a physician.

CONCLUSION
Research findings on the role of eye contact and vocal tone in patients' outcomes highlight physicians' need for increased education in the area of communication. Techniques to improve nonverbal skills include obtaining constructive feedback and instruction from a medical communication skills expert who directly observes you and your staff interacting with patients, reviews audio- or videotapes of such discussions, and/or provides role-playing exercises. These activities increase the staff awareness of nonverbal cues in their patients and themselves. Increase your practice's success by learning the cues, both the ones you send to patients and the ones patients send to you and your staff.

Jennifer S. Morse, MD, is in private practice as a consultant for medical and surgical psychiatry in San Diego. Dr. Morse may be reached at (619) 405-5919; www.the-doctor-is-in.com; jmorsemd@aol.com.

1. Hall JA, Harrigan JA, Rosenthal R. Nonverbal behavior in clinician-patient interaction. Appl Prev Psychol. 1995;4:21-37.
2. Bensing JM, Kerssens JJ, van der Pasch M. Patient-directed gaze as a tool for discovering and handling psychosocial problems in general practice. J Nonverbal Behav. 2005;19:223-242.
3. DiMatteo MR, Taranta A, Friedman HS, Prince LM. Predicting patient satisfaction from physicians' nonverbal communication skills. Med Care. 1980;18:376-387.
4. Roter DL, Frankel FM, Hall JA, Sluyter D. The expression of emotion through nonverbal behavior in medical visits-mechanisms and outcomes. J Gen Intern Med. 2006;21:S28-34.
5. Ambady N, LaPlante D, Nguyen T, et al. Surgeons' tone of voice: a clue to malpractice history. Surgery. 2002;132:5-9.