The link between perception of clinical empathy and nonverbal behavior: The effect of a doctor’s gaze and body orientation
Introduction
Empathy is considered to be one of the most important skills in the medical field [1], both from the patient perspective and in terms of health communication outcomes, such as information transfer, diagnosis quality, faster recovery and patient-related psychosocial outcomes [2], [3], [4], [5]. However, due to a number of factors, medical students show a decline in empathy when entering the field [6], [7] and even experienced doctors feel restricted in expressing empathy due to time pressure [8]. The lack of empathy does not go unnoticed by patients, who often feel that they are being treated as a set of symptoms rather than a person, as expressed in the statement “I am not a knee cap!” [9].
Given the importance of empathy in medical interactions, the interest in empathy training is not unexpected [10], [11], [12] and some studies show that, in principle, it is possible [2], [13]. However, little is known about the importance of different types of cues, particularly, of the conscious (as opposed to automatic) use of particular nonverbal behavior, on the perception of empathy. In line with the challenge discussed by Benbassat and Baumal [10] and Montague et al. [14], the objective of the current study is to explore the link between nonverbal communication and the patient’s perception of empathy.
There is a lack of consensus about the definition and measurement of empathy in a medical setting [3], [15], [16], [17], particularly, with respect to the issue whether an emotional component is a necessary part of empathy [18]. Outside of the clinical setting, general empathy has been described as a multi-dimensional construct [15], [19]. It is considered to be an automatic and involuntary response in reaction to the emotional signals of an interaction partner, similar to what the other is experiencing [15], [20], [21]. In terms of its dimensions, it consists of a cognitive component, in which one mentally represents the situation of the other, and an affective component, in which one emotionally identifies with the other [15], [19], [22].
Clinical empathy [23], on the other hand, can be seen as a professional skill, which is instrumentally and consciously applied by doctors who are aware of its benefits for patients. It consists of (1) cognition: the intellectual capacity to recognize and understand the patient’s emotion, (2) motivation: the motivation to communicate this understanding, and (3) behavior: the capacity to transfer this understanding through effective communication [3], [6], [23], [24]. It is important to mention that the distinction between general and clinical empathy does not wipe out the importance of sincere emotions in the medical practice; both forms of empathy can exist separately and simultaneously during a medical consultation. However, from the point of view of professional training, general empathy is considered an attitude, which can hardly be taught, as opposed to clinical empathy, which is considered a trainable skill [13], [25].
The definition of clinical empathy determines how the construct should be assessed in the context of empirical investigations. In several studies, clinical empathy has been measured, e.g., by means of self-reports collected from medical practitioners [26] and by using judgments of trained observers [27] and colleagues [28]. However, it is primarily the patient’s perception that is of importance in the context of research on clinical empathy and its outcomes [1], [3], [14] because the communication of clinical empathy only succeeds when the patient decodes the message as empathetic. Therefore, it can be argued that clinical empathy should preferably be measured and described in terms of patient perception.
In the study reported here, we focused on the perception of simple nonverbal cues as possible signals of empathy. Research on the effects of nonverbal communication in medical interactions is scarce [29], [30], [31], despite the fact that nonverbal behavior is considered the most important medium for expressing empathy [32], [33]. Particularly, the direction of gaze and body orientation appear to play an important role [14] but their effects on perceived clinical empathy have not been sufficiently explored.
Gaze is sometimes considered the key cue in conveying clinical empathy [14], [34] because it offers insight into the mental state of the other [35]. By monitoring the doctor’s gaze, the patient can estimate the doctor’s engagement and if the interest displayed by the doctor is sincere [36]. Importantly, engagement, defined as “the degree to which one is cognitively preoccupied with, engaged in, and concerned with one’s present job” ([37]: 224), can be seen as a prerequisite to the first step in the process of clinical empathy, i.e., recognizing and understanding the patient’s emotion. In fact, patients themselves demand engagement from their doctors [38]. If patient-centered gaze is absent (for example during the process of medical record completion), it is perceived as a signal of disengagement that leads to feelings of exclusion [39]. Although gaze thus appears crucial for the communication of clinical empathy in all kinds of medical contexts, until now, existing research has mainly focused on its role in mental health care [35], [40], [41]. The first objective of the current study is to add to the existing findings by exploring the effect of gaze on perceived clinical empathy in a more general setting.
Similarly to gaze, body orientation communicates engagement with one’s interaction partner [42], [43]. Past research in the area of mental health care [29], [34], [40] stresses the importance of an open body orientation, with a slight forward lean, to decrease the distance between the doctor and the patient and to indicate engagement and interest. The second objective of our experiment is to explore the impact of body orientation on perceived clinical empathy.
Next to examining the effect of gaze and body orientation in isolation, the third objective of the experiment is to study the link between these nonverbal cues and the patient’s perception of clinical empathy from the point of view of congruence, as discussed by Benbassat and Baumal [10] and Montague et al. [14]. Previous findings show that patients are sensitive to signals of incongruence in a doctor’s (non) verbal behavior [35], interpreting it as a lack of sincerity [44]. Incongruence in (non) verbal communication occurs, for example, when a doctor’s gaze and body orientation display a lack of engagement while the doctor verbally expresses clinical empathy, or when the nonverbal cues themselves are not aligned. Since the perception of sincerity is integral to cooperative communication, we expect congruence between the two nonverbal cues to be a prerequisite for clinical empathy to be perceived. However, since gaze is considered to be the most important cue in doctor-patient communication [43], it could be the case that in interactions with patient-centered gaze, averted body orientation would have a less (negative) impact on the patient’s perceived clinical empathy. Concluding, we expect a link between (non) verbal behavior and a patient’s perception of clinical empathy, sincerity and engagement.
Section snippets
Study design
The experiment was based on a 2 × 2 within-subject design. The independent variables were the direction of a doctor’s gaze (patient-centered, averted) and body orientation (patient-centered, averted). The dependent variables were the measures of perceived clinical empathy, general empathy, sincerity and engagement. The study received the approval of the Institutional Review Board.
Respondents
From the total of 120 respondents who started the experiment, 77 (52 females) completed the task (298 potential
Procedure
The experiment was administered via an online survey conducted with the open source program LimeSurvey. The experiment was presented as a study of the performance of medical interns in simulated consultations with a fictive patient, who was diagnosed with curable skin cancer. Cancer is a frequent disease in the Netherlands and skin cancer is the most encountered gender independent cancer type [52]. The respondents were asked to assess the performance of the “intern” in the video through the
The effect of gaze and body orientation
Below, we first present the raw data in terms of gender, condition and the score on the general perceived empathy (GPE). Table 3 presents an overview of the descriptive values.
A one-way analysis of variance (SPSS, v. 19) was used to estimate the effect of gaze and body orientation on the GPE. The analysis revealed an effect of gaze on the GPE: F(1,612) = 269.81, p < .001, η2 = 0.31; intern actors who gazed into the camera were rated significantly higher on the GPE than when their gaze was averted.
Discussion
In our study, we explored the effect of gaze and body orientation on perceived empathy in medical interactions. Both patient-centered gaze and body orientation had a positive effect on perceived empathy; the effect of gaze was stronger than the effect of body orientation. The outcomes support earlier observations regarding the effect of gaze and body orientation in empathic communication [14], [34] and provide further evidence for the importance of nonverbal cues as signals of empathy in
Role of funding and conflicts of interest
The authors declare that no external funding has been received for the conduct of this study. The authors declare no conflicts of interest.
Acknowledgments
The authors would like to thank Jacqueline Dake for technical support and Jorrig Vogels for statistical support.
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