The role of non-verbal behaviour in racial disparities
in health care: implications and solutions
Cynthia S Levine & Nalini Ambady
CONTEXT People from racial minority back-
grounds report less trust in their doctors and
have poorer health outcomes. Although these
disparities have multiple roots, one impor-
tant set of explanations involves racial bias,
which may be non-conscious, on the part of
providers, and minority patients’ fears that
they will be treated in a biased way. Here, we
focus on one mechanism by which this bias
may be communicated and reinforced:
namely, non-verbal behaviour in the doctor–
METHODS We review 2 lines of research on
race and non-verbal behaviour: (i) the ways in
which a patient’s race can inﬂuence a doctor’s
non-verbal behaviour toward the patient, and
(ii) the relative difﬁculty that doctors can have
in accurately understanding the nonverbal
communication of non-White patients.
Further, we review research on the implica-
tions that both lines of work can have for the
doctor-patient relationship and the patient’s
RESULTS The research we review suggests
that White doctors interacting with minority
group patients are likely to behave and
respond in ways that are associated with worse
DISCUSSION As doctors’ disengaged non-
verbal behaviour towards minority group
patients and lower ability to read minority
group patients’ non-verbal behaviours may
contribute to racial disparities in patients’ sat-
isfaction and health outcomes, solutions that
target non-verbal behaviour may be effective.
A number of strategies for such targeting are
Medical Education 2013: 47: 867–876
Discuss ideas arising from the article at
Department of Psychology, Stanford University, Stanford,
Correspondence: Dr Cynthia S Levine, Department of Psychology,
Stanford University, Bldg. 420, 450 Serra Mall, Stanford, CA
94305, USA. Tel: +1 650 725 2449; E-mail: email@example.com
ª2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 867–876 867
the cross-cutting edge
‘The [doctor’s] tone of voice, their whole
demeanour changes to me. They change when
they treat somebody White as opposed to [some-
one Black]. They look at me and everything
changes. They want to make sure [White
patients] are ok.’ (An African American patient
explaining her distrust in doctors.
‘The physician …tells the patient [an older Chi-
nese woman] she must begin medication to treat
her newly diagnosed high blood pressure, and
hands her a prescription. The patient nods
respectfully. A year later the patient is seen again
and found to have dangerously high blood pres-
sure, and it becomes clear that she has not been
taking her medication. [What the doctor has
failed to understand is] that nodding or smiling
in many cultures simply means “I hear you and I
want to show you respect”. It does not typically
mean “I agree with you and commit to taking the
treatment you prescribe”.’ (Example of a cultural
misunderstanding from an article on instructing
doctors in cultural competence.
Race inﬂuences many aspects of interactions
between doctors and patients, including the quality
of communication during medical treatment. As the
examples cited here illustrate, it can play a role not
only in what patients and doctors say, but also in
the nature and meaning of their non-verbal behav-
iour towards one another. For a variety of reasons,
a doctor’s tone of voice, facial expression, posture
or degree of eye contact can shift when he or she
interacts with a minority group patient, potentially
leading the patient to conclude that the doctor
cares less about that patient than about patients of
another race. At the same time, a patient’s own
non-verbal communication, including his or her
facial expressions, level of eye contact or, as in the
second example, nods of agreement may be difﬁ-
cult for a doctor from a different background to
understand. The assumptions and misunderstand-
ings that arise in non-verbal communication have
important consequences for patient trust and satis-
faction, adherence to prescribed medical treatment
and eventual health outcomes. In this article, we
summarise research from the ﬁeld of social psychol-
ogy into the ways in which race can affect doctors’
and patients’ non-verbal communication, and dis-
cuss subsequent outcomes of patients’ medical visits
and treatment. We then outline a number of sug-
gestions for improving non-verbal communication
between doctors and patients of different racial or
DISTRUST AND DISSATISFACTION AMONG RACIAL
Members of racial minority groups report consider-
ably more dissatisfaction with their health care than
Trust in doctors is a particular
concern. For example, African American patients are
less likely than White patients to trust their doctors
and to feel that their doctors listen to them,
communicate well, and treat them with dignity and
Compared with White patients, African
American patients also feel that doctors do not
involve them in medical decisions, which leaves them
less satisﬁed overall with medical visits.
dissatisfaction are especially pronounced in encoun-
ters in which doctors and patients have different
which is a common experience
for people from many racial minority groups.
A patient’s trust, satisfaction and relationship with
his or her doctor have important consequences for
adherence with prescribed treatment and for long-
term follow-up, which themselves are important to
Because differences in adherence
to medical treatment may contribute to racial dis-
parities in health,
identifying the sources of racial
minorities’ relative dissatisfaction with and distrust
in their doctors is especially pressing.
Many factors contribute to this lack of trust in doctors
and dissatisfaction with their care. Suspicion of insti-
tutions that have historically treated particular groups
poorly, actual differences in doctors’ treatment deci-
sions, and concerns about discrimination may be at
However, even in the absence of overt bias,
subtler differences in the doctor–patient interactions
experienced by White and minority group patients,
respectively, may produce these discrepancies in trust
and satisfaction. The non-verbal behaviour of doctors
and patients is one key component to consider.
We focus here primarily on interactions between
White doctors and African American patients, largely
because these are the two groups on which the
social psychological research we review has tended
to focus. However, many processes similar to those
we describe in this article may also unfold in interac-
tions between doctors and patients who come from
a variety of different backgrounds. In general, doc-
tors interacting with patients who differ from them
in socially meaningful ways, such as racial group
868 ª2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 867–876
C S Levine & N Ambady
membership, may shift their behaviour in subtle but
important manners that have consequences for the
doctor–patient relationship and the patient’s even-
tual health outcomes. Likewise, doctors may have
particular difﬁculty in accurately interpreting the
non-verbal behaviours of patients whose back-
grounds differ signiﬁcantly from their own. Further,
although non-verbal miscommunications can and do
occur between any two members of different groups,
they may be especially likely or especially pro-
nounced when the doctor is from a dominant or
powerful social group and the patient is from the
minority or less powerful group. We revisit this issue
of generalisability to other groups and elaborate on
this issue at the end of this paper.
DOCTORS’ NON-VERBAL BEHAVIOUR TOWARDS
WHITE AND NON-WHITE PATIENTS
American society values and promotes ideas and
practices of racial equality, but at the same time,
many of its institutions (e.g. the media) perpetuate
stereotypes about racial groups.
These two fea-
tures of American society can lead people, including
doctors, to exhibit different non-verbal behaviours
towards, respectively, White individuals and mem-
bers of racial minorities. Speciﬁcally, both stereo-
types about minorities, and concerns about
appearing prejudiced can contribute to disengaged
or inattentive non-verbal behaviours on the part of
doctors. Both can give rise to what we will refer to
throughout this paper as non-verbal behaviour that
conveys disengagement on the part of the doctor.
This includes a collection of subtle behaviours such
as sitting further away, leaning forward less, averting
one’s eyes, gesturing less, ﬁdgeting, nodding less,
having an open body posture, or exhibiting more
facial rigidity, all of which may convey lack of atten-
tion or empathy towards a patient.
non-verbal behaviours that convey engagement,
such as sitting close to the patient, leaning forward,
making eye contact, nodding, having a closed body
posture and exhibiting facial expressiveness, can
have more positive consequences for the doctor–
Importantly, behaving in
these ways does not necessarily mean the doctor is
actually engaged or disengaged. Rather, these labels
describe the messages that these sets of behaviours
tend to convey to the patient.
Firstly, doctors may hold stereotypical ideas about
what patients of other races are like. Some doctors
might, for example, believe that African American
patients are of lower intelligence, more likely to
abuse drugs and less likely to follow medical advice
than White patients,
or they might hold other
negative views about patients who are not White.
The assimilation of these stereotypes can derive
merely from living in this society and being exposed
to American culture (e.g. the media).
including doctors, know the negative stereotypes
prevalent in their culture and may harbour stereo-
typical associations, even without consciously realis-
Furthermore, these stereotypes may come
to mind automatically when a person who holds
them encounters someone of the relevant racial
group, even in people who value equality and genu-
inely do not want to discriminate according to
In fact, merely being in a position of power
in an interaction (e.g. being the doctor in a doctor–
patient interaction) makes stereotypes especially
likely to come to mind.
Valuing equality and explicitly wishing to behave
fairly can go a long way towards promoting effective
interracial doctor–patient interactions. Doctors who
try to be unbiased can avoid obvious discriminatory
behaviours towards a non-White patient.
ever, when it comes to subtler components of inter-
actions, unconsciously activated stereotypes can exert
their inﬂuence. Doctors who hold negative stereotyp-
ical beliefs about their patients’ racial groups may
display non-verbal behaviour that conveys disengage-
ment towards these patients, even if they are unaware
of doing so.
This may be especially true when
the doctor is rushed and lacks the time or attention
to devote to considering these subtle behaviours.
Concerns about appearing prejudiced
Ironically, for different reasons, concerns about
appearing prejudiced –in a society that explicitly
values not appearing prejudiced –can have similarly
disadvantageous consequences through doctors’
subtle, non-verbal behaviours. Social norms in many
contexts dictate that one ought not to behave in a
racially biased manner,
and many doctors genu-
inely do not wish to treat patients differently based
on the patient’s race. Because interactions with
minority group patients present situations in which
it is possible for White doctors to appear biased
(even if they are not), these contexts can make
White doctors anxious or apprehensive.
ety can create cognitive demands that, ironically,
lead to types of behaviour that are associated with
prejudice, namely, non-verbal behaviours that con-
ª2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 867–876 869
Non-verbal behaviour and racial disparity
There is little research on non-verbal behaviours
towards minorities in a speciﬁcally medical setting.
However, one study using audio-recordings of doc-
tor–patient interactions found that doctors were
more dominant, had less positive affect, and were
less patient-centred in their communication with
African American than with White patients.
and the larger literature on interracial interactions,
suggests that White doctors are likely to behave in a
more disengaged manner when interacting with
minority group patients.
Consequences of behaviour conveying disengagement
The type of non-verbal behaviour that doctors might
display towards racial minority patients has impor-
tant consequences. Patients report less satisfaction
with visits when doctors’ non-verbal behaviour indi-
cates that they are disengaged.
indicate engagement make patients feel their doc-
tors are paying close attention to them and treating
them with respect.
These ﬁndings hold across a
wide range of patient complaints, from chest pain
to risk for human immunodeﬁciency virus (HIV)
infection to depression,
and are strongest when
patients have more serious ailments.
Part of this satisfaction may stem from what occurs
during a medical visit. When doctors’ non-verbal
behaviour conveys engagement, patients disclose
more about medical symptoms and social and psy-
Patients are also more
likely to bring up structural and organisational fac-
tors that interfere with health and wellness.
thermore, not only do patients reveal more
themselves, but they respond better to what the
doctor tells them. Speciﬁcally, they tend to agree
more with their doctor,
and at the end of the visit,
understand their conditions better.
Further, the beneﬁts derived from these encounters
matter when patients leave their doctors’ ofﬁces.
Doctor engagement in non-verbal behaviour helps
to build relationships with patients that, in turn,
inﬂuence patient intentions to comply with the doc-
Indeed, doctors’ communication
skills, including the effectiveness of their non-verbal
behaviour, are associated with patients’ adherence
to prescribed treatment.
Perhaps as a result of patient satisfaction with and
adherence to treatment, the doctor’s non-verbal
behaviour also matters to the patient’s long-term
prognosis. Patients whose health care providers’
non-verbal behaviour conveys engagement experi-
ence greater reduction in a variety of symptoms. By
contrast, doctor behaviours that convey disengage-
ment are associated with poorer outcomes.
relationship extends to outcomes in psychological
illnesses, such as depression, and outcomes in ill-
nesses such as cancer.
Thus, a doctor’s non-verbal
behaviour has both immediate consequences at a
patient’s ﬁrst visit and longer-term consequences for
the patient’s eventual recovery and well-being. Doc-
tors’ non-verbal behaviour inﬂuences not only
patients’ satisfaction with their medical care, but
also their overall health.
UNDERSTANDING PATIENTS’ NON-VERBAL
Another important component of building the rela-
tionship between the doctor and patient is the doc-
tor’s understanding of the non-verbal behaviour of
the patient. In order to build trusting relationships
with their patients and to effectively elicit information
from them, doctors must not only hear what their
patients are saying, but must be able to effectively read
their non-verbal behaviours. As people, especially
majority group members, are less skilled in reading
the non-verbal behaviours of minority group mem-
White doctors may not be properly effective in
responding to and treating minority group patients.
Racial differences in patients’ non-verbal behaviours
Although there are some commonalities in non-
verbal behaviours across race, a patient’s racial or
ethnic background can be an important determi-
nant of his or her non-verbal behaviour. Therefore,
race may inﬂuence how a patient behaves in
interactions with his or her doctor.
The expression of emotions is one important area
in which a patient’s non-verbal behaviour may differ
as a function of his or her background. Patients’
cultural backgrounds are likely to affect the emo-
tions they feel or want to feel in certain situations
(T Sims, J L Tsai, B Koopman-Holm, E A C
Thomas, M K Goldstein; ‘Valuing excitement shapes
medical choices’; unpublished paper, 2013),
well as the likelihood that they will express these
For instance, whereas people from
Western backgrounds tend to want to feel excite-
ment and other positive states that are high in arou-
sal, many from East Asian cultural contexts tend to
place more value on positive states that are lower in
arousal (e.g. feelings of calm and peacefulness).
Furthermore, when emotions are expressed, a
870 ª2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 867–876
C S Levine & N Ambady
person’s cultural background can affect his or her
particular manner of expression in meaningful and
Because people have more
experience and familiarity with their own cultural
context, they are better at identifying the emotions
of people from their own in-group.
group members, such as White people in the USA,
have particular difﬁculty in recognising the emo-
tional expressions of minority group members.
Thus, White doctors or others who are less likely to
have experience interacting with a diverse set of
individuals may be especially unskilled in picking
up on the emotions of minority group patients.
Racial or ethnic background also affects other
important components of non-verbal behaviour. For
example, White individuals are more likely than
those of other racial groups to make eye contact
during interaction and to use eye contact to signal
whether they are paying attention to their conversa-
tion partner and are engaged in the conversa-
Ethnic background may also affect the
extent to which a person is comfortable during a
conversation, as well as how likely he or she is to ini-
tiate a conversation.
Some of these differences arise from divergent cul-
tural values. For example, to Native Americans and
people of Hispanic origin, averting one’s gaze or
waiting to speak until one is spoken to can signal
respect for a conversation partner.
ences, however, can arise out of discrepancies in
power, such as that between majority and minority
racial groups in the USA, and the stereotyped views
groups hold of the other. People who are high in
status tend to have a more open posture, be more
emotionally expressive, gesture more, and put less
distance between themselves and others than people
who are low in status.
with individuals who sit further away, lean forward
less, make less eye contact, have a less open body
posture, and make more speech errors –the types of
behaviour more likely to be directed towards non-
White patients –can lead people to behave the same
way in return.
Finally, even in the absence of
biased behaviour, the stress and fatigue caused by
worrying about possible discrimination may decrease
a person’s engagement with the interaction.
Although these racial differences in non-verbal
behaviour exist, many people, including doctors,
may not recognise some or all of them. As we know,
people tend to have an easier time reading the non-
verbal behaviours of others in their own racial or
Further, majority group mem-
bers often fail to see that out-group members’
behaviour may reﬂect different cultural values and
may misinterpret the behaviour of out-group mem-
As a result, they may draw inaccurate con-
clusions from the behaviour of patients whose
cultural backgrounds differ from their own.
Implications of a doctor’s ability to decode
a patient’s non-verbal behaviour
Relatively little literature exists on the correlates of
doctors’ ability to read patients’ non-verbal behav-
iour. However, the research that does exist suggests
that the ability to perceive and accurately interpret
patients’ non-verbal behaviour results in many of the
same positive consequences as their own expressive
non-verbal behaviour. Patients whose doctors are
more sensitive to their non-verbal communication
are more satisﬁed and have better health outcomes.
In one study, the doctor’s non-verbal sensitivity was
found to be correlated with the patient’s sense that
the doctor understood and cared about the patient
and could tell when he or she was worried.
larly, the patient whose doctor has high non-verbal
sensitivity tends to like the doctor more and to see
the doctor as more compassionate.
The beneﬁts extend beyond patient satisfaction.
Doctors who are more skilled in interpreting
patients’ non-verbal behaviour tend to have fewer
appointment cancellations that do not get resched-
uled, which suggests that their patients may adhere
better to ongoing treatment.
whose genetics counsellors have high non-verbal
sensitivity tend to leave the visit with more knowl-
edge and understanding of their own risk for
Finally, doctors who are more
effective in picking up on and responding to
patients’ emotional cues tend to have shorter visits
with patients, perhaps because they are better able
to effectively and efﬁciently elicit and respond to
information from their patients.
these ﬁndings suggest that racial or ethnic differ-
ences between doctors and patients may impair
doctors’ ability to accurately read their patients’
non-verbal behaviour, which may, in turn, have
negative consequences for the development of trust
within the relationship and for patient health.
THE ROLE OF DOCTOR RACE
Both a doctor’s behaviour towards a patient and a
doctor’s ability to accurate read a patient’s non-ver-
ª2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 867–876 871
Non-verbal behaviour and racial disparity
bal behaviour will, of course, depend not only on
the patient’s race, but also on the doctor’s race.
Some of the difﬁculties in non-verbal communica-
tion we describe here are likely to occur in any
interaction between a doctor and patient from dif-
ferent racial groups, whereas others will be some-
what more common in encounters with doctors
from particular groups. A doctor’s own seemingly
disengaged non-verbal behaviour may stem from
negative stereotypes that doctor holds about the
patient’s racial group and concerns about appear-
ing prejudiced. Doctors of any race may hold nega-
although doctors who themselves
have experienced discrimination may be more moti-
vated to critically examine or change their own
in a way that lessens their effects. Similarly,
any doctor may be concerned about appearing prej-
udiced. However, such concerns may loom espe-
cially large for White doctors, who are more likely
to have had their equitable treatment of others
questioned in the past.
tion of patients’ non-verbal communication, by con-
trast, may occur in any interaction between a doctor
and a patient from different groups. Furthermore,
the likelihood of each of these potential difﬁculties
will depend upon the past experiences of the doc-
tor and the patient, as well as the characteristics of
the setting in which they are interacting. Doctors
who have had a great deal of experience in interact-
ing successfully with patients from other groups or
in working in settings in which they are not judged
too harshly for the occasional misstep in communi-
cation with patients are in a better position to con-
duct productive interactions and relationships with
patients. The challenge for the medical profession
concerns how doctor training and patient treatment
can be set up to most effectively foster these posi-
Understanding the ways in which non-verbal
behaviours contribute to patient satisfaction and
health outcomes is the ﬁrst step in uncovering
possible solutions to racial disparities in health
care. Three types of solution seem promising. The
ﬁrst set of potential solutions targets the sources
of such behaviours (i.e. doctors’ stereotyped views
and concerns about appearing prejudiced) to
improve doctors’ non-verbal behaviour towards
members of racial minorities. A second group of
solutions aims to improve doctors’ relationships
with patients by enhancing their ability to read
patients’ non-verbal cues. Finally, a third type of
solution aims to interrupt the relationship between
ineffective non-verbal behaviour or ineffective
understanding of non-verbal behaviour and
Changing doctors’ non-verbal behaviour towards
Successful steps to improve interracial doctor-
patient communication involve helping to change
physicians’ negative views about minority patients
and allay their fears about appearing prejudiced in
their interactions with their patients. At ﬁrst glance,
these might seem like contradictory goals; it seems
challenging to both recognise (and counter) the ste-
reotypes that doctors hold and simultaneously quell
their anxiety that they will appear biased. However,
we offer suggestions to address each problem with-
out exacerbating the other.
The most effective way to eliminate doctors’ nega-
tive stereotypes about patients is to provide counter
examples to these stereotypes. Research suggests
that thinking about real or ﬁctional examples of
people who do not conform to stereotypes, as well
as exposure to more positive ideas about negatively
stereotyped groups, can decrease people’s bias
against these groups.
Therefore, medical train-
ing that incorporates stories about patients or mock
patients that deliberately counter negative racial ste-
reotypes could shift White doctors’ unconscious
views of minority group patients. This would, in
turn, change doctors’ non-verbal behaviours towards
Reducing concerns about appearing to be prejudiced
At the same time, doctors need to feel less anxious
that their behaviour with patients might reveal pre-
judice. It would not be effective to simply tell doc-
tors that they do not hold any biases because
stereotypes and biases can themselves be part of the
problem. Instead, doctors must be able to recognise
that bias exists without becoming so anxious about
possibly expressing bias that the interaction suffers.
Research suggests that seeing interracial interactions
as an opportunity to learn and grow can decrease
anxiety and lead to more engaged and effective non-
verbal behaviour in such interactions.
interracial interaction, White individuals who think
they might be seen as prejudiced will worry that even
one mistake will conﬁrm this view. By contrast, when
White people approach such interactions with the
872 ª2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 867–876
C S Levine & N Ambady
idea that they can learn from them, one slip is not as
much of a cause for concern or a source of anxiety;
instead, it is an opportunity for growth. As an addi-
tional beneﬁt, this type of ‘learning mindset’ can
actually reduce the extent to which people endorse
In addition, it may actually open a per-
son up to learning more about race, which in itself
has been shown to reduce racial bias.
Talking explicitly about how bias can be unlearned
and how interactions with patients from other
groups present opportunities for doing so will help
to foster such a learning mindset. In addition, when
discussing racial bias, speaking of behaviours that
may be seen as prejudiced, rather than of preju-
diced people, can help. As behaviours can be chan-
ged, discussing behaviours suggests that learning
and improvement are possible. By contrast, speaking
about bias as a characteristic of a person (e.g. by
describing a person as ‘prejudiced’ or ‘racist’) sug-
gests that this is a permanent part of that person’s
character. Framing bias in this way makes it possible
to discuss –and reduce –the racial bias that people
do have while minimising their anxiety about inter-
actions that might reveal this bias.
Improving doctors’ ability to read minority patients’
Doctors must also learn to accurately recognise
and interpret the non-verbal behaviours of a
diverse group of patients. To this purpose, pro-
grammes speciﬁcally designed to train doctors to
read the non-verbal behaviours of patients might
be most effective. In one study, people who
attempted to identify the emotions on the faces of
people from other cultures and received feedback
after doing so became more accurate over time.
Although this study was conducted with lay people,
another study with medical students suggested that
their communication skills can be improved by
teaching them to more accurately recognise the
emotions on people’s faces.
Although both of
these studies investigated the non-verbal expression
of emotion, similar training programmes that focus
on many different types of non-verbal behaviour
could be developed.
Interrupting the negative consequences of racial
bias and non-verbal behaviours
A ﬁnal potential solution involves addressing the
consequences of doctors’ non-verbal behaviours.
Doctors might learn to recognise the potentially
negative consequences of poor non-verbal commu-
nication and take steps to avoid them. Taking extra
time to ask patients about their lives or displaying
in waiting rooms materials that acknowledge the
diversity of the patient pool may go a long way
towards making minority patients feel comfortable.
Similarly, doctors who are concerned about their
patients’ knowledge and comprehension of their
own conditions might ask patients to describe their
illnesses and treatment in their own words and thus
be able to correct any misunderstandings. Even if
these strategies do not directly improve non-verbal
communication, they may still help to avoid many
of the problems that poor non-verbal communica-
tion can create.
Teaching doctors to approach interracial interac-
tions with the goal of learning could open them to
learning more about race and cultural differences;
such learning might counter harmful stereotypical
knowledge and improve doctors’ abilities to read
others’ non-verbal expressions, in addition to reduc-
ing their anxiety about such interactions. Similarly,
asking more questions to ascertain a patient’s level
of understanding of his or her medical condition
might improve the doctor’s relationship with the
patient in a way that reduces the doctor’s anxiety
about interacting with that patient. These strategies
are not mutually exclusive. Consequently, the wisest
approach might be to implement many of these
Implemented together, these solutions might effec-
tively improve non-verbal communication between
doctors and patients who come from different
racial groups. As we have shown, doctors are likely
to display non-verbal behaviour towards minority
group patients that signiﬁes that they are disen-
gaged, and they are also likely to be less skilled in
reading the non-verbal behaviours of minority
group patients. Both problems impair the
doctor–patient relationship, prevent the effective
communication of information, decrease patients’
adherence to prescribed treatments and harm
Improving the medical experiences and overall
health of African American individuals and of mem-
bers of other minority groups is an important goal
of multiculturalist efforts and cultural competence
training in medical education.
of the role played by non-verbal communication on
the part of both doctors and patients in interactions
ª2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 867–876 873
Non-verbal behaviour and racial disparity
between White doctors and minority group patients
should be a key part of these efforts. Recognition of
how poor non-verbal communication can cause such
doctor–patient interactions to go awry is an impor-
tant step in understanding and addressing racial dis-
parities in trust in the health care system and
potentially even long-term health outcomes.
Contributors: both authors jointly wrote and revised the
manuscript and approved it for publication.
Acknowledgements: we thank Hazel Rose Markus for her
helpful feedback on earlier drafts.
Conﬂicts of interest: none.
Ethical approval: not applicable.
1 Jacobs EA, Rolle I, Ferrans CE, Whitaker EE,
Warnecke RB. Understanding African Americans’
views of the trustworthiness of physicians. J Gen Intern
Med 2006;21 (6):642–7.
2 Rust G, Kondwani K, Martinez R et al. A crash-course
in cultural competence. Ethn Dis 2006;16 (3):29–36.
3 Haviland MG, Morales LS, Dial TH, Pincus HA. Race/
ethnicity, socioeconomic status, and satisfaction with
health care. Am J Med Qual 2005;20 (4):195–203.
4 Institute of Medicine. Unequal Treatment: Confronting
Racial and Ethnic Disparities in Health Care. Washington,
DC: National Academies Press 2002.
5 Boulware LE, Cooper LA, Ratner LE, LaVeist TA,
Powe NR. Race and trust in the health care system.
Public Health Rep 2003;118 (4):358–65.
6 Gordon HS, Street RL, Sharf BF, Kelly PA, Souchek J.
Racial differences in trust and lung cancer patients’
perceptions of physician communication. J Clin Oncol
7 LaVeist TA, Nickerson KJ, Bowie JV. Attitudes about
racism, medical mistrust, and satisfaction with care
among African American and White cardiac patients.
Med Care Res Rev 2000;57 (Suppl 4):146–61.
8 Blendon RJ, Buhr T, Cassidy EF et al. Disparities in
physician care: experiences and perceptions of a
multi-ethnic America. Health Aff 2008;27 (2):507–17.
9 Cooper-Patrick L, Gallo JJ, Gonzales JJ et al. Race,
gender, and partnership in the patient-physician
relationship. JAMA 1999;282 (6):583–9.
10 LaVeist TA, Nuru-Jeter A. Is doctor-patient race
concordance associated with greater satisfaction with
care? J Health Soc Behav 2002;43 (3):296–306.
11 Chen FM, Fryer GE, Phillips RL, Wilson E, Pathman
DE. Patients’ beliefs about racism, preferences for
physician race, and satisfaction with care. Ann Fam
12 Kerse N, Buetow S, Mainous AG et al. Physician-
patient relationship and medication compliance: a
primary care investigation. Ann Fam Med 2004;2
13 Lee Y-Y, Lin JL. The effects of trust in physician on
self-efﬁcacy, adherence and diabetes outcomes. Soc Sci
Med 2009;68 (6):1060–8.
14 Dula A. African American suspicion of the healthcare
system is justiﬁed: what do we do about it? Camb Q
Healthc Ethics 1994;3(03):347–57.
15 Dovidio JF, Gaertner SL. Aversive racism. Adv Exp Soc
16 Gilliam FD, Iyengar S. Prime suspects: the inﬂuence
of local television news on the viewing public. Am J
Polit Sci 2000;44(3):560–73.
17 Robinson JD. Non-verbal communication and
physician–patient interaction: review and new
directions. In: Manusov V, Patterson ML, eds. The
SAGE Handbook of Nonverbal Communication. Thousand
Oaks, CA: Sage Publications 2006;437–59.
18 Sabin JA, Rivara FP, Greenwald AG. Physician implicit
attitudes and stereotypes about race and quality of
medical care. Med Care 2008;46 (7):678–85.
19 van Ryn M, Burke J. The effect of patient race and
socio-economic status on physicians’ perceptions of
patients. Soc Sci Med 2000;50 (6):813–28.
20 Greenwald AG, McGhee DE, Schwartz JLK. Measuring
individual differences in implicit cognition: the
implicit association test. J Pers Soc Psychol 1998;74
21 Jost JT, Hamilton DL. Stereotypes in our culture. In:
Dovidio JF, Glick P, Rudman LA, eds. On the Nature of
Prejudice: Fifty Years After Allport. Malden, MA:
Blackwell Publishing 2005;208–24.
22 Bigler RS, Liben LS. Developmental intergroup
theory: explaining and reducing children’s social
stereotyping and prejudice. Curr Dir Psychol Sci
23 Devine PG. Stereotypes and prejudice: their
automatic and controlled components. J Pers Soc
24 Richeson JA, Ambady N. Effects of situational power
on automatic racial prejudice. J Exp Soc Psychol
25 Dovidio JF, Kawakami K, Gaertner SL. Implicit and
explicit prejudice and interracial interaction. J Pers
Soc Psychol 2002;82 (1):62–8.
26 Dovidio JF, Kawakami K, Johnson C, Johnson B,
Howard A. On the nature of prejudice: automatic
and controlled processes. J Exp Soc Psychol 1997;33
27 Fazio RH, Jackson JR, Dunton BC, Williams CJ.
Variability in automatic activation as an unobtrusive
measure of racial attitudes: a bona ﬁde pipeline? J
Pers Soc Psychol 1995;69 (6):1013–27.
28 McConnell AR, Leibold JM. Relations among the
Implicit Association Test, discriminatory behavior,
and explicit measures of racial attitudes. J Exp Soc
Psychol 2001;37 (5):435–42.
29 Crandall CS, Eshleman A, O’Brien L. Social norms
and the expression and suppression of prejudice: the
874 ª2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 867–876
C S Levine & N Ambady
struggle for internalization. J Pers Soc Psychol 2002;82
30 Stephan WG, Stephan CW. Intergroup anxiety. J Soc
Iss 1985;41 (3):157–75.
31 Feldman RS. Nonverbal behavior, race, and the
classroom teacher. Theory Into Practice 1985;24 (1):45–9.
32 Richeson JA, Shelton JN. When prejudice does not
pay Effects of interracial contact on executive
function. Psych Sci 2003;14 (3):287–90.
33 Trawalter S, Richeson JA. Let’s talk about race, Baby!
When Whites’ and Blacks’ interracial contact
experiences diverge. J Exp Soc Psychol 2008;44
34 Johnson RL, Roter D, Powe NR, Cooper LA. Patient
race/ethnicity and quality of patient-physician
communication during medical visits. Am J Public
Health 2004;94 (12):2084–90.
35 Bensing J. Doctor-patient communication and the
quality of care. Soc Sci Med 1991;32 (11):1301–10.
36 Hall JA, Harrigan JA, Rosenthal R. Nonverbal
behavior in clinician—patient interaction. App Prevent
37 Larsen KM, Smith CK. Assessment of nonverbal
communication in the patient-physician interview. J
Fam Pract 1981;12 (3):481–8.
38 Weinberger M, Greene JY, Mamlin JJ. The impact of
clinical encounter events on patient and physician
satisfaction. Soc Sci Med [E] 1981;15 (3):239–44.
39 Conlee CJ, Olvera J, Vagim NN. The relationships
among physician nonverbal immediacy and measures
of patient satisfaction with physician care. Commun
40 Grifﬁth CH, Wilson JF, Langer S, Haist SA. House
staff nonverbal communication skills and
standardized patient satisfaction. J Gen Inter Med
41 Ben-Sira Z. Lay evaluation of medical treatment and
competence development of a model of the function
of the physician’s affective behavior. Soc Sci Med
42 Bensing J, Kerssens J, Pasch M. Patient-directed gaze
as a tool for discovering and handling psychosocial
problems in general practice. J Nonverb Behav 1995;19
43 Bensing J, Schreurs K, Rijk AD. The role of the
general practitioner’s affective behaviour in medical
encounters. Psychol Health 1996;11 (6):825–38.
44 Beck RS, Daughtridge R, Sloane PD. Physician-patient
communication in the primary care ofﬁce: a systematic
review. J Am Board Fam Pract 2002;15 (1):25–38.
45 Duggan P, Parrott L. Physicians’ nonverbal rapport
building and patients’ talk about the subjective
component of illness. Hum Commun Res 2001;27
46 van Dulmen AM, Verhaak PFM, Bilo HJG. Shifts in
doctor-patient communication during a series of
outpatient consultations in non-insulin-dependent
diabetes mellitus. Patient Educ Couns 1997;30 (3):227–
47 Haskard Zolnierek KB, DiMatteo MR. Physician
communication and patient adherence to treatment:
a meta-analysis. Med Care 2009;47 (8):826–34.
48 Ambady N, Koo J, Rosenthal R, Winograd CH.
Physical therapists’ nonverbal communication
predicts geriatric patients’ health outcomes. Psych
Aging 2002;17 (3):443–52.
49 Kaplan SH, Greenﬁeld S, Ware JE. Assessing the
effects of physician-patient interactions on the
outcomes of chronic disease. Med Care 1989;27 (3)
50 Arora NK. Interacting with cancer patients: the
signiﬁcance of physicians’ communication behavior.
Soc Sci Med 2003;57 (5):791–806.
51 Elfenbein HA, Ambady N. On the universality and
cultural speciﬁcity of emotion recognition: a meta-
analysis. Psychol Bull 2002;128 (2):203–35.
52 Eid M, Diener E. Norms for experiencing emotions
in different cultures: inter- and intranational
differences. J Pers Soc Psychol 2001;81 (5):869–85.
53 Tsai JL. Ideal affect: cultural causes and behavioral
consequences. Persp Psychol Sci 2007;2(3):242–59.
54 Matsumoto D. Cultural similarities and differences in
display rules. Motiv Emot 1990;14 (3):195–214.
55 Matsumoto D. Ethnic differences in affect intensity,
emotion judgments, display rule attitudes, and self-
reported emotional expression in an American
sample. Motiv Emot 1993;17 (2):107–23.
56 Jack RE, Garrod OGB, Yu H, Caldara R, Schyns PG.
Facial expressions of emotion are not culturally
universal. Proc Natl Acad Sci U S A 2012;109
57 Marsh AA, Elfenbein HA, Ambady N. Nonverbal
“accents” cultural differences in facial expressions of
emotion. Psychol Sci 2003;14 (4):373–6.
58 Elfenbein HA, Ambady N. When familiarity breeds
accuracy. J Pers Soc Psychol 2003;85 (2):276–90.
59 Fugita SS, Wexley KN, Hillery JM. Black-White
differences in nonverbal behavior in an interview
setting. J Appl Soc Psychol 1974;4(4):343–50.
60 LaFrance M, Mayo C. Racial differences in gaze
behavior during conversations: two systematic
observational studies. J Pers Soc Psychol 1976;33
61 Smith A. Nonverbal communication among Black
female dyads: an assessment of intimacy, gender, and
race. J Soc Iss 1983;39 (3):55–67.
62 Sue DW, Sue D. Barriers to effective cross-cultural
counseling. J Couns Psychol 1977;24 (5):420–9.
63 Albert RD, Ah Ha I. Latino/Anglo-American
differences in attributions to situations involving
touch and silence. Int J Intercult Relat 2004;28
64 Garrett MT. Understanding the “medicine” of Native
American traditional values: an integrative review.
Couns Val 1999;43 (2):84–98.
65 Ellyson SL, Dovidio JF. Power, dominance, and
nonverbal behavior: basic concepts and issues. In:
Ellison SL, Dovidio JF, eds. Power, Dominance, and
ª2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 867–876 875
Non-verbal behaviour and racial disparity
Nonverbal Behavior. New York: Springer-Verlag 1985;1–
66 Word CO, Zanna MP, Cooper J. The nonverbal
mediation of self-fulﬁlling prophecies in interracial
interaction. J Exp Soc Psychol 1974;10 (2):109–20.
67 Richeson JA, Shelton JN. Negotiating interracial
interactions costs, consequences, and possibilities.
Curr Dir Psychol Sci 2007;16 (6):316–20.
68 Trawalter S,Richeson JA, Shelton JN. Predicting
behavior during interracial interactions: a stress and
coping approach. Pers Soc Psychol Rev 2009;13 (4):243–68.
69 Bailey W, Nowicki S, Cole SP. The ability to decode
nonverbal information in African American, African
and Afro-Caribbean, and European American adults.
J Black Psychol 1998;24 (4):418–31.
70 Weathers MD, Kitsantas P, Lever T et al. Recognition
accuracy and reaction time of vocal expressions of
emotion by African-American and Euro-American
college women. Percept Motor Skill 2004;99 (2):662–8.
71 McIntosh P. White privilege: unpacking the invisible
knapsack. In: Rothenberg PS, ed. Race, Class, and
Gender in the United States: An Integrated Study. New
York: Worth 1998;188–92.
72 Shelton JN, Richeson JA. Intergroup contact and
pluralistic ignorance. J Pers Soc Psychol 2005;88 (1):91–107.
73 Shweder RA. Thinking Through Cultures: Expeditions in
Cultural Psychology. Cambridge, MA: Harvard
University Press 1991.
74 DiMatteo MR, Taranta A, Friedman HS, Prince LM.
Predicting patient satisfaction from physicians’
nonverbal communication skills. Med Care 1980;18
75 Hall JA, Roter DL, Blanch DC, Frankel RM. Observer-
rated rapport in interactions between medical
students and standardized patients. Patient Educ Couns
76 DiMatteo MR, Hays RD, Prince LM. Relationship of
physicians’ nonverbal communication skill to patient
satisfaction, appointment noncompliance, and
physician workload. Health Psychol 1986;5(6):581–94.
77 Roter DL, Erby LH, Hall JA et al. Nonverbal sensitivity:
consequences for learning and satisfaction in genetic
counseling. Health Educ 2008;108 (5):397–410.
78 Levinson W, Gorawara-Bhat R, Lamb J. A study of
patient clues and physician responses in primary care
and surgical settings. JAMA 2000;284 (8):1021–7.
79 Madon S, Guyell M, Aboufadel K, Montiel E, Smith
A, Palumbo P, Jussim L. Ethnic and national
stereotypes: the Princeton trilogy revisited and
revised. Pers Soc Psychol Bull 2001;27(8):996–1010.
80 Rudman LA, Ashmore RD, Gary ML. “Unlearning’
automatic biases: the malleability of implicit prejudice
and stereotypes. J Pers Soc Psychol 2001;81(5):856–68.
81 Shelton JN, Richeson JA. Interracial interactions: a
relational approach. Adv Exp Soc Psychol 2006;38:121–81.
82 Vorauer J, Main K, O’Connel G. How do individuals
expect to be viewed by members of lower status
groups? Content and implications for meta-
stereotypes. J Pers Soc Psychol 1998;75(4):917–37.
83 Cheryan S, Monin B.“Where are you really from?”:
Asian Americans and identity denial. J Pers Soc Psychol
84 Blair IV. The malleability of automatic stereotypes
and prejudice. Pers Soc Psychol Rev 2002;6(3):242–61.
85 Blair IV, Ma JE, Lenton AP. Imagining stereotypes
away: the moderation of implicit stereotypes through
mental imagery. J Pers Soc Psychol 2001;81 (5):828–41.
86 Dasgupta N, Asgari S. Seeing is believing: exposure to
counterstereotypic women leaders and its effect on
the malleability of automatic gender stereotyping. J
Exp Soc Psychol 2004;40 (5):642–58.
87 Dasgupta N, Greenwald AG. On the malleability of
automatic attitudes: combating automatic prejudice
with images of admired and disliked individuals. J Pers
Soc Psychol 2001;81 (5):800–14.
88 Foroni F, Mayr U. The power of a story: new,
automatic associations from a single reading of a
short scenario. Psychon B Rev 2005;12 (1):139–44.
89 Olson MA, Fazio RH. Reducing automatically activated
racial prejudice through implicit evaluative
conditioning. Pers Soc Psychol Bull 2006;32 (4):421–33.
90 Carr PB, Dweck CS, Pauker K. ‘Prejudiced’ behaviour
without prejudice? Beliefs about the malleability of
prejudice affect interracial interactions. J Pers Soc
Psychol 2012;103 (3):452–71.
91 Murphy MC, Richeson JA, Molden DC. Leveraging
motivational mindsets to foster positive interracial
interactions. Soc Pers Psychol Compass 2011;5(2):118–31.
92 Neel R, Shapiro JR. Is racial bias malleable? Whites’
lay theories of racial bias predict divergent strategies
for interracial interactions. J Pers Soc Psychol 2012;103
93 Trawalter S, Richeson JA. Regulatory focus and
executive function after interracial interactions. J Exp
Soc Psychol 2006;42 (3):406–12.
94 Levy SR, Stroessner SJ, Dweck CS. Stereotype
formation and endorsement: the role of implicit
theories. J Pers Soc Psychol 1998;74 (6):1421–36.
95 Rudman LA, Ashmore RD, Gary ML. ‘Unlearning’
automatic biases: the malleability of implicit prejudice
and stereotypes. J Pers Soc Psychol 2001;81 (5):856–68.
96 Elfenbein HA. Learning in emotion judgments:
training and the cross-cultural understanding of facial
expressions. J Nonverb Behav 2006;30 (1):21–36.
97 Endres J, Laidlaw A. Micro-expression recognition
training in medical students: a pilot study. BMC Med
98 Betancourt JR, Green AR, Carillo JE, Park ER.
Cultural competence and health care disparities: key
perspectives and trends. Health Aff 2005;24 (2):499–
99 Institute of Medicine. Crossing the Quality Chasm: A
New Health System for the 21st Century. Washington, DC:
National Academies Press 2001.
Received 9 October 2012; editorial comments to the author 22
October 2012; accepted for publication 25 February 2013
876 ª2013 John Wiley & Sons Ltd. MEDICAL EDUCATION 2013; 47: 867–876
C S Levine & N Ambady