Eye contact in patient-centered communication§
Rita Gorawara-Bhata,*, Mary Ann Cookb
aThe University of Chicago, Chicago, USA
bJVC Radiology and Medical Analysis LLC, Clayton, USA
Physician–patient communication comprises both verbal and
nonverbal dimensions . Thus, any comprehensive understand-
ing of physician–patient interaction needs to include an analysis of
verbal as well as nonverbal aspects of communication . While
several instruments exist for studying verbal dimensions, the
nonverbal dimensions have received limited attention . This is
especially true for physician–elderly patient interactions. To
address this gap, prior research by the authors proposed an
instrument to capture the Nonverbal Dimensions in Doctor–
Elderly Patient Transactions (NDEPT) . In this earlier study, we
found eye contact to be the most frequently invoked nonverbal
dimension in physician–elder patient interaction. Building on this
earlier work, the present study seeks to understand the relation-
ship between eye contact and physician–patient interaction in a
sample of elder patients (>65 years of age).
into the patient‘s face, regardless of what the patient does . Eye
contact is salient for understanding physicians’ communicative
behaviors with older patients for several reasons. Older patients’
common functional impairments (e.g. hearing deficits) may limit
their ability for effective verbal communication, leading to a
greater reliance on nonverbal cues. Further, when verbal and
nonverbal aspects are in contradiction, the nonverbal more than
the verbal guides individuals’ behavior . Most importantly,
cognitively and/or verbally impaired older patients perceive the
affective climate of their environment to be more important than
they did prior to their illness . And, eye contact can be critical for
enhancing the affective component of interaction [8,9].
Over the last several decades, patient-centeredness has become
a key indicator of the quality of patient care delivered by
physicians [10,11]. However, patient-centeredness is recognized
as multidimensional, and as of yet there is no universal agreement
on the scope of the term or the means to measure it [12,13]. At the
core of the varied elements used to describe patient-centeredness
is the conception of the patient as an ‘‘experiencing individual
rather than the object of some disease entity’’ [12, see also 14,15].
Patient Education and Counseling 82 (2011) 442–447
A R T I C L EI N F O
Received 2 August 2010
Received in revised form 2 December 2010
Accepted 3 December 2010
A B S T R A C T
Objective: To understand the relationship between eye contact and patient-centered communication
(PC) in physician–elder patient interactions.
Methods: Two instruments—Patient-centered Behavior Coding Instrument (PBCI) and Eurocommunica-
tion Global Ratings Scale—were used to measure PC in 22 National Institute of Aging videotapes. Eye
contact was measured using a refined eye contact scale in NDEPT. Qualitative observational techniques
were used to understand how eye contact can implicate communication.
Results: ‘High’ eye contact tapes were found to be ‘high’ in PC using both instruments. However, the
majority of ‘low’ tapes were also found to be ‘high’ in PC. Physicians’ behavior distinctly differed in two
ways: (1) high tapes were characterized by more ‘sustained’ eye contact episodes; low tapes consisted of
a greater number of ‘brief’ episodes; (2) brief episode tapes showed a greater focus on ‘charts’, i.e.
‘listening’ was bereft of ‘looking’; sustained episodes showed a focus on ‘patients’, i.e. ‘listening’ was
accompanied by ‘looking’ indicating patient-centered communication.
Conclusions: A comprehensive understanding of elder patient–physician interaction needs to include
both—‘listening’ and ‘looking’—components of patient-centered communication.
Practice implications: Eye contact serves as a salient factor in the expression of PC, making it imperative
to incorporate as a nonverbal dimension in PC instruments.
? 2010 Elsevier Ireland Ltd. All rights reserved.
§An earlier version of this manuscript was presented as an Oral presentation at
* Corresponding author at: The University of Chicago, Department of Medicine,
Section of Geriatrics and Palliative Medicine, 5841 S Maryland Avenue, MC 6098,
Chicago, IL 60637, USA. Tel.: +1 773 834 2644.
E-mail address: firstname.lastname@example.org (R. Gorawara-Bhat).
Contents lists available at ScienceDirect
Patient Education and Counseling
journal homepage: www.elsevier.com/locate/pateducou
0738-3991/$ – see front matter ? 2010 Elsevier Ireland Ltd. All rights reserved.
Patient–physician communication is a key to highlighting the
individual’s experience [16,17]. Therefore, the present paper
focuses on elucidating physicians’ communicative behaviors
during interaction, i.e. facilitating and/or inhibiting behaviors that
and health in general [18,19]. Understanding patient-centered
communication(PC) is particularlysalient for elderly patients with
their unique needs and expectations since physicians’ communi-
cative behaviors need to be responsive to their choice of topics and
style of communication (instrumental versus affective) to be
The main goal of the present paper is to ask the question: does
eye contact have any relationship within the narrow construct of
PC given above? In this research, eye contact is measured using
NDEPT  and PC is measured using the Patient-centered Behavior
Coding Instrument (PBCI) developed specifically to code facilitat-
ing and inhibiting behaviors in the interaction . Since PBCI had
chose to include this instrument as well.
2.1. Sample and methodology
PC and eye contact were measured by viewing videotapes of
routine clinical visits. The present study is a secondary analysis of
50 National Institute of Aging (NIA) archived videotapes of
eye contact was coded based on percent of time physician makes
eye contact with patient during the encounter. We found that the
measured eye contact followed a standard bell curve, with
medium eye contact (35–65% of the time) in the maximum
number of tapes (N = 28); low eye contact (0–34% of time) in 9
tapes; and high eye contact (66–100% of time) in 13 tapes. For the
present analysis only ‘high’ (N = 13) and ‘low’ (N = 9) tapes—for a
total of 22—were selected to easily distinguish between PC
As indicated elsewhere, each videotaped clinical visit can be
portion comprises the history-taking and post-physical exam
discussion. During history-taking, both physician and patient are
actively engaged in asking and answering questions. The history
taking segment also involves more of ‘patient-initiated’ and less of
‘doctor-initiated’ utterances  with the physician listening and
(likely) displaying attention to the patient’s story. Thus, this
segment, more than any other, affords the latitude for eye contact
and patient-centered communication evaluation. Consequently, in
the present study, we used the history-taking portion for
elucidating the relationship between eye contact and PC.
2.2. Eye contact instrument (nonverbal dimension)
The 22 tapes identified above were used by one coder (RGB) for
measuring eye contact. A focused review of a sample of ‘high’ (3)
and ‘low’ (2) eye contact tapes highlighted the nuancesof the types
of eye contact made by physicians. For example, some tapes
showed fleeting amounts of eye contact made more frequently,
while others showed instances in which physicians made eye
contact over a longer duration but with less frequency. These
examples underscored the fact that the total length of eye contact
as originally proposed in the NDEPT instrument may not capture
the gestalt of gaze for fully understanding the implications for PC.
Therefore, the eye contact measurement was further refined to
incorporate two elements: (1) type of eye contact episodes; (2)
frequency of these episodes. Two specific types of eye contact were
(2) ‘Sustained’ (>10 s).
2.3. Patient-centered communication (verbal dimension)—
As indicated earlier we chose two observation-based instru-
ments to measure PC: (i) PBCI and (ii) Eurocommunication Scale.
Initially two tapes were coded with these two instruments by both
coders (RGB and MAC); results were identical. Thus, having
established reliability between the two coders for both instru-
ments, the 20 remaining tapes were independently coded by the
two coders, with each coder using one of two instruments.
2.3.1. Patient-centered Behavior Coding Instrument (PBCI)
PBCI is an interaction behavior coding instrument designed to
assess patient-centeredness in medical encounters  by tallying
physician facilitating and inhibiting behaviors. The inclusion of
nonverbal behaviors in the PBCI is limited to gestures, nods or
facial expressions and eye contact is not explicitly identified. Thus
the focus of PBCI is more on verbal dimensions rather than
nonverbal aspects [for details, see 18]. We used PBCI mainly to
code, ‘‘verbal encouragement to continue talking’’ (echoing
included) to understand the ways in which patient-centered
communication manifests in the encounter. This sub-item is
operationalized as: physician verbally encouraging the patient to
continue their story, expressed as: (a) Explicit encouragement: ‘‘go
on, yes’’; (b) Neutral Expressions: ‘‘uh-huh, Mmm’’; (c) Interjec-
tions: brief conclusions, ‘‘so you want....’’ .
The 22 tapes were analyzed using a scoring range from 1 = not
at all; 2 = some small degree; 3 = medium degree; 4 = high; and,
5 = to a very high degree, and NA = not applicable. We chose to
the eye contact scoring of ‘‘low,’’ ‘‘medium,’’ or ‘‘high,’’ by
collapsing the 1 and 2 into 1 = ‘‘low’’ PC category; 3 = 2 or
‘‘medium’’ PC category; and 4 and 5 into a 3 or ‘‘high’’ PC category.
2.3.2. Eurocommunication Scale
This scale enables measuring global ratings of patient-centered
communication on a 3-point scale as ‘‘not very often’’, ‘‘moderate-
ly’’ to ‘‘very often.’’ The nonverbal dimensions included are:
looking, nodding, active attitude, and lean backwards. This
instrument allowed for operationalizing global ratings of PC by
noting when physicians:
(1) encourage patients to express in their own words their
complaints, problems, anxiety and concerns,
(2) encourage patients to decide about their treatment plan,
preferences and concerns,
(3) are in general receptive/responsive towards patient, i.e. listen/
answer in the right context.
Again, the history taking segments of 22 tapes were analyzed
using the above scale.
2.4. Analysis of eye contact and PC
To pursue our goal of gaining qualitative insight into how eye
contact gets interwoven with communication, we adapted and
followed research methods of conversational organization [24–26]
to document how patients monitor doctors’ movements and
direction of gaze to coordinate their own turns of talk to the
physician’s level of engagement. Thus, we conducted systematic
observations ofthe organization of
(including nonverbal and verbal communication) during the
history-taking phase of 22 tapes.
R. Gorawara-Bhat, M.A. Cook/Patient Education and Counseling 82 (2011) 442–447
3.1. Patient-centered communication using PBCI Scale
Using the scoring method described earlier, verbal expressions
of physicians in the 22 tapes were found to be distributed on the
three sub-items as follows:
(1) Explicit encouragement (‘Go on’, ‘tell’)—22 of 22 visits.
(2) Neutral Expressions (‘uh-huh’, ‘Mmm’)—15 of 22 visits.
(3) Interjections (‘So you want...’)—7 of 22 visits.
Using the collapsed 3-point scale, 20 visits were coded as ‘high’
and two visits were coded ‘low’ for PC.
3.2. Patient-centered communication using Eurocommunication
The main results from the analysis of the history-taking
segment of 22 tapes showed that physicians:
(1) Were generally receptive to the patients in the majority (20 of
22) of visits.
(2) Encouraged patients to express complaints, problems, anxi-
eties and concerns in a little over half (13 of 22) of visits.
(3) Encouraged patients to share in decision-making in about a
third (8 of 22) of visits (this particular finding is not a focus of
the present study).
3.3. Eye contact
The length of the history taking segment of the visits ranges
from 0.30 to 22.98 min. Since the time spent in listening to the
patient’s history is dependent on their medical condition and the
ensuing interaction between patient and physician, eye contact
was measured as a percentage of the time spent in history taking
rather than as the absolute length of time. Measured in this
fashion, eye contact duration varied from 3 to 97% for the 22 tapes.
well-known that ‘thin slices’ of interaction are widely used in
understanding both social life outcomes [27,28] and medical care
outcomes [29–31], we accepted even the low tapes as adequate in
length for this analysis.
The qualitative description along with characteristics of ‘high’
and ‘low’ eye contact tapes (N = 22) are summarized in Table 1. The
average length of the history-taking segment in both the ‘high’ and
‘low’ eye contact tapes was not significantly different (6.9 and
6.7 min). However, the percentage of time spent in making eye
contact in the ‘high’ tapes was distinctly different from, and more
than three times that in the ‘low’ tapes (80% versus 25%). Further,
the dominant type of eye contact in the ‘high’ and ‘low’ tapes was
also different. Brief episodes occurred more often in ‘low’ as
opposed to ‘high’ tapes (44 versus 10). In contrast, ‘sustained’
episodes occurred more frequently in ‘high’ rather than in ‘low’
tapes (41 versus 3). Of the ‘low’ tapes, all (9) exhibited ‘brief’ eye
contact episodes, and only about half (4) of these displayed
‘sustained’ episodes. Interestingly, in the 13 ‘high’ tapes, all
included ‘sustained’ episodes and less than half (5) included ‘brief’
Visual behavior of physicians and patients was also noted.
Patients in both ‘high’ and ‘low’ eye contact tapes visually followed
the physicians’ facial expressions and movements in the exam
room. Physicians visual behavior, on the other hand varied. In the
‘low’ tapes, physicians focused on patients’ charts—reading,
writing in them, arranging sheets into the folder and such. They
made eye contact with patients only when they initiated talk with
the patient; and never when the patients initiated talk. On the
listened attentively to what the patient was saying; their
techniques for explaining were conducted in an active and
therapeutic manner. Most importantly, they made eye contact
with patients’ both when they talked and when patients initiated
3.4. Relationship between PC and eye contact
tapes showed ‘low’ eye contact ratings. As one would expect, the
13 ‘high’ eye contact tapes were also rated ‘high’ on PC using the
Eurocommunication Rating Scale. However, the 9 ‘low’ eye
contact tapes were also rated as ‘high’ in PC. Similarly, the PBCI
showed the 13 ‘high’ eye contact tapes as ‘high’ in PC. However
again, of the 9 tapes ‘low’ in eye contact only 2 were coded ‘low’ in
PC, and the remainder 7 tapes were coded ‘high’ in PC. That is, 13
‘high’ eye contact tapes were concordant on eye contact and PC
(using both instruments). However, seven or nine tapes were
used. Since, it is logical to assume that tapes ‘high’ in eye contact
would also be ‘high’ in PC, and those ‘low’ in eye contact would be
‘low’ in PC, the discrepant results led us to ask whether they were
measuring the same domain conceptualized as ‘‘patient-centered
eye contact measurements could lead to discrepancies in how PC
is read. This dilemma led us to consider a qualitative examination
of what factors go to the making of ‘high’ and ‘low’ eye contact
tapes. Therefore, our next step entailed a systematic observation
Characteristics of high and low eye contact visits; N=22.
Characteristics Low eye contact (N=9) High eye contact (N=13)
Average length (range) of history-taking segment
Average duration (range) of eye contact
Type of eye contact
(a) Total # of brief episodes
(b) Total # of sustained episodes
(a) Occurrence of brief episodes
(b) Occurrence of sustained episodes
In all 9 visits
In 4 visits
In 5 visits
In all 13 visits
Patient visual behavior during
Physician behavior during
Follows physician’s facial expressions
and movements in exam room
Focuses on chart
Reads, writes, pages through sheets in chart
Makes eye contact when physician
speaks, NEVER when patients initiate talk
Follows physician’s facial expressions,
movements, actions in exam room
Focuses on patient
Listens attentively, discusses, explains
Makes eye contact when physician talks
AND when patients initiate talk
R. Gorawara-Bhat, M.A. Cook/Patient Education and Counseling 82 (2011) 442–447
of videotapes to understand the nuances of eye contact in the
medical interaction and consequent implications for PC. Two
examples, one each from the high and low tapes are presented as
3.4.1. Examples of ‘high’ and ‘low’ eye contact videotapes
22.214.171.124. Example 1—high eye contact. An 89-year-old patient
dressed in street clothes is seated on a chair in the exam room,
facing an exam table on the left and physicians’ desk on the right
(such that the physician would have his back to the patient when
sitting in the rolling stool and writing at the desk). The physician
enters, greets the patient, proceeds to the desk to pick up his chart,
moves the rolling stool so as to face the patient at a comfortable
distance, sits down, makes eye contact with the patient and listens
attentively (italics added for emphasis). The patient begins to relate
an incident that occurred, for which he now claims that he needs
the physician’s help. The physician encourages him to relate his
story—a good example of the physicians’ responsiveness to the
patient’s verbal clues. Further, he moves his rolling stool to seat
himself about two and a half feet from, and facing the patient
directly. It becomes apparent that in addition to being verbally
supportive, the physician has modified and used existing physical
setting attributes to physically structure the setting of the
interaction so as to enhance his interaction via eye contact with
the patient. The interaction continues with physician ‘looking’ and
‘listening’ to patient; and elder-patient ‘looking’ and ‘talking’ to
126.96.36.199. Example 2—low eye contact. A patient sits on the width
edge of the exam table facing the physician who is reviewing the
patient’s chart at a counter at the opposite end of the exam room.
As the patient begins to tell her story of ‘‘not good’’ events that
happened since the last visit, the physician is seen walking across
the exam room to a desk, fumbling in drawers, looking for some
item, not even once looking towards the patient who continues the
story, and visually follows the physician’s movements across the
room. The patient is intently narrating the two ‘‘not good’’ events
that have happened—one, a condition of the femur patella that has
gotten aggravated to the point where she may have to undergo
While the patient is intently looking for the physician’s
response as exhibited by her visually following the physician’s
movements, the physician continues to search for the item,
making no eye contact with the patient. The entire history taking
segment continues with patient ‘looking’ and ‘talking’ to
physician, who is ‘not looking,’ perhaps ‘listening,’ but definitely
busy with searching for something in the chart and in the desk
The first tape is an example of high PC and high eye contact.
However, in the second tape the verbal speech alone indicated that
the physician was ‘listening’ to the patient; and the interaction
could thus be categorized as ‘high’ in PC using either of the two
instruments.But,a systematicvisualobservationof thetapebrings
forth the nonverbal behavior of the physician including traversing
the exam room busily searching for something in drawers,
reviewing the patient’s chart, and with no eye contact with the
patient. Thus, the above two examples show that while the
likelihood of a ‘high’ eye contact tape getting coded as ‘high’ is
great, the possibility of a ‘low’ eye contact tape getting erroneously
coded as ‘high’ in PC also has a high probability of occurring in the
above two instruments.
4. Discussion and conclusions
‘low’ eye contact tapes were distinctly different. ‘High’ eye contact
tapes (13) were rated ‘high’ in PC using both scales. Physicians in
these visits exhibited PC through using all means to encourage
patients to continue talking—explicit encouragement, neutral
expressions and interjections in their verbal speech. Further, these
tapes were characterized by sustained episodes of eye contact. In
Ruusvuori  and others [24,26] have described the importance
of coordination of speech and gaze for displaying engagement in
interaction. As illustrated in Example 1, both participants
displayed mutual engagement in interaction with each other.
This representation is termed ‘‘the patient embodied’’ [32,26] and
described as a deliberate and active behavior in which the
physician tries to understand, and consciously gives his attention
to the patient. And displaying attention to the patients’ story by
gaze at critical points of narration can be seen as one constituent of
a patient-centered consultation [32,33,9]. In other words, ‘listen-
ing’ that is characterized by displaying alignment with the patient
and that includes ‘looking’ as a key component is considered
critical for patient-centered communication .
In contrast, as evidenced in Example 2, low eye contact tapes
were characterized by physicians’ focus on medical administra-
tive tasks such as reviewing patients’ charts, corroborating what
Ruusvuori  and Robinson  have termed ‘‘patient
inscribed,’’ and equated with a ‘‘doctor-centered’’ orientation.
Recent research also provides further evidence for these findings
on the relevance of eye contact at appropriate junctures for the
organization of patient-centered communication . Further, in
these tapes, physicians’ speech behaviors comprised mainly
neutral expressions, with limited interjections. Most important-
ly, these visits were marked by brief episodes of eye contact. In
other words, ‘‘listening’’ was taking place with limited (or
without) ‘‘looking.’’ Eckes  would describe our observation in
Example 2 as ‘‘hearing’’—a biological operation of sensory
apparatus—sound waves entering our ears and subsequently
being transmitted to the brain. And it is known that ‘‘hearing’’
alone is not enough to achieve a patient-centered communica-
Patients show a preference for ‘looking’ while ‘listening’ to their
physicians, perhaps trying to absorb information through both
visual and auditory channels. Thus, patients not only ‘take in’ what
physicians are saying/doing, but also consciously and actively
follow the physician’s movements, trying to establish a visual
contact with him/her . These finding further support the
hypothesis, ‘‘within the normative order of conversation, if a
gazing recipient is not found, the speaker will engage in certain
practices in order to secure the gaze of the intended recipient’’
[24,25]. Thus, Example 2 presents a case of none or limited eye
contact, and demonstrates the way in which patient-centered
communication could be inhibited in the interaction.
Systematic observations of the 22 tapes repeatedly show that
‘‘looking’’ is a central component of ‘‘listening.’’ In elder patient–
......and if you let it go, and it gets real bad, then they have to do
Hmmm.......(while writing in chart on a counter, and walking to
desk searching for some item in a cabinet, all done without
any eye contact with patient)
I got glaucoma ......I went to the eye doctor last month and the
pressure was up 38...he (doctor) almost was (stunned)....
Yeah?....(while continuing to focus on searching for item in cabinet)
R. Gorawara-Bhat, M.A. Cook/Patient Education and Counseling 82 (2011) 442–447
of the static, dynamic and kinesic attributes of the exam room .
For example, our earlier research has shown that average eye
contact increased in the visit:
(1) by 18% when physician’s desk was NOT included in the
(2) by 16% when physicians maintained NO height difference
between themselves and their patients, and
(3) by 15–22% when physicians adjusted the static and dynamic
attributes into a spatial configuration that facilitated physi-
cians’ affective expressions.
Thus it is possible to appropriately modify the spatial
configurations of exam rooms to enhance eye contact that in turn
generates an affective climate [see also 9,33].
Beyond eye contact, other kinesic attributes, e.g. nodding
[1,39]; postural orientation [32,40,41,26]; gesturing [24,25]; facial
expression  have been shown to play a role in the expression of
PC in the medical interaction. Therefore, future work in integrating
nonverbal dimensions for a patient-centered communication
would entail developing a systematic taxonomy of specific
nonverbal dimensions influencing various domains of PC, and
understanding how these relationships unfold in the medical
The present secondary analysis relied on videotaped interac-
tions recorded in an earlier project and archived for use by
researchers of doctor–elder patient communication . Since no
patient estimations were obtained in the initial study, they have
not been part of the present study either. Our method for including
the patient perspective was to document patient gaze, e.g. patient
following the physician as the physician moved around the room.
This is a limitation of the current study and future studies should
include a means of measuring patients’ estimation of patient-
4.2. Relevance and application of qualitative methodology in health
The greatest advantage of using qualitative methods is the
latitude it offers researchers for unearthing reasons for the
occurrence of a phenomenon, rather than providing numbers to
illustrate associations [42–45]. Therefore, this methodology was
deemed to be most appropriate for understanding the ways in
which eye contact can implicate patient-centered communication
in the visit. While, a number of nonverbal dimensions have been
mentioned in the literature as facilitating/inhibiting PC, there is, to
our knowledge, no systematic research on how exactly these
unfold in the interaction, and how they are responded to by
participants, thus lacking a precise means to enable researchers to
draw inferences about patient-centered communication in clinical
encounters. At such a stage, qualitative methodologies that
emphasize field observations, documentation and interpretation
techniques drawing from conversational organization are invalu-
able [24,46]. These methods helped generate insights and
hypotheses about the reasons for, and mechanisms through which
observed relationships between eye contact and PC become
Based on a qualitative analysis of 22 videotapes of physician
elder–patient interaction, the major findings of the present
a. The total duration of eye contact may not adequately capture
details of interaction. We refined NDEPT to include type of eye
contact (sustained or brief) and the frequency of occurrence to
capture the subtle nuances in medical interactions.
b. Associating eye contact with two observation-based PC instru-
ments (Eurocommunication Scale and PBCI), we found:
(i) ‘High’ eye contact tapes showed ‘high’ PC measurements.
c. Systematic observational techniques showed that high and low
eye contact tapes were distinctly different from each other. High
tapes were characterized by more sustained episodes of eye
contact, in contrast to low tapes that consisted of a greater
number of brief episodes.
d. Eye contact is an integral component of patient-centered
communication that becomes interwoven with verbal commu-
nication at critical junctures over the duration of the clinical
4.4. Practice implications
1. Research on implications of nonverbal dimensions for commu-
nication is still in its nascent stages. Therefore, the most
efficacious way to highlight these processes is through
qualitative methodologies of observation, documentation, and
interpretation in a sequential organization of observable
2. The refined eye contact measure would need integration into
3. It is recommended that existing and future instruments
designed to measure PC: (a) integrate eye contact and the
refined means to measure it as part of the tool, and (b)
simultaneously measure verbal and nonverbal dimensions
occurring in the interaction.
‘‘I confirmall patient/personal identifiers havebeen removed or
disguisedsothe patient/person(s)describedarenot identifiable
and cannot be identified through the details of the story.’’
Conflict of interest statement
This is to confirm that we, the authors of this manuscript, have
no actual or potential conflict of interest including any financial,
personal or other relationships with other people or organizations
within three years of beginning the submitted work that could
inappropriately influence, or be perceived to influence, their work.
Role of funding
This research was supported by The Section of Geriatrics (RGB)
and JVC Radiology (MAC).
The original research was supported by AHRQ # (1 RO3 HS01
4088-01A1) (RGB) and NIA Grant No. R44 AG15737 (MAC). The
investigators retained full independence in the conduct of this
The authors would like to acknowledge the support and
encouragement of William Dale, MD, PhD, Section Chief of
Geriatrics and Palliative Medicine, Department of Medicine, The
University of Chicago (RGB) and of JVC Radiology (MAC).
 Harrigan JA, Rosenthal R. Nonverbal aspects of empathy and rapport in
physician–patient interaction. In: Blanck PD, Buck R, Rosenthal R, editors.
R. Gorawara-Bhat, M.A. Cook/Patient Education and Counseling 82 (2011) 442–447
Nonverbal communication in the clinical context. University Park: The Penn- Download full-text
sylvania State University Press; 1986. p. 36–73.
 Finset A. Nonverbal communication—an important key to in-depth under-
standing of provider-patient interaction (Editorial). Patient Educ Couns
 Mast MS. On the importance of nonverbal communication in the physician–
patient interaction. Patient Educ Couns 2007;67:315–8.
 Gorawara-Bhat R, Cook MA, Sachs GA. Nonverbal communication in doctor–
elderly patient transactions (NDEPT): development of a tool. Patient Educ
 Exline RV, Fehr BJ. The assessment of gaze and mutual gaze. In: Scherer KR,
Ekman P, editors. Handbook of methods in nonverbal behavior research.
Cambridge: Cambridge University Press; 1982. p. 91–135.
 Mehrabian A. Nonverbal communication. New Brunswick, NJ: Aldine Trans-
 Bartol MA. Nonverbal communication in patients with Alzheimer’s disease. J
Gerontol Nurs 1979;5:21–31.
 Bensing J, Van Dulmen S. From cue to concern: the role of physicians’ verbal
and nonverbal behavior. In: Proceedings of the International Conference on
Communication in Healthcare; 2005.
 Bensing JM, Kerssens JJ, van der Pasch M. Patient-directed gaze as a tool for
discovering and handling psychosocial problems in general practice. J Non-
verbal Behav 1995;19:223–42.
 Committee onQualityof HealthCare in America.Crossing thequality chasm: a
new health system for the 21st century. Washington, DC: Institute of Medi-
cine; National Academies Press; 2001.
 Beach MC. Patient-centeredness as an indicator of quality. In: Towards health
equity and patient–centeredness: integrating health literacy, disparities, re-
duction and quality improvement; 2008.
 Mead N, Bower P. Patient-centeredness: a conceptual framework and review
of the empirical literature. Patient Educ Couns 2000;51:1087–110.
 Epstein RM, Franks P, Fiscella K, Shields CG, Meldrum SC, Kravitz RL, et al.
Measuring patient-centered communication in patient–physician consulta-
tions: theoretical and practical issues. Soc Sci Med 2005;61:1516–28.
 Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, WestonWW, et al. The
impact of patient-centered care on outcomes. J Fam Pract 2000;49:805–7.
 Epstein RM. The science of patient-centered care (Commentary). J Fam Pract
 Bensing J. Bridging the gap. The separate worlds of evidence-based medicine
and patient-centered medicine. Patient Educ Couns 2000;39:17–25.
 Epstein RM. Mindful Practice. J Amer Med Assoc 1999;282:833–9.
 Zandbelt LC, Smets EMA, Oort FJ, de Haes HCJM. Coding patient-centred
behaviour in the medical encounter. Soc Sci Med 2005;61:661–71.
 Levenstein JH, McCracken EC, McWhinney IR, Stewart MA, Brown JB. The
patient-centred clinical method. 1. A model for the doctor–patient interaction
in family medicine. Fam Pract 1986;3:24–30.
 Zandbelt L, Smets EMA, Oort FJ, de Haes HCJM. Patient Centred Behavior
Coding Instrument (PBCI): sequence and channels; May 2006.
 van den Brink-Muinen A, van Dulmen AM, Bensing JM. Eurocommunication II:
a comparative study between countries in Central and Western-Europe on
doctor–patient communication in general practice. Utrecht, the Netherlands:
NIVEL; Final Report, January; 2003.
 Mead N, Bower P. Measuring patient-centeredness: a comparison of three
observation-based instruments. Patient Educ Couns 2000;39:71–80.
 Goldberg DP, Jenkins L, Millar T, Faragher EB. The ability of trainee general
practitioners to identify psychological distress among their patients. Psychol
 Goodwin C. Conversational organization: interaction between speakers and
hearers. New York: Academic Press; 1981.
 Heath C. Body movement and speech in medical interaction. Cambridge:
Cambridge University Press; 1986.
 Robinson JD. Getting down to business: talk, gaze and body orientation
during openings of doctor–patient consultations. Health Commun 1998;25:
 Gladwell M. The theory of thin slices: how a little bit of knowledge goes a long
way (Chapter 1). In: Blink: the power of thinking without thinking. New York,
NY: Little Brown and Company; 2005. pp. 18–47.
 Ambady N, Bernieri FJ, Richeson JA. Towards a histology of social behavior:
judgmental accuracy from thin slices of the behavioral stream. In: Zanna MP,
editor. Advances in social psychology, vol. 32. 2000. p. 201–71.
 Levinson W, Roter DL, Mulloly JP, Dull VT, Frankel RM. Physician–patient
physicians and surgeons. J Amer Med Assoc 1997;277:553–9.
 Ambady N, LaPlante D, Nguyen T, Rosenthal R, Chaumeton N, Levinson W.
Surgeons’ tone of voice: a clue to malpractice history. Surgery 2002;132:
 Ambady N, Koo J, Rosenthal R, Winograd CH. Physical therapists’ nonverbal
communication predicts geriatric patients; health outcomes. Psychol Aging
 Ruusvuori J. Looking means listening: coordinating displays of engagement in
doctor–patient interaction. Soc Sci Med 2001;52:1093–108.
 Roter D, Hall J. Doctors talking with patients/patients talking with doctors:
improving communication in medical visits. Westport Connecticut: Auburn
 Fredriksson L. Modes of relating in a caring conversation: a research synthesis
on presence, touch and listening. J Adv Nurs 1999;30:1167–76.
 MargalitRS,Roter DL,DunevantMA,LarsonS, ReisS. Electronicmedicalrecord
use and physician–patient communication: an observational study of Israeli
primary care encounters. Patient Educ Couns 2006;61:134–41.
 Eckes LM. Active listening. Gastroenterol Nurs 1996;6:219–20.
 Kemper BJ. Therapeutic listening: developing the concept. J Psychosoc Nurs
 Koshi KT. I only have ears for you. Nurs Times 1989;30:26–9.
 Matteo RM, Prince LM, Hays R. Nonverbal communication in the medical
context: the physician–patient relationship. In: Blanck PD, Buck R, Rosenthal
R, editors. Nonverbal communication in the clinical context. University Park:
The Pennsylvania State University Press; 1986. p. 74–98.
 Kendon A. Conductinginteraction: patternsof behavior in focused encounters.
Cambridge: Cambridge University Press; 1990.
 Teresi JA, Ramirez M, Ocepek-Welikson K, Cook MA. The development and
psychometric analyses of ADEPT: an instrument for assessing the interactions
between doctors and their elderly patients. Ann Behav Med 2005;30:
 Gorawara-Bhat R. The social and spatial ecology of work: the case of a survey
research organization. New York: Plenum Studies in Work and Industry; 2000 .
 Crabtree BF, Miller WL. Overview of qualitative research methods. In: Doing
qualitative research2nd ed., Thousand Oaks, CA: Sage Publications Inc.; 1999.
 Cobb AK, Forbes S. Qualitative research: what does it have to offer to the
gerontologist? J Gerontol 2002;57A:M197–202.
 Black N. Why we need observational studies to evaluate the effectiveness of
health care. Brit Med J 1996;312:1215–8.
 Morse JM, Swanson JM, Kuzel AJ, editors. The nature of qualitative evidence.
Thousand Oaks, CA: Sage Publications Inc.; 2001.
R. Gorawara-Bhat, M.A. Cook/Patient Education and Counseling 82 (2011) 442–447