1 Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
ABSTRACT
The COVID-19 pandemic has changed the patient interview. In the context of personal protective equipment and social distancing guidelines, the development of therapeutic alliance proves more difficult than ever. As a new third-year medical student who is experiencing meaningful clinical work for the first time, the challenge of establishing rapport with patients is particularly great. Nonverbal communication is both essential and at risk of being lost in the current clinical environment. It is the author’s concern that the pandemic has rendered body language—both learned and instinctual—at best muffled and at worst impracticable, and that providers must explore unconventional ways to connect with patients. Use of humor and increased time spent at the bedside, amongst other strategies, represent potential solutions to this problem.
Nonverbal communication in the medical setting is a carefully choreographed dance, one in which two partners, physician and patient, exchange meaning through subtle—often imperceptible—physical cues.
As medical students, we learn this dance through direct and explicit instruction from our supervisors. On camera, in simulated clinic rooms with professional patient-actors, we are assessed on our ability to enter a room swiftly but with appropriate warning (a gentle knock, unmistakable but not jarring); wash our hands while facing our patients (to communicate openness); initiate a firm handshake at the right time and with good eye contact; sit down not too close, not too far, all while armed with a wide smile (but not too wide, for fear of appearing inauthentic). Body language is unquestionably instinctive, learned organically through life experience and social development, but the medical school curriculum enhances and reinforces it, thereby making its performance more intentional.
Much of the ‘meat’ of interpersonal communication comes in the space between the words. This third space, unoccupied by either party’s verbal contributions, is populated instead by facial expression, posture, eye contact, arm and hand movement, and physical positioning. These signals are understated and often difficult to identify directly, but through their subconscious interpretation carry great meaning. A nod and unbroken stare say, “I hear you.” An appropriate touch on the arm or shoulder says, “I understand and support you.” Studies have consistently demonstrated that nonverbal communication has a direct effect on patient outcomes. Maintaining eye contact and a respectful closeness in space conveys warmth and attention, and has been shown to increase patient satisfaction [1], [2]. One review of the literature found that nodding, smiling, leaning forward, making respectful contact, and maintaining symmetrical arm position with uncrossed legs were all associated with improved therapeutic alliance between physician and patient [3]. In short, these seemingly trivial acts are anything but—in fact, they play a foundational role in the development of rapport and conveyance of empathy in the medical setting.
I recently finished my first clinical rotation as a third-year medical student: four weeks in a primary care clinic in Pawtucket, Rhode Island. For many medical students like me, the COVID-19 pandemic has provided an opportunity to witness and contribute to a healthcare system stretched to its limits. When I received my ceremonial white coat two years ago, I never considered that my first days of meaningful clinical work would take place in the midst of a global health crisis. The level of flexibility and teamwork on display every day amongst my colleagues is indicative of medicine’s resilience and ethical foundation, the belief that every patient deserves our full effort regardless of the circumstances.
Yet, despite all of our best efforts, it is undeniable that something essential is missing in this new normal. Fresh out of our didactic sessions and simulated patient interviews, students like me are vexed by the challenges of patient interaction in the pandemic. We are painfully aware of how much of our training in nonverbal communication seems impracticable in the current version of clinical practice. White coats and dress clothes are traded for scrubs, gowns, face shields, masks, and gloves. Greetings are offered with nervous waves, muffled words, maybe a mutual bump of the elbow—handshakes are out of the question. Eye contact is made through fogged plastic. Histories are taken, lab results given, good and bad news delivered, all from a safe yet impersonal six-foot distance. Smiles and grimaces stay hidden under blue fabric. That ‘third space’ of communication, once occupied by body language, has been both physically widened and filled with barriers, material and psychological. In short, the nuanced language we learned as preclinical students feels like a forgotten dialect, no longer spoken.
Perhaps this issue is less of a concern for attending physicians, whose experience may allow them to build therapeutic alliance in ways difficult for new students on the wards to replicate. As medical students, we are faced with the task of re-learning the art of the patient interview in a fashion that contradicts both our instruction and our long-held instincts about how to connect with others. It will take time to develop this skill; both patient and provider will need to acknowledge the necessity of learning this new language together, on the fly.
Patients seen in the hospital setting typically experience some level of anxiety associated with their medical condition; these days, that anxiety is often heightened by the concern for potential exposure to the virus while seeking care. Injecting humor, even in the form of a simple joke or quip, into the patient interview may help cut the tension and relieve some of this stress. Acknowledging the strangeness of the situation, laughing about—but not downplaying the importance of—the masks and gowns and shields and gloves, can help minimize the negative effects of those material barriers on caregiver-patient relationships. Studies have suggested that appropriately-used humor can communicate caring and foster interpersonal connection between physician and patient [4]. Across a diversity of different clinical settings including primary care, palliative care, and rehabilitation medicine, humor has been shown to have a positive effect on patient-provider relationships and even health outcomes [5–7]. It is important to recognize, however, that not all patients or situations are equally amenable to humor. Sarcastic or offensive humor have no place in the patient interview and are likely counterproductive to the goal of establishing therapeutic alliance.
When social distancing and layers of personal protective equipment diminish the power of nonverbal communication, the words that are spoken—as well as their tone and volume—attain heightened importance. With kind or compassionate facial expressions obscured by masks, empathy must be conveyed in more explicit fashion through our language. Speaking loudly enough to be heard clearly through face coverings is a simple yet essential component of effective communication in our new clinical reality. Without body language, more words may be required to convey the same meaning; in order to avoid leaving our patients feeling unheard or unsupported, this may mean extending the length of time spent at the bedside. Even the action of chatting for an extra minute about something other than their health—the weather, the news, how they are coping with the pandemic—can help patients feel that they have been given adequate time to express their concerns and have their questions answered. Despite our busy schedules as medical students, we often have more time to spend in direct contact with our patients than the resident or attending physicians. Directing our extra time—a scarce resource in medicine—toward increased patient interaction and improved therapeutic alliance may be the most meaningful way for medical students to contribute to the fight against COVID-19.
In some hospitals, clinical staff are taking a creative approach toward fostering personal connections with their patients. A burgeoning movement called “Share Your Smile” encourages masked students and healthcare workers to tape large, laminated photos of their cheerful faces to the front of their gowns in an effort to put patients at ease. With limits on visitation, video calls are increasingly being used to combat patient isolation and allow for shared conversation and decision making between patient, family, and physician. Newly designed negative pressure respirator helmets being introduced in some hospitals may look like props from a science fiction movie but allow for full view of one’s face by making traditional masks unnecessary.
Now more than ever, our patients are lonely, scared, and in need of human interaction and support. Whether wrestling with the virus or another medical issue, they are confronted with strict visitor restrictions, a tense clinical environment, and a lack of meaningful contact with others. As medical students during the COVID-19 pandemic, we can play a meaningful role in improving our patients’ experiences with healthcare. We must demonstrate our empathy, even if by strategies at odds with our natural instincts and untaught by our pre-pandemic medical school curricula.
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