Oh, Say, Can You Say?

An incredible 93 percent of communication is unspoken, says a well-known UCLA study. Add to this stat the fact that many people in the U.S. are unable to read beyond a functional fifth-grade level, and it's easy to understand why what the doctor does often matters a lot more than what she says.

So, what are the two primary, nonverbal ways to shut patients down in a hurry?

• The hand-on-the-doorknob wrap-up statement

What you mean by it:This concludes our time today; I have other patients to care for.

What the patient thinks you mean by it:Next! I've already mentally checked out and so I won't hear anything else you say.

Alternative approach:
Without changing your body position, ask the patient to make a reflective summary statement, recapping what you covered during the visit and outlining any actionable items. Now you're saying, "Let's make sure we're on the same page."

• The head-down, furious-scribbling posture

What you mean by it:Nothing; how else am I going to get my charting finished before next July?

What the patient thinks you mean by it:This writing, not you, is my real work; I'd better write everything down so I don't forget.

Alternative approach:
Let the patient see what's being recorded, either by telling him what you're noting or actually positioning yourself so he can view the computer monitor. Now you're saying, "You share in the responsibility for how this turns out."

Observe patients' actions through this same lens. Maybe they're not ready to change, or to hear what you have to tell them. What happens when a family member comes into the room? Is there a relationship you can leverage?

Here's a real-life example:

I spent an enlightening morning with a group of disgruntled endocrinologists recently. As providers for diabetes patients who frequently have other medical problems that also require continuous, close monitoring, these guys often find themselves at the forefront of chronic illness care initiatives, pay-for-performance pilots, and the like. The endocrinologists were upset at being held accountable - financially and otherwise - for something largely beyond their control, namely, if a patient refuses to give up his two-Krispy-Kremes-a-day habit, why should his doctor be blamed for uncontrolled blood sugar levels? They feel stymied and irritated, and justifiably so.

Rather than throwing up your hands in frustration at your seemingly insurmountable task of convincing patients to make needed lifestyle changes - and, therefore, broadcasting disapproval to your patients - try to focus on the tremendous influence you do have. Improved care-tracking processes, motivational interviewing techniques, and so forth are important tools in encouraging patients to take more responsibility for their health, and they do work. Make sure your nonverbal maneuvers reinforce the message you want patients to hear.

Laurie Hyland Robertson is senior editor of Physicians Practice journal. She regularly conducts practice makeovers for its readers. She can be reached at lrobertson@physicianspractice.com.