Chapter 12 Establishing Rapport

Robert E. Rakel

Chapter contents

Respect 147

Patient Satisfaction 147

Patient Dissatisfaction 148

Communication 148

Verbal Communication 148

Nonverbal Communication 149

Paralanguage 149

Hidden or Masked Communication and Patients’ Expectations 158

Listening Well 158

Rapport comes from the French en rapport, which means “in harmony with.” Rapport is most easily established during the patient’s first visit, and achieving rapport enhances the likelihood that the patient will comply with the treatment plan. When rapport has been established, patients are more likely to forgive a less than perfect experience or an unexpected poor clinical outcome.

Even the most knowledgeable and skilled physician will have limited effectiveness if he or she is unable to develop rapport with patients. Unfortunately, rapport is one of those intangibles that is more than the sum of its parts. Rapport is not analyzed easily within any one body of knowledge. The basis of rapport, however, is the development of communication skills that instill in patients a sense of confidence and trust by conveying sincerity and an interest in their care and well-being. The patient’s satisfaction and compliance with the physician’s instructions (both measures of rapport) depend on the ability of the physician to communicate understanding, compassion, and genuine interest in the patient and to display a thorough approach to solving the patient’s problems. Patient satisfaction also is related to the physician’s efforts in educating patients about the disease process and motivating them to participate in their treatment.

Failure of communication between physician and patient also can affect the outcome of treatment, often as seriously as an error in treatment. More complaints against physicians result from a breakdown of the caring aspect of the doctor-patient relationship than from the technical quality of treatment.

Most complaints against physicians—and those that too frequently lead to legal action—are the result of a lack of communication between physician and patient. The potential for a serious problem always exists when a patient is inadequately informed regarding a diagnostic procedure, treatment, prognosis, or anticipated cost. The misunderstandings that result cause unnecessary expense and grief for both parties.

Similarly, the worries that result from distorted information can jeopardize the physician-patient relationship. When a patient is discussed on hospital rounds or with a colleague in the office, take care that the discussion is not within the patient’s hearing distance or within that of other patients. Patients overhearing the conversation may believe the comments apply to them, or they may know the patient involved and relay the information in a distorted manner. Fragments of such conversations, overheard by the patient or others, are too easily taken out of context and can become the focus of fearful fantasies that only serve to increase uneasiness and apprehension.

Compassion, interest, and thoroughness are essential components of successful patient care. These features traditionally have been embodied in the term bedside manner, which also connotes qualities of concern, kindness, friendliness, wit, and cheerfulness, all of which result in an atmosphere of trust and confidence between physician and patient. The physician with the best bedside manner may be the one who makes no special effort to communicate these feelings but acts in a concerned, natural, and comfortable manner.

Oliver Wendell Holmes said that to be effective, the physician should “speak softly, be well-dressed, have quiet ways and have eyes that do not wander” (1883, p. 388). Lack of eye contact may be interpreted as a lack of concern. A good first impression is certainly a great help in establishing rapport. You do not get a second chance to create a first impression. The physician should approach the patient in an assured, confident (but not cocky or arrogant) manner and present a personal appearance that is acceptable to the patient. Empathetic frankness and honesty are important factors in instilling confidence and trust.

Personal appearance is a significant part of nonverbal communication. Patients consider house staff who wear white coats with conventional street clothes as more competent than those who wear scrub suits. If white coats are worn, the patient sees only the collar, tie, and shoes, and it is therefore important to keep these items neat.

Posture is also important in conveying an image of confidence and competence. Standing erect, moving briskly with head up and stomach in, is better than slouching. Energetic people seldom slump; they sit upright and appear alert. A listless or lethargic appearance can be interpreted as lack of concern.

Before entering the examining room or hospital room to see a patient, review the record briefly and become familiar with the patient’s name and its proper pronunciation. If the pronunciation is unusual or difficult, place phonetic markings on the chart as a reminder for future use. Repeat the patient’s name when first given it to confirm the pronunciation, and then use the name twice in the first minute to help it register. Review the medical record for particular aspects of the previous visit that should be remembered and commented on, such as the illness treated at that time, family conditions, or other problems. Patients will believe that the well-informed physician is truly interested in them. Additional courtesy, such as opening the door and assisting patients with their coats (especially elderly patients), shows a consideration that aids in establishing and maintaining rapport.

Respect

Patients should believe that their comments are being listened to, carefully considered, and taken seriously. They must believe that the physician values their comments and opinions before trusting him or her with information of a more personal nature. As long as the physician’s attitude toward the patient embodies respect, concern, and kindness and a sincere effort is made to understand the patient’s difficulties, the patient will overlook or forgive myriad other problems.

Oliver Wendell Holmes advised patients to “Choose a man who is personally agreeable, for a daily visit from an intelligent, amiable, pleasant, sympathetic person will cost you no more than one from a sloven or a boor, and his presence will do more for you than any prescription the other will order” (1883, p. 391).

A lack of confidence, rather than an excess of it, may lead physicians to appear aloof and unconcerned. Too often, physicians think that a godlike image of omnipotence is necessary for the maintenance of the patient’s respect and confidence. It is usually a lack of self-confidence that causes physicians to retreat behind this protective image, which limits their ability to help. Secure physicians are freer to establish close personal relationships with patients without fearing their position will be threatened. A physician with a positive self-image is also willing to recognize and admit the limits of personal competence and feels comfortable seeking help from a colleague when such consultation is of value to the patient’s care.

The bond of mutual respect is enhanced if the physician makes positive statements about other people. Patients find it difficult to respect a physician who is regularly detractive, making negative statements about other people or other physicians. Any comments that can be interpreted as “building yourself up by tearing someone else down” merely accomplish the reverse.

The effectiveness of physicians depends on the degree of their insight into the limitations of their personalities and the psychological defenses that distort their perceptions of patients. Physicians must recognize patients or situations that make them unreasonably angry or provoked (e.g., a whining, complaining individual who shows no interest in being rehabilitated, preferring a role of social dependency). The physician’s emotions, if they go unrecognized, can serve as a barrier to the development of mutual respect. If the physician is aware of negative feelings toward a patient, an effort can be made to avoid showing signs of irritation or anger. It has been said that clenching of the physician’s fist is a clinical sign of a hysterical patient. The physician should attempt to remain objective and analyze the situation for its diagnostic value.

Patients with trivial complaints or somatic manifestations of emotional disease sometimes are given less attention than those with clear-cut organic abnormalities. The frequency with which a physician complains about the triviality and inappropriateness of patients’ problems has been found to be related to the volume of patients seen and the degree to which the physician feels overburdened. The more patients that physicians see and the more overloaded their practices, the more likely they are to describe patients’ complaints as trivial, inappropriate, or bothersome. Physicians who have more time or take more time per patient, and who investigate the patient’s complaints more thoroughly, frequently uncover significant factors and less often tend to view the complaints as trivial. Respect for patients involves taking their fears and apprehensions seriously and withholding value judgments. Patients who frequently seek help for nonspecific somatic and functional complaints may be depressed (Widmer et al., 1980).

Patient Satisfaction

A close relationship exists between rapport and patient satisfaction, and this chapter deals with the many facets of that relationship. It is important that the physician make an effort to understand what patients are “going through” (not only their pain and discomfort, but also the effect these have on their lives) and communicate this understanding to them.

Most studies indicate that patient satisfaction depends on information and the degree to which the patient understands the illness. Joos and associates (1993) found that patients whose desires for information and attention to emotional and family problems went unmet were significantly less satisfied with their physicians than those whose desires were met. Even patients with chronic diseases who had lived with the problem for years had questions they wanted answered. Their satisfaction was related more strongly to the desire for information and affective support than to whether the physician conducted examinations and tests. The greater the patients’ satisfaction, the more likely they are to comply with treatment recommendations.

Although patient satisfaction is strongly associated with the length of the visit, it can be further enhanced by spending some time talking about nonmedical topics. Even brief chatting about the weather or something nonmedical can give the impression that more time was taken with the patient, thereby reducing the feeling of being rushed through the visit (Gross et al., 1998).

Patient Dissatisfaction

In a typical business, only 4% of customers voice their dissatisfaction. The other 96% say nothing, and 91% never return. This has led to many practices conducting regular patient satisfaction surveys so that problems can be identified.

Communication

The patient should be able to gain access to the clinician on the phone, by e-mail, or by an early appointment, without having to run an obstacle course created by an overly protective staff. Delay in returning a phone call may result in a patient remaining home all day waiting; if the call is not returned at all, the negative effect on rapport is great.

Unwillingness to make communication convenient for the patient usually results in a spiral of increasingly frequent attempts to reach the physician and mounting frustration for everyone. In contrast, physicians who give a high priority to communicating discover that most patients are considerate and even protective of the physician’s time. At the beginning of a practice, patients do a certain amount of testing to determine a physician’s accessibility; physicians who pass the test find that they are rarely inconvenienced by unnecessary calls or patient visits.

Verbal Communication

Much of the communication process in the clinical interview centers on verbal interchange. Symptoms, past medical history, family medical history, and psychosocial data are transmitted primarily by verbal means. The chief complaint is extremely important because it explains why patients believe they need the physician’s help.

Patients who do not mention a concern and who withhold requests are less satisfied with their care and experience less improvement in their symptoms. Bell and colleagues (2001) found that 9% of patients had one or more unvoiced desires and were most hesitant to ask their physician for referrals and for physical therapy. These patients were also less likely to trust their physician. This is an important reason to be sensitive to subtle clues that the patient may be suppressing something important to them. What the patient does not say may be as important as what the patient says.

“Slips of the tongue” or major areas of omission (e.g., a married person who never mentions a spouse) may signify problem areas that, when explored, help establish the interviewer as a perceptive person who understands the underlying issues. The interviewer constantly must consider, “Why is the patient telling me that?” Even simple, casual remarks may be the patient’s way of broaching issues of great concern; the man who says, “Oh, by the way, a friend of mine has been having some chest pain when he walks a lot. Do you think that sounds serious?” may actually be talking about his own concern that he is unable to face directly. A child may be brought to the office with a trivial problem so that the mother has a chance to discuss with the physician something that is troubling her; the child is a calling card, signaling the need to open the communication channel. The physician who is sensitive to these subtle clues and encourages the patient to discuss what is actually troublesome will find that the rapport established allows future interviews to be much more open and direct.

Hand-on-the-Doorknob Syndrome

The patient’s parting phrase is sometimes a clue to the primary reason for the visit, or it may reflect another issue of great concern that is emotionally threatening and could not be voiced until adequate courage was summoned at the moment of departure. It sometimes surfaces as a last, desperate attempt to communicate because, with a hand on door, escape is readily accessible if the physician’s reaction is unfavorable. Reasons for this hidden communication by the patient are important and must be recognized and addressed. Because of fear of rejection or humiliation, the patient may test the physician with minor complaints before mentioning the real reason for the visit (Quill, 1989). The physician must be alert to any unusual behavior during an interview (e.g., slips of the tongue, unexpected responses, overenthusiastic denials) and should search further for the underlying reason for the visit when a patient presents with a trivial complaint that appears inappropriate. It is a good practice to ask the patient routinely at the end of a visit, “Is there anything we have not covered, or anything else you would like to ask me?”

Patients with a fear of cancer, for example, often are unable to voice their concern to the physician. Instead, they present with somatic complaints or contrived reasons that necessitate a complete examination. They are hopeful that the examination will allay their fears without it being necessary to express them openly. A female patient presenting for a complete physical examination actually may be concerned over the possibility of a carcinoma of the breast, which her elder sister might have had at the same age or for which a friend recently had surgery. Such situations emphasize the need for a complete family history and a discussion of any patient concerns in an effort to allow these feelings to surface. Attention then should be paid to alleviating the anxiety. Apprehension regarding cancer is widespread, and the only cure for this fear often is a therapeutic conversation with the physician.

Physicians in private practice who have established rapport during an ongoing relationship with patients communicate more easily than do physicians seeing a patient for the first time in an emergency department (ED). Korsch and Negrete (1972) showed that ED physicians did more talking than the patients, although their perception was just the opposite. This was attributed to interaction with unfamiliar patients by house staff in a setting where the stress level is high and the orientation therapeutic. However, Arntson and Philipsborn (1982) found that physicians in private practice for 26 years who knew their patients and saw them in a low-stress situation for diagnosis or health maintenance also talked more than the patients (twice as long). One difference in the two settings was a strong, reciprocal affective relationship between physician and patient in the private office. If either made an affective statement, the other would respond similarly, whereas in the ED, patients expressed twice as many affective statements as did the physicians.

Vocabulary

The use of appropriate vocabulary assists in establishing rapport by ensuring easy and accurate communication. Phrasing questions in simple language appropriate to the patient’s level of understanding and avoidance of medical jargon help establish a sense of working together. The patient’s cultural background and educational level should be considered, and the physician should avoid using slang or a contrived accent, because the patient will detect the artificiality and consider this patronizing.

Patients prefer to be enlightened, and they demand maximum insight into their care. It is best to start all explanations at a basic level and proceed only as rapidly as the patient’s understanding permits. An analysis of 1057 audiotaped patient interviews with 59 primary care physicians and 65 surgeons showed that in 9 of 10 cases, patients did not receive good explanations of proposed treatments or tests (Braddock et al., 1999).

Medical terminology should be avoided unless it is familiar to the patient. For example, some patients have interpreted “lumbar puncture” to mean “an operation to drain the lungs.” No longer does the physician gain a therapeutic advantage by writing prescriptions in Latin or impressing the patient with medical terms.

Metaphors can be harmful and are often used without the physician being aware of the negative connotation, unknowingly raising the patient’s anxiety level. Attempts to coerce a patient into having surgery with phrases such as “you are living on borrowed time” may cause anxiety and increase postoperative morbidity (Bedell et al., 2004).

Physicians should be sure of what patients mean to convey by their word selection and make certain they are operating at a common level of understanding. When the patient says he or she “drinks a little,” inquire further to clarify “a little.” If the patient “spits up blood,” determine whether it is truly spitting or really vomiting. A major barrier to accurate interpersonal communication is the tendency of people to react to a statement from their own points of view, rather than attempting to interpret it from the speaker’s vantage point. If a question exists regarding the clarity of the interpretation, it is best to repeat it to the speaker’s satisfaction. Contract negotiators have found that when parties in a dispute realize that they are being understood and each party sees how the situation appears to the other, there is less need to exaggerate and act defensively. Korsch and Negrete (1972) found that some of the longest interviews between physician and patient were caused by failures in communication; they had to spend considerable time trying to “get on the same wavelength.” An analysis of the conversations revealed that less than 5% of the physician’s conversation was personal or friendly in nature, and that although most of the physicians believed that they had been friendly, fewer than half of patients had this impression.

Nonverbal Communication

Verbal communication occupies so much of daily social interaction that nonverbal communication often is ignored. However, much that is said is unspoken. Communications specialists have demonstrated convincingly that nonverbal messages play a major role in validating or contradicting verbal messages, with great influence as communication symbols in their own right.

Communication between two people is usually one-third nonverbal. What is said verbally often is emphasized nonverbally, and personal attitudes and emotions usually are communicated at the nonverbal level. Nonverbal communicative signals are under less censorship from conscious control than are verbal messages, so they are likely to be more genuine.

Charles Darwin held that there is a unique pattern of nonverbal actions for each emotion. In Expressions of the Emotions in Man and Animals (1872), Darwin suggested that emotional expressions are evolutionary remnants of previous adaptive behavior that persist even though currently useless. Snarling as a sign of aggression is one example. Although recent knowledge indicates that emotional expression is learned and genetically mediated, Darwin’s idea of a unique pattern of actions has been shown for depression and anxiety and is likely in the future to be demonstrated for other emotional states.

Paralanguage

Paralanguage is the voice effect that accompanies or modifies talking and often communicates meaning. It includes velocity of speech (e.g., fast, slow, hesitant), tone and volume of voice, sighs and grunts, pauses, and inflections. Urgency, sincerity, confidence, hesitation, thoughtfulness, gaiety, sadness, and apprehension all are conveyed by qualities of voice. McCaskey (1979) believes that the literal interpretation (i.e., definition) of words accounts for only 10% of communication between two people, whereas facial expression and tone of voice account for up to 90% of the communication.

There is a real difference between verbal and vocal information. The verbal message refers to the words literally transmitted. The vocal message includes the emotional quality, the tone of voice, and the frequency and length of pauses—information that is lost when the words are written. Tone of voice, for example, can reverse the meaning of words. Sarcasm is a common example of a contradiction between vocal and verbal messages. Comparative studies have shown that when the vocal and verbal messages transmit contradictory information, the vocal is more accurate.

Physicians should be alert to subtle changes of tone, such as when patients ask whether everything will be all right. Are they asking for reassurance, showing fear, or doubting the diagnosis? Rather than concentrating exclusively on what patients are saying, the astute physician will concentrate on how they are saying it.

In a study of recordings of surgeons who had been sued and those who had not, the sued group could be identified by their tone of voice. They sounded dominant, whereas the nonsued group sounded less dominant and more concerned. “In the end it comes down to a matter of respect, and the simplest way that respect is communicated is through tone of voice” (Gladwell, 2005, p.43).

Touch

A close personal interest in the patient can be communicated by the appropriate use of touch. The most socially acceptable method in this country is a handshake, enabling the physician to establish early contact with the patient. The handshake, properly used, can convey to the patient sincerity and interest as well as security and poise. It is an inoffensive intrusion into the other person’s area of privacy and can be extended under certain circumstances to include the application of the left hand to the lower or upper arm. This technique is often used by politicians to emphasize sincerity and concern (Figure 12-1). A variation of the politician’s handshake is the “double-hander,” which some equate to a miniature hug.

Figure 12-1 The politician’s handshake.

The handshake as a traditional greeting of friendship began by the raising of exposed hands by two approaching individuals to give evidence that they held no weapons. This proceeded to the grasping of hands or, in the Roman society, the forearms. In the United States, a firm handshake is most acceptable. Usually, the limp or “wet dishrag” handshake indicates lack of interest or insincerity, especially if it is rapidly withdrawn. A moist palm is a sign of nervousness or apprehension, and the “halfway there,” fingers-only handshake indicates reluctance or indecision. However, the handshake continues to be modified culturally, and a person should be extremely wary of misinterpreting another person’s handshake without understanding his or her cultural background.

In the past in China, the Confucian code of etiquette dictated that there should never be a touching of persons, and even today, Chinese officials may appear reluctant to grasp an extended hand; a Chinese man formerly shook his own hand (Butterfield, 1982). Some young people in the United States have modified the traditional palm-to-palm handshake to a grasping of the thumb and thenar eminence and continue to develop new variations reminiscent of the secret handshakes of fraternal groups.

Touching can be an effective method for communicating concern or compassion and can break down some of the defensive barriers to communication. Caution should be exercised, however, not to use it excessively or earlier than is socially permissible. If used without adequate preparation, touch can be interpreted as an invasion of privacy and a forward and inconsiderate act. During the physical examination, it is best to talk before touching by explaining to the patient what will be done next. Studies of primates have shown that touching gestures usually are considered nonaggressive and calming in nature. When used properly by the physician, touch can be facilitative and welcome.

The tremendous symbolic value of touch as a healing power was demonstrated during the Middle Ages, when people sought relief from scrofula (i.e., tuberculous lymphadenitis) through the king’s touch, or royal touch, despite the notoriously low cure rates. This power has been transferred to physicians, and patients often feel better after a routine physical examination. Friedman (1979) stated that 85% of patients leaving a physician’s office feel better even if they have not received medication or treatment, and 50% of patients in the waiting room feel better in anticipation of the help they will receive.

Touch, or “laying on of hands,” may promote healing, especially if it is imbued by the patient with a special symbolic value. Franz Mesmer (1734–1815) was among the first to emphasize the medical importance of laying on of hands. Mesmer, however, believed that there was a magnetic power in his hands, which he called “animal magnetism” and which he applied to ailing individuals. His theory was unscientific, and although he became famous for successfully treating a number of hysterical patients, he finally was discredited by a committee that included Benjamin Franklin and Antoine Lavoisier. They found his treatments to be without magnetism and essentially useless. They did agree, however, that he had helped many people and had brought about many cures. They attributed these cures to unknown factors rather than to the animal magnetism he claimed. Mesmerism was the forerunner of hypnosis, initially called “artificial somnambulism,” developed by Puysegur, a disciple of Mesmer.

The magic of touch can be good medicine, especially when combined with concern, support, and reassurance. Stroking, a special kind of touching, describes a physical or symbolic recognition of a person’s finer attributes. A stroke may be a kind word, a warm gesture, or a simple touch of the hand. Infants deprived of touch and stroking suffer mental and physical deterioration. Adults also require stroking to maintain a healthy emotional state. Stroking occurs when an interchange between two people leaves one or both with a good or fulfilled feeling.

Lightly touching someone’s elbow for less than 3 seconds can give you up to three times the chance of getting what you want (Pease and Pease, 2004). Elbow touching works better in places where touching is not the cultural norm, such as Great Britain and Germany.

Body Language

The astute physician will cultivate observational skills that enable the detection of hidden or subtle clues to diagnosis contained in the patient’s nonverbal behavior. Kinesics is the study of nonverbal gestures, or body movements, and their meaning as a form of communication. However, specific gestures and their interpretation are of importance only when judged in the context of the circumstances surrounding them. Body language alone does not reveal the entire behavioral image any more than verbal language does alone. Just as one word does not make a sentence or even have much meaning without the sentence, a single gesture has clinical relevance only as part of a sequence of actions. Although they have significance, individual signs are not reliable when they stand alone; they are meaningful only when considered in the context of a person’s total behavioral pattern.

When there is congruence between the verbal and nonverbal message—when the gesture conveys the same message as the spoken word—communication and its meaning are probably in agreement. When a person indicates something different from the other, however, the nonverbal message usually is more accurate. Unless body language, tone of voice, and words spoken all match, look more closely for the reason.

Attempts by the patient to mask feelings can be detected readily by observing body behavior. True feelings are more likely to leak through conscious efforts to conceal feelings. Likewise, a physician’s attempt at deception will be detected by patients and can destroy confidence and damage rapport. Positive verbal communication (e.g., “You’re looking better today”) accompanied by negative nonverbal cues will be interpreted by the patient as insincere. For example, a patient who is not told the true nature of a terminal illness usually knows it anyway and may distrust family, friends, and physician if they persist in the charade.

In a medical school commencement address, Alan Alda (star of TV’s M∗A∗S∗H) challenged new physicians to be able to read a patient’s involuntary muscles as well as their radiographic studies. He asked, “Can you see the fear and uncertainty in my face? If I tell you where it hurts, can you hear in my voice where I ache? I show you my body, but I bring you my person. Will you tell me what you are doing and in words I can understand? Will you tell me when you don’t know what to do?” (Time, May 28, 1979, p. 68). The physician will see the fear and uncertainty in the patient’s face only if she or he is looking at the patient rather than the medical record. Alda’s statement reflects the concern and compassion that patients desire. By using appropriate body language, the physician can convey this attention and concern in the most effective manner possible.

Body Position

The body position when sitting can show various degrees of tension or relaxation. The tense person sits erect with a fairly rigid posture. A person who is moderately relaxed has a forward lean of approximately 20 degrees and a side lean of up to 10 degrees. A very relaxed position (usually too relaxed for physicians interacting with patients) is a backward lean (i.e., recline) of 20 degrees and a sideways lean of more than 10 degrees.

Higher patient satisfaction is associated with a physician’s forward body lean and rotation of the torso toward the patient. Larsen and Smith (1981, p. 487) found that “the patient also responds more favorably to the physician who relaxes his chin in his hands and gazes directly at the patient, rather than a physician who elevates his chin (unsupported) as if to imply a more superior status.” Physicians whose communication styles have been considered patient oriented have been observed to change body position more frequently than physicians whose conversations were physician centered.

An attempt should be made, whenever possible, to sit rather than stand when interviewing a patient. Rapport is improved if the physician does not intimidate the patient by placing him or her in a submissive position. Patients feel more comfortable and less helpless speaking in a sitting position rather than prone. Sitting on the patient’s bed is usually not recommended, but for some patients, it is an effective means of establishing closeness and conveying warmth in a relaxed yet attentive manner.

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