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Patient Education and Counseling: Stephen G. Henry, Andrea Fuhrel-Forbis, Mary A.M. Rogers, Susan Eggly
Patient Education and Counseling: Stephen G. Henry, Andrea Fuhrel-Forbis, Mary A.M. Rogers, Susan Eggly
Patient Education and Counseling: Stephen G. Henry, Andrea Fuhrel-Forbis, Mary A.M. Rogers, Susan Eggly
Review
A R T I C L E I N F O A B S T R A C T
Article history: Objective: To conduct a systematic review and meta-analysis of studies reporting associations between
Received 25 February 2011 patients and clinicians nonverbal communication during real clinical interactions and clinically
Received in revised form 21 June 2011 relevant outcomes.
Accepted 5 July 2011
Methods: We searched 10 electronic databases, reference lists, and expert contacts for English-language
studies examining associations between nonverbal communication measured through direct observa-
Keywords: tion and either clinician or patient outcomes in adults. Data were systematically extracted and random
Nonverbal communication
effects meta-analyses were performed.
Systematic review
Meta-analysis
Results: 26 observational studies met inclusion criteria. Meta-analysis was performed for patient
Patientclinician communication satisfaction, which was assessed in 65% of studies. Mental and physical health status were evaluated in
Clinically relevant outcomes 23% and 19% of included studies, respectively. Both clinician warmth and clinician listening were
Direct observation associated with greater patient satisfaction (p < 0.001 both). Physician negativity was not related to
patient satisfaction (p = 0.505), but greater nurse negativity was associated with less patient satisfaction
(p < 0.001). Substantial differences in study design and nonverbal measures existed across studies.
Conclusion: Greater clinician warmth, less nurse negativity, and greater clinician listening were
associated with greater patient satisfaction. Additional studies are needed to evaluate the impact of
nonverbal communication on patients mental and physical health.
Practice implications: Communication-based interventions that target clinician warmth and listening
and nurse negativity may lead to greater patient satisfaction.
Published by Elsevier Ireland Ltd.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
2.1. Data source and searches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
2.2. Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
2.3. Data extraction and quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
2.4. Data synthesis and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
4. Discussion and conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
4.1. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
4.2. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
4.3. Practice implications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Appendix A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Appendix B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Appendix C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
* Corresponding author at: Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, 6312 Medical Science Building 1, 1150 W. Medical Center
Drive, Ann Arbor, MI 48109, USA. Tel.: +1 734 647 4844; fax: +1 734 647 3301.
E-mail address: henrstep@umich.edu (S.G. Henry).
Table 1
Inclusion and exclusion criteria for study selection.
Inclusion criteria
Independent variables include nonverbal behaviors measured through direct observation (real-time observation, video recording, or audio recording) of actual
clinical interactions between adult patients and clinicians
Dependent variables include measures of clinically relevant outcomes, including patient or clinician satisfaction
Study reported in Englisha
Exclusion criteria
Studies of nonverbal behavior during interactions conducted for research rather than therapeutic purposes
Studies of composite behavior measures that combined verbal and nonverbal behaviorsb
Studies evaluating nonverbal behaviors for purposes other than communicationc
Studies evaluating measures that could not be observed by interaction participantsd
Studies involving actorse
Studies of gender, age, or race as moderators of communication
Studies of communication involving nonverbal patientsf
Studies with fewer than 20 interactions
a
Studies in languages other than English always included English titles and abstracts, so in order to estimate the number of potentially eligible studies published in
languages other than English, language exclusion criteria were applied at the stage of full article review rather than during the initial search.
b
If studies provided sufcient detail to evaluate the association between specic nonverbal behaviors used in the composite measure and outcomes, those specic
nonverbal behaviors, but not the results from the overall composite measure, were included in the review.
c
For example, studies of therapeutic touch, involuntary movements, vocal tics, pre-post studies of reconstructive procedures, or speech therapy interventions.
d
For example, studies of skin conductance or other physiologic measures.
e
Simulated, standardized, or analog patients.
f
For example, patients in comas or with dementia.
2.3. Data extraction and quality assessment comes; we evaluated summary or composite measures of
nonverbal communication when studies used such measures for
The primary author reviewed all the article titles to exclude their primary analysis. We classied studies according to the types
those that were clearly ineligible, and then reviewed the abstracts of nonverbal communication and outcomes assessed.
of the remaining articles to identify studies that were potentially For those studies in which the communication variable,
eligible. These potentially eligible articles were reviewed in full by outcome variable and estimate of effect were similar for at least
two authors (SGH and AFF) using an abstraction instrument 3 studies, we conducted random effects meta-analyses [42]. Three
developed by the authors (Appendix C). Disagreements about measures of nonverbal communication were evaluated: (1)
study inclusion were resolved by discussion with the senior author clinician warmth, measured by ratings of warmth, caring, or
(SE). In some cases, we emailed study authors for clarication sensitivity; (2) clinician negativity, measured by ratings of
about study design. Seven of the eight authors we contacted negativity, anger, hostility, or being argumentative; and (3)
responded. Multiple studies published in a single article were clinician listening, measured by ratings of listening or interest.
included separately, as were studies reporting different associa- The unifying estimate of effect in these studies was the correlation
tions using the same data. coefcient (r); the Fisher transformation was used to obtain a
As suggested by the Cochrane Collaboration [36] and PRISMA mean and standard error of the normal distribution prior to
guidelines [37], we evaluated each studys risks of bias by examining pooling in meta-analysis. Forest plots were graphed to illustrate
specic study components relevant to this topic and constructing a results across studies. To assess heterogeneity we used Cochrans Q
risk of bias table. We evaluated major sources of bias in test, between-study variation (t2), and I2 (measuring the degree of
observational research, such as participant selection bias and consistency of study results). For studies that reported estimates of
information bias [38]. Several common sources of bias were not effect other than r, we converted these estimates to r and included
applicable to this review because no included studies involved them in meta-analyses whenever possible.
interventions. Potential sources of bias or error relevant to nonverbal
communication research are low inter-rater reliability and failing to 3. Results
account for verbal content [39,40]. Verbal and nonverbal communi-
cation happen simultaneously during interactions, so the interpre- The database search retrieved 6536 articles. Of these, 6269 were
tation of specic nonverbal communication behaviors often excluded after reviewing article titles and another 210 were
depends on both verbal communication behaviors and the topic excluded after reviewing article abstracts. After reviewing the
under discussion. For example, a clinicians smile might convey remaining 51 English-language publications in full, 26 studies met
encouragement and support in the context of a patients successful our inclusion criteria. Fig. 1 summarizes the study selection process.
weight loss, but sadness and empathy in the context of discussing Included studies (23 cohort studies and 3 case-control studies) are
unfavorable test results with a patient. No single criterion standard described in Table 2. Most studies were conducted in the United
exists for controlling for verbal content and context [9,39]. Two States (77%) and in primary care settings (65%). The median sample
common methods are including verbal communication variables as size was 82 interactions [mean = 145; range 20749].
covariates in analyses and restricting the study sample to uniform Included studies generally measured nonverbal communica-
clinical scenarios so that verbal content and the relationship tion using one of two methods: quantifying specic nonverbal
between verbal and nonverbal communication are less likely to behaviors or rating nonverbal communication on global affect
vary between interactions [41]. Potential sources of error and bias scales (e.g., anxiety or warmth). Facial expression was almost
were assessed for the purposes of this review and are not necessarily exclusively evaluated with highly specialized coding systems and
relevant to the original goals of the included studies. so was a notable exception to these two methods. Summaries of
the results from each study, along with the measures of nonverbal
2.4. Data synthesis and analysis communication and outcomes used in each study, are shown in
Table 3.
For included studies, we evaluated all reported associations Patient satisfaction was by far the most commonly assessed
between nonverbal communication and clinically relevant out- outcome; 17 of the 26 included studies measured patient
300 S.G. Henry et al. / Patient Education and Counseling 86 (2012) 297315
Table 2
Study characteristics (studies are organized in reverse chronological order within study design).
Gilbert and Hayes [43] Cohort Primary care clinic 31 nurse practitioners; 155 Patient and clinician body Patient satisfaction; patient
patients; 155 visits language adherence; patient mental
health; patient physical health
Haskard et al. [50] Cohort Primary care clinic 81 nursing staff; 235 patients; Patient and clinician global Patient satisfaction; clinician
235 visits affect satisfaction
Haskard et al., Cohort Primary care clinic 51 physicians; 199 patients; 199 Physician tone of voice Patient satisfaction; clinician
study a [26] visits satisfaction; patient
adherence; patient physical
health; patient mental health
Haskard et al., Cohort Primary care clinic 142 nurses and physicians; 272 Patient and clinician tone of Patient satisfaction; clinician
study b [26] patients; 541 interactionsa voice satisfaction
Prkachin et al. [46] Cohort Workers Compensation Physicians and physical Patient body language; patient Patient physical health; patient
clinic therapistsb; 148 patients; 148 facial expression health care utilization
initial workers compensation
claim evaluations
Troisi et al. [56] Cohort Inpatient psychiatric 1 psychiatrist; 28 patients with Patient facial expression Patient mental health
facility schizophrenia; 28 interviews
Merten [48] Cohort Inpatient psychiatric 10 therapists; 10 patients; 119 Patient and clinician facial Patient mental health
facility therapy sessions expression
Ambady et al. [44] Cohort Inpatient medical 11 physical therapists; 48 Clinician global affect; clinician Patient physical health; patient
facility patients; 57 physical therapy body language; clinician gaze; mental health
sessions clinician facial expression
Koss and Rosenthal [64] Cohort Primary care clinic 24 physicians; 48 patients; 48 Patient and clinician global Patient satisfaction
return visits affect; patient and clinician body
language
Van Dulmen et al. [47] Cohort Internal medicine 1 physician; 18 patients; 44 new Clinician global affect; clinician Patient satisfaction
referral clinic patient visits for diabetes gaze
controlc
Hall et al. [55]d Cohort Primary care clinic 119 clinicians; 749 patients; 749 Patient and clinician tone of Patient mental health; patient
visits voice; clinician body language; physical health
clinician gaze
Greene et al. [74] Cohort Primary care clinic 18 physicians; 81 patients; 81 Patient and clinician (shared) Patient satisfaction
new patient visits laughter
S.G. Henry et al. / Patient Education and Counseling 86 (2012) 297315 301
Table 2 (Continued )
Hall et al., study a [53] Cohort Primary care clinic 50 internists; 97 patients; 97 Clinician gaze; patient and Patient satisfaction
return visits clinician tone of voice
Hall et al., study b [53] Cohort Primary care clinic 127 physicians; 537 patients; Patient and clinician tone of Patient satisfaction
524 return visits voice
von Baeyer [75] Cohort Pain clinic 1 anesthesiologist; 58 patients; Patient global affect; patient Patient health care utilization
58 new patient visits body language
Bensing [52] Cohort Primary care clinic 27 general practitioners; 103 Clinician gaze Patient satisfaction
patients; 103 visits for
hypertension
Larsen and Smith [73] Cohort Primary care clinic 15 physicians; 34 patients; 34 Patient and clinician body Patient satisfaction; patient
new patient visits language; patient and clinician knowledge
eye contact; patient and
clinician touch
Street and Buller [51] Cohort Primary care clinic 10 medical residents; 38 Patient and clinician body Patient satisfaction
patients; 38 visits language; patient and clinician
eye contact; patient and
clinician touch
Comstock et al. [49] Cohort Primary care clinic 15 medical residents; 150 Physician body language Patient satisfaction
patients; 150 visits
Hall et al. [45] Cohort Primary care clinic 2 physicians; 50 patients; 50 Patient and clinician tone of Patient satisfaction; patient
visits voice adherence
Smith and Polis [62] Cohort Primary care clinic 29 physicians; 29 patients; 29 Patient and clinician body Patient satisfaction; patient
new patient visits language; clinician gaze knowledge
Weinberger et al. [61] Cohort Primary care clinic 20 medical residents; 82 Patient and clinician body Patient satisfaction; clinician
patients, 82 visits language; clinician touch satisfaction
Kurtz [63] Cohort Primary care clinic 50 physicians; 50 patients; 50 Clinician body language Patient satisfaction
visits
Rasting and Beutel [67] Case- Inpatient psychiatric 2 therapists; 20 patients; 20 Patient and clinician facial Patient mental health
control facility intake interviews expression
Ambady et al. [57] Case- General and orthopedic 57 general or orthopedic Clinician tone of voice Clinician malpractice history
control surgery clinics surgeons; 114 patients; 114
visits
Dalton et al. [54] Case- Emergency department 28 patients; 28 ED visits for Patient facial expression Patient physical health
control chest paine
a
Included 61 primary care physicians and 81 nurses; 272 patients were rated for 272 physician interactions, 269 of which were preceded by nurse interactions.
b
Number of clinicians not reported; all were physicians or physiotherapists employed to perform workers compensation evaluations.
c
Included initial visit and up to 2 subsequent visits for 18 patients.
d
This meta-analysis report pooled results from several studies. Results by individual study are not available.
e
Clinicianpatient interactions were analyzed based on patient expression during interactions; study does not report number of clinicians, clinician characteristics, or
clinician nonverbal communication.
forest plot of the results. For nurses, there was consistency across Information about potential sources of bias and error in the
studies; the greater the negativity, the less patient satisfaction included studies can be found in the risk of bias table (Table 4).
with the nurses personal manner (pooled estimate of Many authors did not report information about participant refusal
effect = 0.35, 95% CI: 0.53 to 0.17, p < 0.001). For physicians, rates or participant selection bias. Most studies used convenience
however, there was little consistency across studies (p = 0.002 (rather than systematic or random) sampling. Patient attrition was
from Cochrans Q test for heterogeneity, I2 = 79.7%). The pooled rarely reported, but is unlikely to be a problem in cohort studies
estimate of effect for the association between physician negativity that follow patients for only a few hours. Nearly all studies that
and patient satisfaction was 0.07 (95% CI: 0.29 to 0.14; used more than one judge to measure nonverbal communication
p = 0.505). In a sensitivity analysis, we conducted a meta-analysis reported some measure of inter-judge reliability. Only 10 studies
for the association between nurse negativity and patient satisfac- used statistical methods that can control for covariates or
tion with nurses competence. The results were similar to those moderators. Many studies also tested multiple communication-
above (pooled estimate of effect = 0.18 (95% CI: 0.28 to 0.07; outcome associations without adjusting the threshold for type I
p = 0.001), suggesting that nurse negativity is inversely associated error to account for multiple comparisons. For example, research-
with patient satisfaction with nurse competence. ers in one study found that among patients presenting to the
Finally, we conducted a meta-analysis of the association emergency room with chest pain, 4 of 40 separate measures of
between ratings of clinician listening and patient satisfaction facial expression were signicantly associated with positive
across studies [26,49,5153]. The pooled estimate of effect was cardiac enzymes [54]. However, researchers in this study used
0.25 (95% CI: 0.130.37; p < 0.001), suggesting a positive associa- p < 0.1 as the signicance threshold, so on average 4 of 40
tion between patient satisfaction and clinician listening. However, measured associations would meet this threshold by chance alone.
there was considerable variation in the effect across studies, with Finally, only 9 studies used at least one of the strategies mentioned
Cochrans Q statistic = 46.5 (p < 0.001), I2 = 80.7% and t2 = 0.028. previously to control for verbal content when evaluating associa-
For other communicationoutcome pairs investigated in the tions between nonverbal communication and outcomes.
included studies, differences in study design and measures of Two studies assessed patient-reported health status [55] and
nonverbal communication and outcome precluded meta-analysis. clinician-reported mental health status [56] immediately after
For example, eight studies tested associations between body clinical interactions. Although nonverbal communication is
language and patient satisfaction. However, each study used a unlikely to immediately change mental or physical health, it
different method for measuring body language and these measures could immediately change patients and clinicians perceptions of
were too dissimilar to combine across studies. patients health. One casecontrol study evaluated associations
302
Table 3
Results categorized by category of nonverbal communication.
Nonverbal communication Study Nonverbal measure Observation type Outcome Outcome measure Comment on resultsa
Body language
Physician nonverbal gesturesb Comstock Global ratings Real-time Patient satisfaction Satisfaction assessment Not signicant
et al. [49] observation
Physician nonverbal encouragement Weinberger Global rating; Real-time Patient satisfaction; Patient satisfaction More physician nonverbal encouragement (nods, gestures)
and physical distance between et al. [61] distance observation physician satisfaction assessment; physician associated with higher patient (p < 0.001) and clinician
patient and physician satisfaction assessment (p < 0.001) satisfaction; less physical distance between patient
and physician associated with higher patient satisfaction
(p < 0.001)
Physician attentiveness and Kurtz [63] Mehrabian Video without Patient satisfaction Liebig satisfaction Not signicant
dynamism systemc audio measure
Patient and physician distance, Larsen and Mehrabian Video without Patient satisfaction; Satisfaction assessment; More physician neck relation and backward lean associated
body orientation, forward lean, Smith [73] systemc audio patient understanding knowledge assessment with less patient satisfaction (p < 0.01); more direct physician
backward lean, sideways lean, body orientation associated with more patient satisfaction
and limb position (p = 0.05) and better patient understanding (p < 0.01); more
303
304
Table 3 (Continued )
Nonverbal communication Study Nonverbal measure Observation type Outcome Outcome measure Comment on resultsa
Patient and nurse global affect Haskard Global ratings Video without Nurse satisfaction; patient Patient Satisfaction Nurses rated more caring/sensitive (r = 0.33, p < 0.01),
et al. [50] audio satisfaction Questionnaire [90]; professional (r = 0.35, p < 0.01), and less rushed (r = 0.23,
clinician satisfaction p < 0.05) associated with higher patient satisfaction; patients
assessment rated more pleasant (r = 0.30, p < 0.01) and involved (r = 0.30,
p < 0.01) associated with higher patient satisfaction; nurses
rated more caring/sensitive (r = 0.25, p < 0.05) and patients
rated as more accommodating (r = 0.24, p < 0.05) associated
with higher nursing satisfaction
Physical therapist global affect Ambady Global ratings Video without Percent change in patient Confusion assessment At discharge: therapist distancing associated with worse patient
et al. [44] audio functional status and [44]; geriatric activities of daily living (r = 0.34, p < 0.01); more therapist
patient confusion from depression scale [79]; professionalism associated with worse patient depression
admission; patient mental mobility assessment (r = 0.35, p < 0.01); greater therapist nervousness associated
status at discharge scale [52]; physical self- with more patient will to function (r = 0.29, p < 0.05).
maintenance scale [80]; At 3 months: more therapist professionalism (r = 0.51,
will to function p < 0.0005) and nervousness (r = 0.52, p < 0.0005) associated
305
306 S.G. Henry et al. / Patient Education and Counseling 86 (2012) 297315
Percent
Author Year Fisher r (95% CI) Weight
Physician
Hall 1981 0.50 (0.21, 0.78) 6.25
Comstock 1982 0.19 (0.03, 0.35) 16.08
Haskard 2008 study b 0.23 (0.11, 0.35) 24.19
Haskard 2008 study a 0.40 (0.26, 0.54) 19.73
Subtotal (I2 = 54.7%, p = 0.085) 0.31 (0.18, 0.43) 66.25
Nurse
0 .2 .4 .6 .8
Correlation coefficient (higher numbers indicate stronger
positive associations)
Fig. 2. Association between clinician warmth and patient satisfaction.
Physician
Hall 1981 0.39 (0.10, 0.67) 13.66
St
Streett 1987 0 22 ((-0.55,
-0.22 0 55 0.11)
0 11) 12 12
12.12
Nurse
-0.42 (-0.54, -0.30) 19.61
Haskard 2008 study b
Study Study design Clinician Patient Participation rate Attrition rate Statistical analysis Accounts Judges blind to Interrater reliability
selection selection for verbal patient outcome or
strategy strategy communi- research question
cation
Gilbert and Hayes [43] Cohort Systematic Convenience Not reported 45% of clinicians; Multiple linear Yesb Not reported All discrepancies in
99% of patients regression nonverbal behavior
ratings resolved by
principal investigator
Haskard et al. [50] Cohort Systematic Convenience Not reported Not reported Pearson correlation No Not reported Cronbachs alpha = 0.52
for patients, 0.64 for
clinicians
Haskard et al. [26] Cohort Systematic Not reported Not reported Not reported Pearson correlation No Not reported Cronbachs alpha = 0.41
Haskard et al. [26] Cohort Not reported Not reported Not reported Not reported Pearson correlation No Not reported Cronbachs alpha = 0.55
for nursing staff
voice, 0.33 for
307
308 S.G. Henry et al. / Patient Education and Counseling 86 (2012) 297315
Mean interrater
reliability = 0.82
Median r = 0.54
Not reported
Single rater
Single rater
Single rater 4.1. Discussion
Not reported
Not reported
Not reported
Attrition is not applicable to case-control studies; however, in all 3 case-control studies that met inclusion criteria, cases and controls were selected from the same population.
measuring tone of voice [26,45], global affect [50], and body
Yesd
Yesd
Yesd
Yesc
No
No
No
No
No
Pearson correlation
Statistical analysis
Multiple logistic
Multiple linear
Multiple linear
regression and
Unadjusted
regression
odds ratio
analysis
Not applicablef
Attrition rate
Not reported
Not reported
Not reported
Not reported
81% of clinicians;
100% of patients
Not reported for
80% of patientsa
Not reported
Not reported
Not reported
Not reported
Convenience
Convenience
Convenience
Convenience
Systematic
in our meta-analyses.
Studies included in this review illustrate the complicated
potential relationships between nonverbal communication and
Not reported
Not reported
Not reported
Not reported
Convenience
Convenience
strategy
Case-control
Case-control
Case-control
Cohort
Cohort
Cohort
e
c
Our review has several limitations. We were only able to examine nonverbal communication [43,51], and the clustered data struc-
English-language publications (Fig. 1). We did not include unpub- ture common in research on clinicianpatient interactions [71,72].
lished or gray literature in our review and so did not assess Another limitation of the current evidence on associations
publication bias. However, publication bias generally leads to an between nonverbal communication and outcomes is the prepon-
overestimate of signicance [68]. Our review of published studies derance of descriptive, correlational, hypothesis-generating studies.
revealed only a few consistent associations across studies, so our Numerous correlation studies have generated many statistically
conclusions are unlikely to have been affected by excluding signicant associations (e.g., between clinicians neck relaxation and
unpublished research. We did not conduct a comprehensive review patient satisfaction [73]) that are difcult to interpret or build upon.
of nonverbal communication research in non-clinical or simulated Future studies should test specic hypotheses, which could be based
settings, but as discussed previously we believe focusing on real on clinical experience, theories from communication or social
clinical interactions is important in order to evaluate the evidence psychology, or results from prior studies involving students or
that is most directly relevant to real outcomes. Studies of simulated actors. Studies that evaluate interventions targeting nonverbal
or contrived clinical interactions can provide important insights into communication (including clinical trials) could also provide
nonverbal communication, but, by denition, they do not inuence valuable insight regarding the causal pathways underlying associa-
real clinically relevant outcomes. Finally, despite the many potential tions between nonverbal communication and outcomes. To our
direct and indirect ways nonverbal communication may affect knowledge no such studies have been conducted using real clinical
clinical interactions, our review focused only on clinically relevant interactions. Studies that test hypotheses should specify their
outcomes. We believe this focus is critical because efforts to improve analysis plan prospectively and, when applicable, adjust for multiple
communication during clinical interactions should be ultimately comparisons to reduce the probability that statistically signicant
directed towards improving these outcomes. associations occur by chance.
The variety of nonverbal measures in our review reects the
4.2. Conclusion variety and complexity of nonverbal communication. However, the
use of many different measures also makes it difcult to compare
Despite the many challenges of studying nonverbal communi- results across studies. Nonverbal communication researchers
cation during real clinical interactions, the existing literature does should consider developing a consistent set of validated measures
suggest that certain global affect ratings clinician warmth, for research on nonverbal communication during clinical interac-
negativity, and listening are consistently associated with patient tions. Use of similar measures would facilitate comparisons across
satisfaction. We identied no specic nonverbal behaviors or studies and may make it easier for researchers to build on each
gestures (by patients or clinicians) that were consistently others ndings to advance understanding of the links between
associated with clinically relevant outcomes, nor did we identify nonverbal communication and outcomes.
consistent associations between nonverbal communication and Finally, future studies of nonverbal communication and out-
outcomes other than patient satisfaction. comes should follow patients over longer periods of time in order to
While our meta-analyses did not include all possible nonverbal investigate outcomes other than patient satisfaction. For example,
measures, our ndings that some ratings were consistently and following patients for a few months could allow researchers to
signicantly associated with patient satisfaction represent an evaluate whether ratings of clinician warmth are associated with
important contribution to the literature. These associations (e.g., outcomes such as patient adherence and health care utilization.
that greater clinician warmth is associated with greater patient Nonverbal communication during clinical interactions is unlikely to
satisfaction) may seem intuitive or obvious, but it is important to immediately affect patient physical or mental health, but it may lead
critically evaluate whether obvious associations are supported to changes in health that are mediated, for example, through patient
by empirical data. For example, although gaze and eye contact play satisfaction or adherence. Assessing patient physical and mental
an important role in everyday conversations [69], we were unable health over longer time periods would allow investigators to
to perform a meta-analysis to evaluate whether eye contact is investigate these hypotheses prospectively. These recommenda-
consistently or signicantly associated with patient satisfaction tions may seem daunting, but two recent studies in our review
during real clinical interactions. The estimates of effect size from followed all or nearly all of them [43,46]. We believe the majority of
our meta-analyses may also help researchers plan future studies our recommendations can be implemented without setting
that investigate the associations between nonverbal communica- unrealistic expectations for future studies in this eld.
tion and patient satisfaction. As discussed previously, association Researchers who study the verbal components of clinician
does not necessarily imply causation. We believe additional patient communication in isolation have been likened to singers
research on the association between nonverbal communication who study words without music; [11] that is, they can learn a
during real clinical interactions and outcomes is important both to great deal but cannot capture the full meaning and impact of
conrm our ndings and to elucidate the pathways through which communication during clinical interactions. The variety of studies
nonverbal communication and patient satisfaction are related. in this review reects the many different types of nonverbal
Our review suggests that existing research on nonverbal communication (e.g., body language, tone of voice), the wide range
communication during clinical interactions and clinically relevant of outcomes they may inuence, and the difculties inherent in
outcomes is characterized by many of the same strengths and studying nonverbal communication during real clinical interac-
weaknesses that experts in the eld described over 15 years ago tions. Although our ndings indicate associations between
[11]. Therefore, we conclude with recommendations for how clinician warmth, negativity, and listening and patient satisfaction,
future studies can address these limitations and further advance much additional research is needed to better elucidate the
our understanding of the links between nonverbal communication relationship between nonverbal communication and outcomes.
and outcomes. The results of this review and our recommendations for future
First, our ndings suggest that future studies of real clinical studies provide an important starting point for this work.
interactions should take into account the mutual inuence of
clinicians, patients, and context during clinical interactions 4.3. Practice implications
[12,16], and the interrelation of verbal and nonverbal communi-
cation [9,35]. Statistical techniques can be used to account for Nonverbal communication is an important component of face-
mutual inuence [70], the relationship between verbal and to-face clinical interactions, especially for conveying relational or
310 S.G. Henry et al. / Patient Education and Counseling 86 (2012) 297315
83 nonverbal*.mp.
Complete nonverbal communication search:
84 exp Nonverbal Communication/
nonverbal* OR nonverbal communication/exp OR nonverbal
85 exp Interpersonal Relations/ communication OR non verbal OR sign language/exp OR manual
86 interpersonal*.mp. communication OR (human relation/exp OR interpersonal com-
87 or/8086 munication/exp OR interpersonal* OR non verbal OR nonverbal*
Potential nonverbal AND communication AND (facial expression/exp OR gesture/exp OR eye movement/exp
88 79 and 87 OR odor/exp OR body posture/exp OR gait/exp OR emotion/exp
OR touch/exp OR gaze/exp OR personal appearance/exp OR
Complete nonverbal communication set
orientation/exp OR paralanguage OR para language OR physical
89 40 or 88
appearance OR backward lean OR forward lean OR body lean OR
Combined: clinician AND outcomes AND complete nonverbal set
nods OR nodding OR proxemic* OR vocalic* OR silence* OR voice
(limited to humans)
tone OR pauses OR speak time OR back channel OR self touch OR
90 12 and 30 and 89 haptics OR hand shake OR shakes hands OR guard OR guarding OR
91 limit 90 to humans smile OR smiles OR smiling OR looks away OR frown* OR eye
contact OR body position OR bodily position OR physical contact
* The (*) at the end of search statements is an Ovid MEDLINE OR pain behavior OR pain behavior OR encounter event OR
truncation symbol. Using (*) to truncate a search term will return all chronemic* OR kinesic*))
conceivable endings for that term. Therefore, a search for commu- Complete outcomes search:
nica* in effect searches for communication, communicating, AND (satisfaction/de OR patient satisfaction/exp OR recurrent
communicate, etc. The (.mp.), which also appears at the end of disease/exp OR recurrence OR treatment outcome/exp OR patient
many search statements, is an Ovid MEDLINE notation that describes compliance/exp)
the elds that the term will be searched as a keyword. These elds Complete clinician search:
generally include title, abstract, subject headings, substance name, AND (medical specialist/exp OR medical expert/exp OR medical
registry words, among others. The (exp) that appears at the beginning staff/exp OR physician/exp OR physician assistant/exp OR psy-
of many search statements is Ovid MEDLINE code for explode, a chotherapist/exp OR resident/exp OR medical personnel/de OR
concept that relates to MEDLINEs Medical Subject Heading (MeSH) nurse/exp OR doctor patient relation/exp OR clinician*)
terminology. The MeSH terminology is structured hierarchically, and Limits:
an exploded (exp) subject heading will pick up all terms that AND [humans]/lim AND ([embase]/lim OR [embase classic]/lim)
312 S.G. Henry et al. / Patient Education and Counseling 86 (2012) 297315
Channels for NVB: real-time video only A+V audio only filtered audio multiple
Was primary goal to evaluate associations between NVB and outcomes? Y N other: __________
Attempts to control for content when analyzing NVB? Y N other ____________________________
Notes on study:
S.G. Henry et al. / Patient Education and Counseling 86 (2012) 297315 313
#2 #2
#3 #3
#4 #4
#5 #5
#6 #6
#7 #7
#8 #8
#9 #10
#10 #11
References [10] Albrecht TL, Penner LA, Cline RJW, Eggly SS, Ruckdeschel JC. Studying the
process of clinical communication: issues of context, concepts, and research
[1] Haskard-Zolnierek K, DiMatteo MR. Physician communication and patient directions. J Health Commun 2009;14:4756.
adherence to treatment: a meta-analysis. Med Care 2009;47:82634. [11] Hall JA, Harrigan JA, Rosenthal R. Nonverbal behavior in clinician-patient
[2] Mead N, Bower P. Patient-centred consultations and outcomes in primary interaction. Appl Prev Psychol 1995;4:2137.
care: a review of the literature. Patient Educ Couns 2002;48:5161. [12] Street Jr RL, Gordon H, Haidet P. Physicians communication and perceptions of
[3] Williams S, Weinman J, Dale J. Doctorpatient communication and patient patients: is it how they look, how they talk, or is it just the doctor? Soc Sci Med
satisfaction: a review. Fam Pract 1998;15:48092. 2007;65:58698.
[4] Knapp ML, Hall JA. Nonverbal communication in human interaction, 7th ed., [13] Penner LA, Dovidio JF, West TV, Gaertner SL, Albrecht TL, Dailey RK, et al.
Boston, MA: Wadsworth, Cengage Learning; 2009. Aversive racism and medical interactions with black patients: a eld study. J
[5] Manusov V, Patterson ML, editors. The SAGE handbook of nonverbal commu- Exp Soc Psychol 2010;46:43640.
nication. Thousand Oaks: SAGE Publications; 2006. [14] Heath C. In: Ekman P, Scherer KR, editors. Body movement and speech in
[6] Frankel RM, Stein T, Krupat E. The Four Habits approach to effective clinical medical interaction. Cambridge, UK & Paris: Cambridge University Press &
communication. Physician education and development. Oakland, CA: Kaiser Editions de la Maison des Sciences de lHomme; 1986.
Permanente; 2003. [15] Mast MS. On the importance of nonverbal communication in the physician
[7] Roter DL, Hall JA. Doctors talking with patients/patients talking with doctors: patient interaction. Patient Educ Couns 2007;67:3158.
improving communication in medical visits, 2nd ed., Westport, CT: Praeger; [16] Cappella JN, Schreiber DM. The interaction management function of nonverbal
2006. cues. In: Manusov V, Patterson ML, editors. The SAGE handbook of nonverbal
[8] Levinson W, Lesser CS, Epstein RM. Developing physician communication communication. Thousand Oaks: SAGE Publications; 2006. p. 36179.
skills for patient-centered care. Health Affair 2010;29:13108. [17] Robinson JD. Nonverbal communication and physicianpatient interaction:
[9] Jones SE, LeBaron CD. Research on the relationship between verbal and review and new directions. In: Manusov V, Patterson ML, editors. The sage
nonverbal communication: emerging integrations. J Commun 2002;52:499 handbook of nonverbal communication. Thousand Oaks, CA: Sage Publica-
521. tions; 2006. p. 43760.
314 S.G. Henry et al. / Patient Education and Counseling 86 (2012) 297315
[18] Roter DL, Frankel RM, Hall JA, Sluyter D. The expression of emotion through [47] van Dulmen AM, Verhaak PFM, Bilo HJG. Shifts in doctorpatient communi-
nonverbal behavior in medical visits: mechanisms and outcomes. J Gen Intern cation during a series of outpatient consultations in non-insulin-dependent
Med 2006;21:S2834. diabetes mellitus. Patient Educ Couns 1997;30:22737.
[19] Hall JA, Roter DL, Blanch DC, Frankel RM. Observer-rated rapport in interac- [48] Merten J. Facial microbehavior and the emotional quality of the therapeutic
tions between medical students and standardized patients. Patient Educ relationship. Psychother Res 2005;15:32533.
Couns 2009;76:3237. [49] Comstock LM, Hooper EM, Goodwin JM, Goodwin JS. Physician behaviors that
[20] Hall JA, Roter DL, Blanch DC, Frankel RM. Nonverbal sensitivity in medical correlate with patient satisfaction. J Med Educ 1982;57:10512.
students: implications for clinical interactions. J Gen Intern Med 2009;24: [50] Haskard K, DiMatteo MR, Heritage J. Affective and instrumental communica-
121722. tion in primary care interactions: predicting the satisfaction of nursing staff
[21] Henry SG. A Piece of my mind. Playing doctor. J Am Med Assoc 2005;294: and patients. Health Commun 2009;24:2132.
213840. [51] Street Jr RL, Buller DB. Nonverbal response patterns in physicianpatient
[22] Wear D, Varley JD. Rituals of verication: the role of simulation in developing interactions: a functional analysis. J Nonverbal Behav 1987;11:23453.
and evaluating empathic communication. Patient Educ Couns 2008;71: [52] Bensing J. Doctorpatient communication and the quality of care. Soc Sci Med
1536. 1991;32:130110.
[23] Malhotra A, Gregory I, Darvill E, Goble E, Pryce-Roberts A, Lundberg K, et al. [53] Hall JA, Irish JT, Roter DL, Ehrlich CM, Miller LH. Satisfaction, gender, and
Mind the gap: learners perspectives on what they learn in communication communication in medical visits. Med Care 1994;32:121631.
compared to how they and others behave in the real world. Patient Educ Couns [54] Dalton JA, Brown L, Carlson J, McNutt R, Greer SM. An evaluation of facial
2009;76:38590. expression displayed by patients with chest pain. Heart Lung 1999;28:168
[24] Ram P, van der Vleuten C, Rethans JJ, Grol R. Assessment of practicing family 74.
physicians: comparison of observation in a multiple station examination using [55] Hall JA, Roter DL, Milburn MA, Daltroy LH. Patients health as a predictor of
standardized patients with observation of consultations in daily practice. Acad physician and patient behavior in medical visits: a synthesis of four studies.
Med 1999;74:629. Med Care 1996;34:120518.
[25] Grifth CH, Wilson JF, Langer S, Haist SA. House staff nonverbal communica- [56] Troisi A, Pompili E, Binello L, Sterpone A. Facial expressivity during the clinical
tion skills and standardized patient satisfaction. J Gen Intern Med 2003;18: interview as a predictor of functional disability in schizophrenia: a pilot study.
1704. Progr Neuro-Psychopharmacol Biol Psychiat 2007;31:47581.
[26] Haskard KB, Williams SL, DiMatteo MR, Heritage J, Rosenthal R. The providers [57] Ambady N, LaPlante D, Nguyen T, Rosenthal R, Chaumeton N, Levinson W.
voice: patient satisfaction and the content-ltered speech of nurses and Surgeons tone of voice: a clue to malpractice history. Surgery 2002;132:59.
physicians in primary medical care. J Nonverbal Behav 2008;32:120. [58] Bos EH, Bouhuys AL, Geerts E, van Os TW, Ormel J. Stressful life events as a link
[27] Baumann C, Rat AC, Osnowycz G, Mainard D, Cuny C, Guillemin F. Satisfaction between problems in nonverbal communication and recurrence of depression.
with care after total hip or knee replacement predicts self-perceived health J Affect Disorders 2007;97:1619.
status after surgery. BMC Musculoskelet Disord 2009;10:150. [59] Geerts E, Bouhuys N, Van den Hoofdakker RH. Nonverbal attunement between
[28] Weisman CS, Nathanson CA. Professional satisfaction and client outcomes: a depressed patients and an interviewer predicts subsequent improvement. J
comparative organizational analysis. Med Care 1985;23:117992. Affect Disorders 1996;40:1521.
[29] Street RL, Makoul G, Arora N, Epstein RM. How does communication heal? [60] Bouhuys AL, Sam MM. Lack of coordination of nonverbal behaviour between
Pathways linking clinician-patient communication to health outcomes. Pa- patients and interviewers as a potential risk factor to depression recurrence:
tient Educ Couns 2009;74:295301. vulnerability accumulation in depression. J Affect Disorders 2000;57:189
[30] Performance Measurement. The Joint Commission; Available from: [accessed 200.
20.8.2010]. [61] Weinberger M, Greene JY, Mamlin JJ. The impact of clinical encounter events
[31] HCAHPS. Patients perspectives of care survey. Centers for Medicare & on patient and physician satisfaction. Soc Sci Med Part E Med Psychol
Medicaid Services; Available from: http://www.cms.gov/HospitalQualityInits/ 1981;15:23944.
30_HospitalHCAHPS.asp [accessed 20.8.2010]. [62] Smith CK, Polis E, Hadac RR. Characteristics of the initial medical interview
[32] Cooper LA, Roter DL. Patientprovider communication: the effect of race and associated with patient satisfaction and understanding. J Fam Pract 1981;12:
ethnicity on process and outcomes of healthcare. In: Smedley BD, Stith AY, 2838.
Nelson AR, editors. Institute of Medicine (U.S.). Committee on Understanding [63] Kurtz S. Physician nonverbal behavior and patient satisfaction in physician
and Eliminating Racial and Ethnic Disparities in Health Care. Unequal treat- patient interviews. PhD diss. Denver, CO: University of Denver; 1975.
ment: confronting racial and ethnic disparities in health care. Washington, DC: [64] Koss T, Rosenthal R. Interactional synchrony, positivity, and patient satisfac-
National Academy Press; 2003. p. 55293. tion in the physicianpatient relationship. Med Care 1997;35:115863.
[33] Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: a [65] Giles H, Ogay T. Communication accommodation theory. In: Whaley BB,
meta-analytic review. J Am Med Assoc 2002;288:75664. Santer W, editors. Explaining communication: Contemporary theories and
[34] Adelman RD, Greene MG, Ory MG. Communication between older patients and exemplars. Mahwah, NJ: Lawrence Erlbaum Associates; 2007. p. 32544.
their physicians. Clin Geriatr Med 2000;16:124. vii. [66] Ekman P, Friesen WV. Unmasking the face: a guide to recognizing emotions
[35] Dovidio JF, Hebl M, Richeson JA, Shelton JN. Nonverbal communication, race, from facial clues. Cambridge, MA: Malor Books; 2003.
and intergroup interaction. In: Manusov V, Patterson ML, editors. The SAGE [67] Rasting M, Beutel ME. Dyadic affective interactive patterns in the intake
handbook of nonverbal communication. Thousand Oaks: SAGE Publications; interview as a predictor of outcome. Psychother Res 2005;15:18898.
2006. p. 481500. [68] Dickersin K. Publication bias: recognising the problem, understanding its
[36] Higgins J, Altman DG. Assessing risk of bias in included studies. In: Higgins J, origin and scope, and preventing harm. In: Rothstein HR, Sutton AJ, Borenstein
Green S, editors. Cochrane handbook for systematic reviews of interventions M, editors. Publication bias in meta-analysis: prevention, assessment, and
version 501: The Cochrane Collaboration. 2008. p. Available from www.co- adjustments. West Sussex, UK: John Wiley & Sons; 2005. p. 1134.
chrane-handbook.org [accessed 29.7.2010]. [69] Hall JA, Coats EJ, LeBeau LS. Nonverbal behavior and the vertical dimension of
[37] Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JPA, et al. social relations: a meta-analysis. Psychol Bull 2005;131:898924.
The PRISMA statement for reporting systematic reviews and meta-analyses of [70] Kenny DA, Kashy DA, Cook WL. Dyadic data analysis. New York: Guilford Press;
studies that evaluate health care interventions: explanation and elaboration. 2006.
Ann Intern Med 2009;151:W6594. [71] Lipsitz SR, Fitzmaurice GM, Orav EJ, Laird NM. Performance of generalized
[38] Grimes DA, Schulz KF. Bias causal associations in observational research. estimating equations in practical situations. Biometrics 1994;50:2708.
Lancet 2002;359:24852. [72] Raudenbush SW, Bryk AS. Hierarchical linear models: applications and data
[39] Burgoon JK. The relationship of verbal and nonverbal codes. In: Dervin B, Voigt analysis methods, 2nd ed., Thousand Oaks: Sage Publications; 2002.
MJ, editors. Progress in communication sciences. Norwood, NJ: Ablex Publish- [73] Larsen KM, Smith CK. Assessment of nonverbal communication in the patient
ing; 1985. p. 26398. physician Interview. J Fam Pract 1981;12:4818.
[40] LeBaron CJ. Considering the social and material surround: toward microeth- [74] Greene MG, Adelman RD, Friedmann E, Charon R. Older patient satisfaction
nographic understandings of nonverbal communication. In: Manusov V, with communication during an initial medical encounter. Soc Sci Med
editor. The sourcebook of nonverbal measures. Mahwah, NJ: Lawrence Erl- 1994;38:127988.
baum Associates; 2005. p. 493506. [75] von Baeyer CL. Social and pain behavior in the rst 3 min of a pain clinic
[41] Noller P. Standard content methodology: controlling the verbal channel. In: medical interview. Pain Clin 1994;7:16977.
Manusov V, editor. The sourcebook of nonverbal measures. Mahwah, NJ: [76] Buller MK, Buller DB. Physicians communication style and patient satisfac-
Lawrence Erlbaum Associates; 2005. p. 41730. tion. J Health Soc Behav 1987;28:37588.
[42] DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials [77] Ware JE, Kosinski M, Keller SD. How to score version 2 of the SF-12 health
1986;7:17788. survey. Lincoln, RI: Quality Metric Inc.; 2000.
[43] Gilbert DA, Hayes E. Communication and outcomes of visits between older [78] Bernieri FJ, Reznick JS, Rosenthal R. Synchrony, pseudosynchrony, and dis-
patients and nurse practitioners. Nurs Res 2009;58:28393. synchrony: measuring the entrainment process in mother infant interactions.
[44] Ambady N, Koo J, Rosenthal R, Winograd CH. Physical therapists nonverbal J Pers Soc Psychol 1988;54:24353.
communication predicts geriatric patients health outcomes. Psychol Aging [79] Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development
2002;17:44352. and validation of a geriatric depression screening scale: a preliminary report. J
[45] Hall JA, Roter DL, Rand CS. Communication of affect between patient and Psychiat Res 1983;17:3749.
physician. J Health Soc Behav 1981;22:1830. [80] Stewart A, Kamberg C. Physical functioning. In: Stewart A, Ware JE, editors.
[46] Prkachin KM, Schultz IZ, Hughes E. Pain behavior and the development of pain- Measuring functional status and physical well-being: the medical outcomes
related disability: the importance of guarding. Clin J Pain 2007;23:2707. study approach. Durham, NC: Duke University Press; 1989. p. 86101.
S.G. Henry et al. / Patient Education and Counseling 86 (2012) 297315 315
[81] Hays RD, Sherbourne CD, Mazel RM. The RAND 36-item health survey 1.0. [88] Troisi A. Ethological research in clinical psychiatry: the study of nonverbal
Health Econ 1993;2:217. behavior during interviews. Neurosci Biobehav Rev 1999;23:90513.
[82] Ware J. SF-36 health survey update. In: Maruish M, editor. Use of psychologi- [89] Hilsenroth MJ, Ackerman SJ, Blagys MD, Baumann BD, Baity MR, Smith SR, et al.
cal testing for treatment planning and outcomes assessment: instruments for Reliability and validity of DSM-IV axis V. Am J Psychiat 2000;157:185863.
adults. 3rd ed., Mahwah, NJ: Erlbaum; 2004. p. 693718. [90] Marshall GN, Hays RD. The patient satisfaction questionnaire short-form (PSQ-
[83] Wolf MH, Putnam SM, James SA, Stiles WB. The medical interview satisfaction 18): RAND Corporation, 1994 Contract No.: P-7865.
scale: development of a scale to measure patient perceptions of physician [91] Bertakis KD, Roter D, Putnam SM. The relationship of physician medical
behavior. J Behav Med 1978;1:391401. interview style to patient satisfaction. J Fam Pract 1991;32:17581.
[84] Ekman P, Friesen WV, Hager JC. Facial action coding system: the manual [CD [92] Dimatteo MR, Sherbourne CD, Hays RD, Ordway L, Kravitz RL, Mcglynn EA,
ROM]. Salt Lake City, Utah: A Human Face; 2002. et al. Physicians characteristics inuence patients adherence to medical
[85] Friesen, WV, Ekman, P., Emotion Facial Action Coding System, 1984. Available treatment: results from the Medical Outcomes Study. Health Psychol 1993;
at http://www.face-and-emotion.com/dataface/facs/emfacs.jsp. Accessed 22 12:93102.
July 2011. [93] Suchman AL, Roter D, Green M, Lipkin M, Bertakis K, Charon R, et al. Physician
[86] Fahrenberg J. Die freiburger beschwerdenliste FBL [freiburger symptom list]. satisfaction with primary-care ofce visits. Med Care 1993;31:108392.
Zeitschrift fur Klinische Psychologie 1995;4:79100. [94] Mehrabian A. Nonverbal communication. Chicago: Aldine-Atherton; 1972.
[87] Franke G. SCL-90-R die symptom checklist von derogatis: deutsche version. [95] Rosenthal R, DiMatteo MR. Meta-analysis. Recent developments in quantita-
Weinheim: Beltz-Verlag; 1995. tive methods for literature reviews. Ann Rev Psychol 2001;52:5982.