Smize: A Mid-Pandemic Guide to Non-Verbal Communication

Allison Bernstein1
Published online: 31 August 2020
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1Faculty of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
Corresponding Author: Allison Bernstein, email


Communication, whether it be verbal or non-verbal, is a key element in establishing trust and comfort in a physician-patient relationship. In the time of COVID-19, we have seen that non-verbal communication, which is conveyed through facial expression, gestures, and other signs that a person is engaged in the conversation, is lost, largely due to the use of Personal Protective Equipment (PPE). It has become important during these times to find ways to surmount this obstacle to keep providing professional and meaningful care to our patients. This article will discuss the definition and the importance of non-verbal communication in physician-patient care, as well as why effective communication is crucial to good patient outcomes. Finally, this article will present several strategies to overcome the communication obstacles we are currently facing, in order to continue offering elevated levels of care in this time when communication is most needed.

Tags: COVID-19, Communication, PPE, Physician-patient relationship

Section I: Overview of the Problem

It is undeniable that communication is of vital importance to complete and excellent patient care. Communication is a complex science, with many of the important cues being non-verbal. With our return to patient care, the limitations imposed by (Personal Protective Equipment) PPEs are evident in that many of our non-verbal cues will be more difficult, if not impossible, to convey. It has been shown that patients perceive physicians wearing masks as less caring and less empathetic than those without, (1) and in a time where uncertainty and worry is so high among the general public, “concealing social smiles behind masks may contribute to… danger, isolation, or paranoia.” (2) We must now figure out how to overcome our lack of nonverbal cues, while continuing to show warmth and compassion. This will be a time in history where we will need to be at our most compassionate, and at the same time, we may have the most difficulty conveying it. In the time of COVID-19, aside from the fact that patients are struggling physically, there has also been a negative impact to patients’ mental well-being, as well as lifestyle and financial well-being. This article will first define non-verbal communication and explain why it is of vital importance in healthcare. Next, it will address the importance of effective communication in doctor-patient relations and will be exemplified through two fields of scientific studies. Finally, it will discuss potential strategies that we can employ in the healthcare field, to encourage empathic patient relations during these times.

Section II: The Importance of Non-Verbal Communication

On March 13th, 2020, upon the designation of the Quebec government, all non-essential medical services were halted, and medical students were relegated to learning from home. Upon my return to the hospital after a COVID-enforced 2 month-hiatus, I quickly realized that my traditional reflex to smile would be ineffectual as my face was hidden by a mask and visor. I was struck by the fact that patients were unable see the gesture, a reflex that comes so naturally to us to help patients feel at ease. Equally importantly, I could not easily ascertain whether they were at ease, uncomfortable, or terrified, because the lower half of their faces, which were now covered by masks, usually convey a large proportion of important emotions. Non-verbal communication is described by the American Psychological Association (APA) as “the act of conveying information without the use of words,” and lists examples of the concept such as facial expressions, body language, hand gestures, and any other movements we make to convey our emotions or opinions. (3) Nonverbal communication has several key uses. It has been proven that clinicians who show more engagement and caring characteristics through nonverbal cues are ones that can expect a quicker and more complete recovery in their patients, (4) as well as various improvements in physiological values such as blood glucose and cholesterol control, leading to an overall improvement in patient health. (5) In a study done in 2017, it was found that having a warmer interpersonal style, one involving eye contact and use of facial expressions, resulted in increased expectations of patient outcomes as well as patient perception of improvement. (6) In addition, different cultures and different languages largely share the same facial expressions, so being able to see and understand nonverbal communication also allows for inter-cultural and inter-lingual communication.

Section III: How Communication Helps in Patient Care

In general, when physicians communicate effectively, patients respond in kind and thereby contribute more effectively towards their own care, and the overall satisfaction of the doctor’s care improves. Physicians who display true empathy have consistently been shown to have better medical outcomes for their patients; by allowing patients to feel more comfortable, they are better able to express their concerns, which allows doctors to treat them more effectively. (7) Establishing this empathy requires many elements: one, the doctor must be able to show through verbal communication as well as facial expressions that they are there to listen; two, the patient has to understand that message; and three, the patient has to respond to it, and this mutual connection often leads to greater exchange of information. Unfortunately, roadblocks to efficient communication can occur at any one of these steps. Carter Hardy writes in Empathizing with patients: the role of interaction and narratives in providing better patient care, “Much of the information given by a patient is hinted at nonverbally,” (7) and for us to be able to receive these nonverbal clues, understand them, and then implement this new knowledge to reach the correct diagnosis, we have to be able to see them, which is in part impossible due to the mask every doctor and patient must now wear. Further, as Malcolm Gladwell recounted in his book Blink after analyzing articles by Ambady et al. (8) and Levinson et al., (9) doctors are more likely to be sued due to bad communication skills over doctors who administered/performed the wrong treatment. (10) What this means is that if a patient does not feel the doctor is listening to them, or does not form the proper connection with the patient, he/she is more likely to complain than if they had a doctor who did have the communication skills, but did not treat their problem correctly. These two examples show that communication is of vital importance in the healthcare field, and that a lack of communication can lead to significant problems in the relationship between patient and physician, as well as poorer treatment outcomes.

Section IV: What Are Our Options?

Fortunately, there are ways to overcome the obstacle of the mask and PPE when it comes to connecting with patients. Firstly, it can be helpful to use more gestures when communicating, such as becoming more expressive with your eyes and your eyebrows and adding more eye contact. As well, hand movements such as thumbs up as well as more head movements, such as nodding to encourage patients, can also be effective in establishing a meaningful connection. (2) As the famous American model Tyra Banks so famously described, when you can’t smile with your mouth, you should instead smile with your eyes, otherwise known as “smizing.” Next, the facemasks you wear can help ease tension, rather than elicit fear. Physicians can wear interesting masks to express their individuality, or even draw a smiley face on their mask to show patients that even though they can’t physically smile at them, they are still expressing the feeling. Inspiring messages, quotes, or sayings, such as the oft-used “Ça va bien aller,” can also be written or integrated into the face masks, to help put a smile and distract potentially stressed patients. Another potential idea could be to create and utilize clear masks with the same protective level as the ones used in hospitals, so that patients will still be able to see the facial expressions of their physicians, and will then be able to see the smiles that can be so comforting to a suffering or worried patient. This strategy also offers the benefit of helping hearing-impaired patients that rely on lip-reading for communication. Finally, an interesting option that healthcare workers in San Diego started was to wear photos of themselves smiling on their scrubs or PPE to help put patients more at ease and make them feel comfortable, even when they can’t see the full face of their doctor. (11) These suggestions are an excellent starting point, but we must keep working on finding new solutions to better enable effective and compassionate communication.

Section V: Conclusions

In conclusion, communication, and more specifically nonverbal communication, is key to successful physician-patient relationships, to establish empathy, trust, and to work towards better patient outcomes. Unfortunately, the masks that are worn in pandemic situations, such as COVID-19, inhibit these types of connections from forming, which can cause fear, distrust, and worry in the patient population. Fortunately, solutions exist, such as compensating by using other non-verbal cues such as gestures, “smizing,” individualizing and creating reassuring masks, and even using images to diminish the relationship gap that masks and other PPE can cause. In the future, we will have to rely on each other’s creativity in order to establish more and more nonverbal cues towards a goal of maintaining positive doctor-patient relations.


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