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Eye Contact between Physicians and Older-patients in Anxiety-provoking Communication R Gorawara-Bhat*, D Dethmers** and MA Cook*** * Section of Geriatrics & Palliative Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois 60637 ** School of Social Service Administration, The University of Chicago, Chicago, Illinois 60637 *** JVC Radiology and Medical Analysis LLC, Clayton, Missouri 63105The International Conference on Communication in Healthcare 2011 19 October 2011, Chicago, Illinois, USA This research was supported by The Section of Geriatrics & Palliative Medicine (RGB) and JVC Radiology (MAC).The original research was supported by AHRQ # (1 RO3 HS01 4088-01A1) (RGB) and NIA Grant # R44 AG15737 (MAC). The Investigators retained full independence in the conduct of this research.

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Eye Contact in Physician-Older patient Interactions• Routine physician-older patient (> = 65 yrs) interactions: -- Eye contact most frequently invoked nonverbal dimension (Gorawara-Bhat et al 2007) -- Eye contact -- ―Looking‖ and ―Listening‖ Verbal dimension -- ―Talking‖ -- Characteristics of Eye contact related to Patient-Centered (PC) interaction (Gorawara-Bhat et al 2011) -- Type of Eye contact (Sustained or Brief); -- Frequency of occurrence• Literature – Eye contact -- salient nonverbal dimension of Patient-centered communication (MacDonald, 2009; Mast, 2007) 2

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Eye Contact in Anxiety-provoking Interactions• Goals of Present Work: 1) Nature of eye contact in anxiety-provoking interactions 2) Comparison with Routine Interactions• Physician and Older-patient anxiety-provoking communication as ―naturally occurring‖ in office visits• ―Looking and Listening‖ as embedded in ―Talking‖ 3

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Sample Description• Secondary analysis -- NIA (National Institute of Aging) videotapes of physician-older patient interactions (2005)• Search Words: prostate, PSA, mammogram, referral, surgery, cancer, screening, depressi on, exercise, weight, smoking, and diet• Identified 58 out of 489 anxiety-provoking visits from NIA database• Discarded tapes (gaze of physician and/or patient not visible, little info, dysfunctional and/or encrypted tape) (22 out of 58)• Anxiety-provoking visits -- 4 emergent types: 1) cancer 2) depression/suicide 3) behavioral issues (e.g. smoking, substance abuse) 4) acute medical visits• Anxiety-provoking segments coded (n = 37) # of physician older-patient visits: n = 36 ; 3 tapes w multiple segments # of physician older-patient, companion* visits: n = 3 (*companion – an extension of older patient) 4

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Data Analysis – NVivo 9.0 Software• Qualitative Software -- NVivo 9.0 used to code physician and patient nonverbal (―looking‖) and verbal (―talking‖) characteristics in anxiety-provoking segments• NVivo 9.0 — juxtaposition of verbal transcripts alongside visual frames; examined simultaneously• Each physician - older patient visit reviewed within NVivo 9.0; anxiety-provoking segment(s) identified, and time-stamped• 8 segments coded independently by 2 investigators (RGB & DD) Results identical -- Inter-Rater reliability established; 25 segments coded (DD); 4 segments coded (RGB)• Segments reviewed, coded for physician and patient ―looking‖ and ―talking‖ behaviors (RGB, DD) (Table 1)• Comparison w Routine Office visits (n = 8) 5

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Results – Thematic CodesTable 1: Coding Anxiety-provoking segments in physician-older patient visits (n = 37)A. Codes for physician ―looking‖ & ―talking‖ (nonverbal & verbal communication) 1. Physician Looking and Not Talking (listen) 2. Physician Looking and Talking (listen) 3. Physician Not Looking and Talking (not listen) 4. Physician Not Looking and no responsive Talking (not listen)B. Codes for patient ―looking‖ & ―talking‖ (nonverbal & verbal communication) 1. Patient Looking and Not Talking (listen) 2. Patient Looking and Talking (listen) 3. Patient Not Looking and Talking (not listen) 6 4. Patient Not Looking and no responsive Talking (not listen)

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Results - Demographics Table 2: Demographic Characteristics of Physicians & Older-Patients in Anxiety-provoking visits Physicians (n = 18 ) Older-patients (n = 37) Age (years)Average (Range) 52 (34 -82) 74 (65 – 91) RaceCaucasian 16 36African-American 2 1 7

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Anxiety-provoking Communication Example – Suicidal Ideation• Frequency of occurrence of physicians‘ gaze is twice that of patient (96% vs 54%)• Physician - ―sustained‖ gaze establishes ―engagement frame‖• Patient – ―brief‖ gaze no reciprocal frame maintenance 8

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Anxiety-provoking Communication Example -- Smoking• Physician‘s frequency of gaze -- high (92%)• Patient‘s frequency of gaze -- similar (89%)• Physician initiates ―engagement frame‖; patient reciprocates gaze 9

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Anxiety-provoking Communication Example – Acute Medical Issue• Physician‘s frequency of gaze -- low (72%) -- Characterized – ―Brief‖ episode• Patients frequency of gaze -- continuous (95%) -- Characterized as ―Sustained‖ episode -- Establish ―engagement frame‖ 10

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Anxiety-provoking Communication Example – Cancer• Physician -- low eye contact (60%)• Patient -- high eye contact (90%) - tries to establish ―engagement frame‖ 11

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Characteristics of Physician ―Looking & Listening‖ Table 3: Comparison of Anxiety-provoking & Routine Visits EYE CONTACT BY TYPE OF INTERACTION ANXIETY-PROVOKING VISITS ROUTINE Cancer Depression/ Behavioral Acute VISITS (n= 8) (n=14) Suicide (n=7) (n=7) Medical CHARACTERISTICS OF SEGMENTSAvg Segment Length 3.54 8:01 3:41 3:53 6.23(Range) (minutes) (0.17-12.58) (1:50-21:00) (0:28 - 6:39) (1:41 - 6:41) (3.36 - 11.00)Eye contact Duration (minutes) 0.17 1:02 0:25 0:12 3.15 TYPE OF EYE CONTACTNumber of Brief Episodes 47 15 28 58 35Number of Sustained Episodes 25 17 17 13 15Number of Brief Episodes/ Visit 3.1 2.5 4 7.25 4.4Number of Sustained Episodes/ Visit 1.9 2.7 2.3 1.6 1.9 12

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Results – Communication Table 4: Nonverbal & Verbal Communication between Physicians and Older-patients in Different Types of Anxiety-provoking VisitsCommunication Ratios of "Looking" and "Talking" (%) Cancer Depression/ Behavioral Acute Medical (n =14) Suicide (n = 7) Issues (n =7) Issues (n =9)NONVERBAL Ratio of frequency of "Looking" to "Not-Looking" (%)Physician 2.7 (73%) 22.5 (96%) 12 (92%) 3 (72%)Patient 8.5 (90%) 1.2 (54%) 8 (89%) 18 (95%)VERBAL Ratio of frequency of "Talking" to "Not-Talking" (%)Physician 2.3 (70%) 1.1 (51%) 1 (56%) 1.4 (58%)Patient 1 (48%) 1.4 (48%) 1 (48%) 1.3 (57%) 13

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Results – ―Looking‖ and ―Talking‖Table 5: Comparison of ―Looking‖ and ―Talking‖ in Anxiety-provoking and Routine Visits Anxiety-Provoking RoutineCommunication visits (%) visits (%) (n = 8) (n = 8) Ratio of Looking to Not-lookingPhysician 5 ( 83%) 2 (65%)Patient 2 ( 68%) 60 ( 98%) Ratio of Talking to Not-talkingPhysician 1.4 ( 58%) 2 (66%)Patient 1.2 (55%) 1 (47%) 14

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Summary and Conclusions - 1In Verbal Communication:• In Anxiety-provoking and Routine interactions – Frequency of occurrence of ―talking‖ for physicians and patients is similar. Physicians and Patients ―accommodate‖, i.e. ‗complement‘ one another in terms of the functions of their respective utterances (Street, 1991).In Nonverbal Communication (Eye contact):• In anxiety-provoking interactions—physicians seek patients gaze to establish ‗engagement frame‘ - patients reciprocate to some extent (Table 5).• In routine interactions, patients seek physicians gaze to establish ‗engagement frame‘ - physicians show little reciprocal behavior (Table 5) 15

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Conclusions and Implications -- 2• 1. Nonverbal dimension of Eye contact – an essential foundation for patient-centered communication -- used differentially in routine and anxiety-provoking interactions by physicians• 2. When a prescriptive resolution of patients‘ chief complaint is possible, physicians may not invoke eye contact to complement verbal communication. E.g. acute medical issues, routine visits, prostate cancer.• 3. When no prescriptive resolution of patients‘ chief complaint is conceivable, physicians generally invoke eye contact to complement their verbal communication. E.g. suicidal ideation, depression.• 4. To make interaction patient-centered, physician education should emphasize that physicians‘ invoke eye contact to complement verbal communication and establish an ‗engagement frame‘ with patients. 16

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References• Finset A. Nonverbal communication—an important key to in-depth under- standing of provider-patient interaction (Editorial). Patient Educ Couns 2007;66:127–8.• Teresi JA, Ramirez M, Ocepek-Welikson K, Cook MA. The development and psychometric analyses of ADEPT: an instrument for assessing the interactions between doctors and their elderly patients. Ann Behav Med 2005;30: 225–42• Gorawara-Bhat R, Cook MA, Sachs GA. Nonverbal communication in doctor– elderly patient transactions (NDEPT): development of a tool. Patient Educ Couns 2007; 66:223–34.• Gorawara-Bhat R, Cook MA. Eye contact in Patient-centered Communication. Patient Educ Couns 2011; 82: 442-447.• Ruusvuori J. Looking means listening: coordinating displays of engagement in doctor–patient interaction. Soc Sci Med 2001;52:1093–108.• Robinson JD. Getting down to business: talk, gaze and body orientation during openings of doctor–patient consultations. Health Commun 1998;25: 97–123. 17