Kris English, PhD
The University of Akron/NOAC
We get so busy. We have much to accomplish in an appointment, slightly on auto-pilot but the conversation seems to be going well, and then …
…the patient (or parent) breaks eye contact. She looks at the floor, or her hands, or the door (no mystery what that likely means), or at nothing in particular. Do we notice? If we notice, do we pause? Or do we keep talking and ignore the nonverbal cue?
Patient and parent interactions seem so routine, it is easy to overlook the underlying dynamics, although medicine has studied them for years (Finset, 2016). A starting point for audiology is the consideration of eye contact – a simple concept but not much discussed in our literature. So let’s consider it now:
Question #1 How many times during an appointment does a patient or parent break eye contact? As a profession, we don’t know. As professionals, we probably have never noticed.
Question #2 Why do patients break eye contact? What does it mean when a patient looks away from our face, or withdraws from our joint attention on devices or forms? We can’t be sure, but the patient is probably thinking about/feeling something new. Perhaps he is trying to process what we are saying. Perhaps a wave of emotion has interrupted his ability to concentrate. Perhaps our conversation triggered a memory, a doubt, a worry, a question, a regret, a recognition of embarrassing-but-real vanity (Kajimura & Nomura, 2016).
Question #3 What do we do when a patient or parent looks away? As members of Western culture, our instinct is likely to keep talking, because we are socialized to move the conversation forward and avoid awkward silences. And yet as we do so, we must realize that (1) we are wasting effort because the patient is not listening, and (2) we are missing a potential opportunity to help. At this moment, something weighs on this person’s mind and heart, and if allowed an extra moment, he may wish to share it. However, by forging ahead, we unwittingly violate a basic principle of patient-centered care.
Violating Patient-Centered Care? Seriously?
This statement is not as radical as it sounds, and in fact is very basic. Consider the Institute of Medicine’s (2001) definition of patient-centered care:
care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. (p. 3)
As minor as it may seem, being “respectful of and responsive to” a patient’s nonverbal request for a pause may be the essence of patient-centeredness. With the simple act of breaking eye contact, the patient indicates she needs a moment, and may want to take the conversation in another direction. Moving forward as if that preference had not been communicated is, at the least, inconsistent with patient-centeredness.
When a Patient Looks Away … How to Respond?
- Slowly, silently count to 10 as the patient gathers her thoughts and reactions. When she re-establishes eye contact, she may decide to share her concerns. Pauses often precede disclosures which would not have been expressed otherwise (Eide et al., 2004).
- If the patient or parent does not regroup after counting to 10, we can interrupt the reverie with an invitation:
- Were you reminded of something?
- Your thoughts?
- Is there something I missed?
- If the patient declines to elaborate, we should move forward but be vigilant re: potential issues later.
Final Question: “Waiting” sounds easy enough – Why point it out?
Easy doesn’t mean comfortable. Stivers et al. (2009) report that the gap between speaking turns averages around 250 ms, and that silences longer than 2 seconds are relatively rare. We may have been socialized to perceive pauses as uncomfortable silence, and when we are uncomfortable, we tend to choose avoidance. However, Bartels et al. (2016) can help us reframe this learned response by viewing pauses as connectional or invitational silences, a natural part of the “musicality of language” (p. 1584). A pause of 10 seconds could cause us genuine distress, but it also actively focuses us on the patient as the center of our care. And with practice, distress lessens/confidence increases as we experience the value of waiting.
Patient-Centered Audiologic Practices
We currently lack a definitive application of patient-centeredness in audiologic care. As with all changes, small steps are more likely to be successful, and “learning to wait” for patients as they look away is perhaps the smallest step possible. At the end of the day, we have to ask ourselves if “waiting is worth doing,” and the answer is yes. Unlike a social conversation or an informal chat, our interactions with patients (including silences) should be at least as therapeutic as our assessments and technological treatments.
Bartels, F., Rodenback, R., Cieskinski, K., Gramling, R., Kiscella, K., & Epstein, R. (2016). Eloquent silences: A musical and lexical analysis of conversation between oncologists and their patients. Patient Education and Counseling, 99, 1584-1594.
Eide, H., Quera, V., & Finset, A. (2004). Sequential patterns of physician-patient dialogue surrounding cancer patients’ expressions of concern and worry. Social Science & Medicine, 59, 145-155.
Finset, A. (2016). Silence is golden. Patient Education and Counseling, 99, 1545-1546.
Kajimura, S., & Nomura, M. (2016). When we cannot speak: Eye contact disrupts resources available to cognitive control processes during verb generation. Cognition, 157, 352–357.