This PP presentation delineates the nature of eye contact in anxiety-provoking interactions (e.g. cancer, acute medical visits) and compares it with eye contact in routine medical visits.

1. 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 63105
The 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.

2. 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)
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3. 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‖
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4. 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

5. 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)
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6. Results – Thematic Codes
Table 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)
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4. Patient Not Looking and no responsive Talking (not listen)

7. 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)
Race
Caucasian 16 36
African-American 2 1
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8. 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
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9. 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
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10. 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‖
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11. Anxiety-provoking Communication
Example – Cancer
• Physician -- low
eye contact (60%)
• Patient -- high
eye contact (90%)
- tries to establish
―engagement frame‖
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12. 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 SEGMENTS
Avg 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 CONTACT
Number of Brief Episodes 47 15 28 58 35
Number of Sustained Episodes 25 17 17 13 15
Number of Brief Episodes/ Visit 3.1 2.5 4 7.25 4.4
Number of Sustained Episodes/ Visit 1.9 2.7 2.3 1.6 1.9
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13. Results – Communication
Table 4: Nonverbal & Verbal Communication between Physicians and
Older-patients in Different Types of Anxiety-provoking Visits
Communication 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%)
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14. Results – ―Looking‖ and ―Talking‖
Table 5: Comparison of ―Looking‖ and ―Talking‖ in
Anxiety-provoking and Routine Visits
Anxiety-Provoking Routine
Communication
visits (%) visits (%)
(n = 8) (n = 8)
Ratio of Looking to Not-looking
Physician 5 ( 83%) 2 (65%)
Patient 2 ( 68%) 60 ( 98%)
Ratio of Talking to Not-talking
Physician 1.4 ( 58%) 2 (66%)
Patient 1.2 (55%) 1 (47%)
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15. Summary and Conclusions - 1
In 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)
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16. 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.
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17. References
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