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A STUDY ON NON- VERBAL COMMUNICATION STRATEGIES USED BY DOCTORS IN DOCTOR PATIENT INTERACTION.

AREA OF INVESTIGATION
This study seeks to investigate the non-verbal communication strategies used by doctors in doctor-patient interactions during the initial consultation in a clinical setting. Non-verbal communication can be conceptualised as any form of communication that does not use the written or spoken word. (Birdwhistell: 1990, Melirabian: 1981).It is more than just body language since it includes, use of time, space, clothing, furniture, features of the environment (temperature, lighting) how we utter words (inflection, tone, volume) and it can occur in the absence of verbal communication through symbols and physical contexts. This study is in the broad area of interactive sociolinguistics which sees communication as the outcome of exchanges involving more than one active participant. In doctor-patient interactions three parts have been generally recognised ,that is the initial consultation ,treatment and follow ups .Each part has its own characteristic features that can be observed and analysed separately or as part of a larger discourse. In Zimbabwe, many complaints by patients about how doctors communicate non-verbally have being raised. The problem which this proposed study seeks to address is: What non-verbal communication strategies are used by Zimbabwean doctors and their impact on patients? In trying to address this research problem, the study will show through observed medical interactions that although Zimbabwean doctors consciously and unconsciously send and receive non-verbal messages most of them are not fully aware of the ways they communicate. Frequently doctors verbal messages conflict with their non-verbal behaviour making patients to feel anxious and uncertain leading to negative outcomes of medical consultations. The failure by doctors to manipulate non-verbal communication strategies also leads to the use of non-traditional healthcare providers such as traditional healers ,acupuncturists, hypnotists and message
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therapists all of who are often perceived as more interested in the patient as a person. In studying doctor-patient communication researchers have paid relatively more attention to verbal cues despite the universally acknowledged importance of non-verbal than verbal cues in medical interactions. As a consequence non-verbal cues have been seen as part of verbal cues since they validate verbal communication In this regard this research will show that nonverbal strategies are different from verbal strategies because they serve different functions hence the need to be studied separately. Researchers have also come up with a number of different coding tools for verbal strategies (eg: Process Analysis system, Roter Interaction Analysis, The Verbal Response mode) while a few exist for non-verbal strategies (e.g.: Relational communication Scale) hence the need to develop coding tools for non-verbal communication. Non-verbal cues have been shown to have a universal meaning depending on the context and because of this contextual dependency there is no precise interpretation of non-verbal behaviour and our understanding of what specific doctors non-verbal cues signify remain scattered. Therefore this investigation is worth undertaking because it seeks to identify the non-verbal strategies used by doctors in actual interactions in Zimbabwe and how patients of a Zimbabwean culture derive meaning by relating non-verbal cues to contexts in which interactions occur. OBJECTIVES This study aims to: Identify the non-verbal communication strategies used by doctors in doctor-patient interaction during the initial consultation.
Establish the effect of non-verbal communication strategies on

Patient satisfaction and dissatisfaction with the consultation.


Establish the contribution of non-verbal communication on the

patients understanding of the doctors message. JUSTIFICATION


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This study is significant in a number of ways. Positive Non-verbal communication strategies have been discovered to correlate with positive outcomes such as, patient satisfaction with health care, compliance with medication and positive treatment outcomes while negative non-verbal behaviours of doctors have been found to relate to decreased patients physical and cognitive functioning. Thus the choice of doctor-patient interaction as a viable area for research is by no means accidental since the research aims to make a contribution towards effective health communication in Zimbabwe by making doctors aware of non-verbal behaviours which hinder or facilitate positive medical outcomes. I have set out in this research to focus on the initial consultation because it is the first process towards healing since communication is in itself therauptic. The initial consultation is an important social occasion because this is when the doctor makes the diagnosis; outlines a plan of treatment and the patient can ask a host of questions and can have his worries addressed. The initial consultation also has an impact on the patients perceptions of subsequent consultations and further interactions between a doctor and patient. .The issues discussed in this research are relevant between a patient and a doctor during the initial consultation, not because activities outside the consultation are of lesser importance but because they are informed by the consultation. This research has also been motivated by observations i made as a communication skills Lecturer in the Faculty of medicine at the University of Zimbabwe where i observed that medical students tend to concentrate on learning verbal communication skills while relegating non-verbal skills. The researcher hopes that the research will be an invaluable contribution not only to the field of doctor-patient interaction but also to the field of applied linguistics where it is becoming increasingly important to look at communication in the workplace so as to meet the needs of a world that is becoming globalised. METHODOLOGY DATA GATHERING

The primary sources of data in this research are audio-taped and video-taped doctor-patient interactions which will be used to evaluate the actual medical encounter since patients may have greater impact on their own outcomes than the doctors and non-verbal behaviour since these perceptions are subjective to bias depending on factors such as, patient health status and status of mind which might not actually reflect the reality of the consultation. Formal and informal interviews and questionnaires will also be used to gather data on patient satisfaction with the medical interview .since some patients are sensitive about their health and may refuse to co-operate or might not self disclose to a doctor in the presence of an observer. The research will be conducted at Parirenyatwa Group of Hospitals and the researcher has been granted permission by the Clinical Director to conduct the research on the condition that the anonymity of patients and doctors and that the professional integrity of doctors will be preserved. To cater for ethical considerations the research will be conducted in a conscientious manner. The researcher will seek consent from all the participants and participation will be voluntary. No one other than the researcher will have access to raw data and real names will be excluded from the recordings. The researcher is aware that the quality of data can be affected by the data collection process itself since the presence of recording equipment and the process of gaining consent mean that there is a heightened awareness of being observed. Several strategies will be used to reduce the potential of the observers paradox such as the use of discreet recording equipment and self recording so that there is no need for a third part to be present with the sole purpose of collecting data. DATA ANALYSIS The recorded and observed interactions will be coded following the rules of coding interactions and then analysed .A detailed transcription which is inductive driven will be used to identify recurring patterns of interaction and from this the researcher will be able to identify the doctors non-verbal communication strategies. Quantitative and qualitative methods will be used to characterise patient satisfaction with the medical interviews.
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An ethnographical analysis of the interactions will permit the understanding of the interview from a functional role while a conversational analysis framework allows analysis of interactions beyond the sentence level that is into the social and cultural context. LITERATURE REVIEW Medical literature contains a large number of research studies that have investigated the use of verbal and non-verbal communication strategies by doctors in doctor patient interactions. (Gordon: 1995, Korsh and Negrete: 1972). A systematic review of such literature show that many of the studies are based on audiotapes that are analysed for verbal behaviour using a variety of coding strategies such as, the Roter Interaction analysis System and Bales Interaction Process Analysis. Such studies have concentrated on what doctors say and not how doctors say it. Patient satisfaction in such instances is measured from analogs that is, university students listening to audio-tapes of a doctors standardised patient encounter .In such instances whether patients were really satisfied is unclear since the simulations are impressions of listeners . In studies of non-verbal communication strategies of doctors there is also a predominance of analogue studies (80% of studies reviewed) compared with studies of actual consultations. This disadvantage limits conclusions that can be drawn regarding the generalizability and validity of findings. A reason for such lukewarm findings lies in the methodologies which do not use actual medical but simulated medical interviews. Non-verbal communication strategies of doctors have also been easily overlooked in medical research since many instruments for measuring qualities such as patient satisfaction are designed to be applied to audio rather than video recordings. For example in many studies questionnaires for patients are not sufficiently detailed to seek their views on the verbal cues of doctors. In doctor-patient interaction a number of non-verbal cues have been identified and linked to positive and negative health outcomes. Non-verbal communication strategies have been cited as unambiguous and there are conflicting views on the evidence that non-verbal cues can influence patient outcomes .Several studies have found no association of patient satisfaction
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with doctors non-verbal cues and patient satisfaction was also discovered to be high regardless of the absence of doctors non-verbal cues (Larsen and Smith: 1990).Such studies ignore the importance of non-verbal communication Many non-verbal cues have been assumed to be markers of dominance. Various studies (Buller and Street: 1992, Hall: 1995) also show that patients were found to be less satisfied when doctors dominated the interviews by interrupting patients or when the emotional tone was charactised by doctors dominance. Verbal cues such as, body proximity and and touch were correlated to distancing behaviour of doctors and increased disclosure of patients psychosocial information. Less touch by a physician was shown to be associated with greater patient satisfaction possibly because touch may communicate power and dominance. (Mehrabian; 1972: Hall: 1973, Smith: 1981: Bertakis: 1991). With regards to the sociolinguistic structure of communication doctors were often found to adopt a style of high control which involved doctor initiated questions, interruptions and neglect of patients feelings and world view. In these studies (Bertakis:1991) doctors are perceived as dominant when they used less interpersonal distance, gaze at another and smile less, use a louder voice, interrupt others more while in fact truly dominant people do approach others more closely and have louder voices. Many of the behaviours said to reflect dominance in these studies are actually inconsistently related to actual dominance. Female and Male doctors have also been shown to communicate differently. Female doctors were shown to exhibit more supportive behaviours than male doctors and they were also shown to be able to adjust their status to equal that of the patients thereby making patients to self disclose. Burgoon et al found out that patient satisfaction is also dependent on the doctors gender. He discovered that patient satisfaction decreased with greater aggressiveness with female doctors whereas patient satisfaction was less affected aggressive male doctors. Consistent evidence has been found from analogue studies on doctors nonverbal communication strategies and these results will provide the groundwork for investigating actual consultations in this research. This research which
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focuses on actual observed interviews will fill in the research gaps doctor patient discussed above.

SELECTED BIBLIOGRAPHY Ambady D et al,Physical Therapists non-verbal communication predicts geriatric patient health outcomes, PUB MED, 17, 2002.pp443-452 Argyle P, Social Interaction, Menthens Press, London, 1969. Birdwhistel K, Interacting with Patients, Churchill Livingstone, London, 1968. Bloomert k, Aspects of Interactive Sociolinguistics, Routledge, London, 2005. Chimombo M and Roseberry R, The Power of discourse: An Introduction to Discourse Analysis, Mahwah, New Jersey, London, Lawrence Erlbam Associates, 1998. DiMatteo and Toraita et al,Predicting patient satisfaction from Physician Nonverbal communication skills, MED CARE, 18, 1979, pp376-387. Hall k,Non verbal behaviour in Clinical-Patient Interaction, APPLIED PSYCHOLOGY, 4, 1995, pp21-35. Halliday M A K, Explorations in the Functions of Language, Edward Arnold, 1973. Korsh B and Negrete,Doctor-Patient Communication SCIENCE AMERICA, 227, 1972, pp66-74. Ley P, Communicating with Patients, Gloom Helm, New York, 1988. Maguire G P,Julier D,Hawton K E,An Experimental Comparison of Three Methods of Presenting an Interview, Nursing Mirror,3 April 1974,pp10-18. Mehrabia P, Non-Verbal Communication, Chicago, Aldine Atherton, 1972. Ong L, The Good Doctor, Neville Press, Indiana, 1995. Spellman B,Caring for the needMEDICAL, 101, 1966, pp11-21.

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