Beyond bedside basics

By Allison Evans, Assistant Managing Editor, February 1, 2025

Imagine you are sitting at a table on the opposite end from the patient with the problem in the middle. What would it take to get on the same side of the table and look at the problem together? This metaphor is commonly used by Neil S. Prose, MD, FAAD, professor of dermatology, pediatrics, and global health at the Duke University School of Medicine. “The reason this is difficult is because doctors and patients come from very different perspectives. Doctors come from the world of medicine, which is centered around diagnosis and treatment, and patients come bearing their own worries, concerns, and conceptions about their health,” he said. “Bridging these two perspectives is not always intuitive.”

Physicians want to provide the best possible care for patients and their families, so there is a lot at stake to exploring effective communication techniques. Studies indicate that effective and empathic communication skills may decrease the likelihood of patients filing malpractice claims against their physicians. Studies also show that the ability to communicate honestly and empathically with patients has a powerful effect on the success of a medical practice. Happy patients are more likely to keep returning.

Anthony Orsini, DO, a neonatal intensive care physician, lecturer, author, and communication expert, has had a life-long passion for how humans connect. “Why do some physicians who are top in their field have very poor patient satisfaction scores? It all has to do with learning how to build rapport, establish trust, and have that one-on-one relationship with patients.”

First steps

For Dr. Prose, the first steps to a successful patient interaction include being mindful and preparing for the visit. “We are all infinitely distractable, so I recommend before entering the exam room, putting your hand on the doorknob, taking a deep breath, and making a conscious decision to pay attention.”

Studies show that patient satisfaction is strongly associated with more emotionally expressive nonverbal behavior, including facial expressiveness, eye contact, head nods, body posture, and tone of voice. A review of the literature on this topic found that greater patient satisfaction was associated with nonverbal indicators of physician interest including less time reading the patient’s chart (probably associated with more eye contact), more physician immediacy (e.g., forward lean), more head nods and gestures, and closer interpersonal distance.

“Why do some physicians who are top in their field have very poor patient satisfaction scores? It all has to do with learning how to build rapport, establish trust, and have that one-on-one relationship with patients.”

Body language is also key to setting a positive tone for the interaction. “In most cultures, establishing eye contact is very helpful. Even more important is sitting instead of standing. There are studies that show that when a doctor sits in the presence of the patient, they perceive that the doctor spent more time with them than they really did. When the doctor stands, the patient has the opposite perception,” Dr. Prose said.

If a physician needs to be at a computer during the visit, position the computer in the room in a way that allows you to look at the patient and not turn your back. “More importantly, physicians should explain what they’re doing when they’re typing and perhaps even ask permission. When serious topics come up, turn your entire body away from the computer and toward the patient,” Dr. Prose recommended.

Establishing a connection

The number one mistake doctors make when it comes to bedside manner is that they don’t take the time to build a rapport, said Dr. Orsini. One study found it only takes 56 seconds to establish a rapport and trust with the patient.

“When you walk into a room, don’t start talking about what brings the patient in today or looking through their chart. Spend one minute talking about non-medical things. This can be difficult to do when we become task-oriented, which happens to physicians every day,” Dr. Orsini said.

“We’re not just information-gathering; we’re trying to make a connection,” Dr. Prose added. He likes to start out his visits with an open-ended question: ‘How have you been since the last visit,’ ‘What worries you most about your symptoms,’ or ‘What are you hoping to accomplish today?’ The hard part, he noted, is listening to the answer.

Physicians may avoid asking open-ended questions for fear of opening up Pandora’s box, in which the patient may bring up a litany of concerns. Having an exit strategy is a tactful way of segueing to the questions you need to ask. Dr. Prose recommends asking, “Would it be okay if I interrupt you to ask you some specific questions?”

Building rapport involves sharing something about your personal life, Dr. Orsini noted. “I teach exercises where a physician must walk into a room and find something about the patient that they can immediately find commonality with. This could be something as simple as noting their running sneakers and that you run too, or your child runs track. This calms everyone down and makes the doctor relatable, which is the basis for trust.”

“The average doctor interrupts the patient in the first 17 seconds of the medical interview,” Dr. Prose said. “You’ll be surprised at how much information you can get when you let a patient talk rather than just asking a bunch of yes or no questions and checking them off in the electronic health record.”

Physical touch is an important part of treating patients in dermatology, although some studies have shown that touch may be viewed as dominating or controlling. “We touch people a lot in our specialty anyway, but I think using physical touch, like a hand on the shoulder, as a form of connection, feels like a human encounter,” said Sara Dill, MD, FAAD, adult and pediatric dermatologist and certified life coach.

An often-neglected part of establishing a trusting relationship with patients is restating what the patient said. “This can be as simple as, ‘So what you’re telling me is the cream we gave you was irritating, and your rash seems to be getting worse. Is that right?’” Dr. Prose said. “This serves two functions: Making sure you got it right because you may have missed something, and the patient knows you were listening. You may be surprised by the positive response when the patient realizes you have actually been paying attention.”

Demonstrating empathy

Demonstrating empathy is foundational to establishing a trusting physician-patient relationship. Studies in which physician–patient interactions were filmed and reviewed for empathic communication found that physicians often allowed the expressions of the patients’ emotions to pass without acknowledgement. These missed opportunities to show empathy may hamper rapport building, resulting in poor adherence, low patient satisfaction, and unfavorable clinical outcomes.

“When a patient comes into the doctor’s office, they are not at their best,” Dr. Orsini said. “They’re likely ill or in some type of distress and, in worst case scenarios, facing down their own mortality. A little compassion goes a long way.”

Empathic statements let patients know that the physician cares. They address the emotion a patient has expressed. Examples of verbal empathic statements include, ‘I can only imagine how overwhelming this must be for you,’ ‘I would feel frustrated as well,’ and ‘I’m here to help you through this.’

“When I walk into a room meeting a patient for the first time, all I have to rely on are stereotypes like dress, age, body type — you name it,” Dr. Prose said. “The only way to get past those stereotypes is to be curious and ask the kinds of questions that enable you to understand who this person really is.”

Diagnosis and treatment

After establishing that initial connection with the patient, a good transition to the clinical interview might be, ‘Would it be okay if I explain what I think is going on and suggest where we might go from here?’ Dr. Prose said. “If you dive right into the information-laden content of the interview as soon as you walk into the room, there’s a good chance the patient is not going to hear a word you say, or they’re not going to be open to the information you present because their mind is still occupied with emotions.”

Dermatologists may face patients who have unrealistic expectations when it comes to the treatment of their condition. “I always try to find a point of agreement,” said Dr. Dill. “Acknowledge their expectations and be honest about what is possible, what isn’t, and next steps.”

“I see a lot of acne, and love treating acne in kids and adults. Acne treatment takes a while to see improvement. It’s not something where you see improvement the next day, or the next week,” Dr. Dill said. “I try to be clear about what’s achievable as far as expectations and timing. I also tend to be a fast talker, so I try to slow down and communicate both verbally and in writing on how to use medications or what to expect after a procedure.”

“As physicians, we have a duty to be honest about things that are uncomfortable and hard to hear. While we can try to communicate in a way that works for the patient; we can’t always know how it’s going to land with them,” Dr. Dill said.

Delivering bad news

Dr. Orsini, who specializes in the communication skills necessary to deliver bad news, advises physicians to be cognizant of body language — ensuring that nonverbal and verbal language are consistent. “If you can master a difficult conversation, then everyday conversation becomes easier.”

“The number one rule of breaking bad news is to always break it gradually, which means you want to build up your evidence first rather than give the bad news,” Dr. Orsini said. “We know that once people hear bad news, they’re only going to retain about 10% of what they heard.”

Afterward, you can provide a reluctant diagnosis, which may begin with a phrase like, ‘I’ve looked at every possibility.’ Then you should be silent, say you’re sorry, and be silent again, Dr. Orsini added.

Dr. Prose recommends using the phrase ‘I wish’ instead of ‘I’m sorry.’ “‘I wish we had better treatments for the disease’ rather than ‘I’m sorry that things aren’t getting better,’ because ‘I’m sorry’ can be confused for an apology or an expression of pity. ‘I wish’ is putting you on the same side of the table with the patient.”

Joint decision-making

After walking the patient through the diagnosis and treatment options, it’s important to include the patient in the conversation. “The whole notion of joint decision-making ends up being very helpful even though patients will most likely rely on your judgement,” Dr. Prose said. “It may sound like ‘We’ve tried a number of creams and ointments for your condition, and they don’t seem to be working. I am going to suggest a medicine to take by mouth. I want to explain the potential benefits and side effects, and then we should decide together what to do next.’”

Dr. Dill views her role as a physician like a consultant. “It’s important for patients to feel in control as much as they can and to have choices. My job is to give options, discuss the different scenarios, and help patients decide what’s best for them.”

“Dermatology visits tend to be short, and you want to avoid the impression that you’re ending the visit prematurely,” Dr. Prose said. “The way to avoid this pitfall is to ask, ‘What questions do you have?’ This has been shown to be much more effective than the phrase, ‘Do you have any questions?’ The former phrasing suggests it’s normal to have questions and that you have an interest in knowing them,” he added. “It’s best to do this without your hand on the doorknob, which suggests the opposite impression.”

Webside manner

The COVID-19 pandemic prompted the rapid deployment and adoption of telehealth services without providing time for physicians to reflect on how to adapt their communication practices to a virtual setting. However, since the pandemic, many patients still prefer and expect the convenience of a virtual appointment. ‘Webside manner,’ the virtual equivalent of bedside manner, has become a point of focus for many physicians who have come to realize that good bedside manner doesn’t necessarily translate seamlessly to virtual visits.

Even though telehealth usage spiked during the pandemic, surveys show that many patients still prefer in-person visits. “I have had several interactions with people lately who don’t want to do telehealth because they crave that in-person connection,” Dr. Dill said. “While convenient, telehealth offers much less of a connection to me.”

North Carolina dermatologist Knox Beasley, MD, FAAD, performs virtual visits most days of the week and finds he can establish successful physician-patient relationships with both synchronous and asynchronous virtual visits. “There are some things that are a little different for virtual visits, but a lot of things are the same.”

Patient expectations

Patients will often seek the type of appointment that appeals to the level of interaction they would like. “Patients may be pulled over on the side of the road or stepping outside of work for a virtual appointment, so they may be looking for a more efficient, to-the-point visit,” Dr. Beasley said.

There is typically less chitchat in a virtual visit, Dr. Beasley noted, but sometimes that’s appreciated. There is a different patient expectation coming into the office.

Dr. Beasley provides an intake form for virtual appointments where patients can ask questions and spell out their concerns. “I ensure that I’ve read what they wrote and that they know I’ve read what they wrote. If the patient asks a specific question, I always address that.”

Nonverbal communication

While eye contact is important for any patient visit, it’s particularly important for virtual visits, although it’s easier to misstep in a virtual environment. “It can be difficult to make eye contact virtually because you have to look at the camera if you want it to look like you’re making eye contact, but that’s not actually looking at the person’s face,” Dr. Dill added.

If a physician needs to look at another screen or look up information that would take attention away from the camera, be sure to communicate exactly what’s being done so the patient doesn’t misinterpret the lack of eye contact as disinterest.

In addition to maintaining eye contact, the ability to express empathy through nonverbal communication is key to establishing a successful connection with patients. This may include nodding instead of saying ‘mmhmm,’ leaning forward to show attention and concern, or placing a hand across your heart when the patient is expressing distress or sadness.

“End every visit by making sure patients have a clear treatment plan and have no further questions.”

Privacy

While virtual visits can take place outside of the physician’s office, the patient needs to feel that their privacy is being respected. For this reason, physicians may choose to conduct virtual appointments from the office. If the visit is conducted from home, it’s helpful for physicians to have a private, sound-proof or well-insulated space to avoid distracting background disturbances. To help keep the experience synonymous with a brick-and-mortar visit, physicians should consider dressing as they would in the office.

Closing the visit

Knowing how to sign off from a virtual visit can be challenging. “End every visit by making sure patients have a clear treatment plan and have no further questions. Also, it’s a good idea to give them a way to follow up if questions arise down the road,” said Dr. Beasley.

“I send written notes to the patient,” Dr. Beasley said, “which lets the patient know you’ve taken the time to provide that recap. As a patient, when I go into a physician’s office, I’m usually in a mindset to receive medical information, whereas a patient may not be in this mindset when pulled over on the side of the road. Patients really appreciate having something to refer back to after the appointment.”

“The overwhelming majority of physicians are compassionate by nature. It is conveying that compassion, however, that we often struggle with,” Dr. Orsini said. “As doctors, we are taught from the beginning to set our emotions aside, but patients have a true desire to connect with their physicians and feel their compassion. Patients need to feel seen and heard, and they need to know they’re more than just a number.”

Additional DermWorld Resources