A new family medicine resident recently wrote to us about the challenges communicating with patients while wearing a mask.
"I want to be able to read their body language," wrote Alyssa Gerth, DO. "I also want to be able to expressively convey joy, empathy, compassion, understanding, and other emotions during a patient visit that can usually be communicated through the face or through professional touch."
She continued, "My fear is that my patient-doctor rapport will suffer with these masks and that I won't be able to connect with my patients as I wish to."
Gerth's concerns are well founded. Nonverbal communication is an essential skill for clinicians and can increase patient satisfaction and adherence. But, wearing a mask hinders our ability to nonverbally communicate effectively. Words are muffled and the facial expressions clinicians rely on to express emotion are concealed. Even more, interpreting patients' emotions and reactions becomes more challenging.
As clinician-educators and researchers in the field of healthcare communication, we turned to the research to compile 10 strategies to help clinicians, like Gerth, communicate while wearing a mask. The strategies represent four types of communication behaviors known to increase empathy and relational closeness:
- Immediate (minimize psychological distance)
- Convergent (express perceived and desired similarity)
- Responsive (convey genuine concern and compassion)
- Affiliative (communicate friendliness, warmth, and openness)
The 10 Strategies:
1. Focus on what you can do. Immediacy behaviors such as moving closer to someone, smiling, and touching may be difficult during COVID-19, but there are other ways to establish interpersonal closeness. You can maintain genuine eye contact, lean forward toward the patient, have an expressive tone of voice, and use gestures. If you are working in an inpatient setting, you may need to re-introduce yourself when you re-enter a room as it will be harder for patients and families to remember faces when masked.
2. Be an active listener. When a patient is speaking, use nonverbal encouragement (head nods, forward lean, etc.) and maintain eye contact. While wearing a mask, the message your eyes and body language are sending becomes amplified. You may feel confident that you can look at a patient's chart and listen at the same time, but not all patients share that perspective. A lack of eye contact can contradict a verbal invitation for patient participation. If you ask the patient, "Is there anything else you'd like to discuss?" but accompany this question with a "no" head shake or pulling away and looking at the chart, the patient gets the impression that no further information is welcomed.
The call for more eye contact comes with an important caveat:
3. Do not engage in uncomfortable levels of eye contact. Eye contact is essential, but too much during your speaking turn can come across as dominant. (And let's be honest, nothing is more awkward than someone forcefully holding direct eye contact.) Genuine eye contact should occur while the patient is speaking, but genuine does not mean continuous. You should gaze comfortably between the patient, the chart, and your notes. Just be aware of those specific conversational moments that require direct eye contact: (1) implicit or explicit requests for attention (i.e., pauses, emotions, and questions) and (2) conversational turns: establish eye contact before you start talking and to signal that it's the patient's turn to talk.
4. Mirror what you are saying with hand gestures and body language. You do not need to use gestures that make you look like a wacky, waving balloon man outside of a car dealership, but do try to integrate simple gestures like a hand wave to signal "hello" and "goodbye"; a thumbs-up or okay sign to deliver positive news, offer encouragement, and confirm understanding or agreement; and a shoulder shrug or "huh" hand gesture to express uncertainty or lack of understanding. These forms of nonverbal communication make your communication more expressive, and reinforce a verbal message that may be muffled behind a mask.
5. Exaggerate emotion with your eyes, not your entire face. Patients may be able to tell that you are smiling from behind a mask, but exaggerating your smile all day can be exhausting. Instead, focus on expressing emotion using your eyes and eyebrows (along with hand gestures).
6. Use vocal variety to convey emotion. Your patients cannot see your smile behind your mask and may misconstrue a neutral expression for a negative one. By varying your rate, pitch, tone, and volume you can more accurately convey emotion. With that being said...
7. Focus on talking slower, not louder. When you face communication challenges with patients due to language barriers or other limitations, you may find yourself speaking louder even if the patient has no trouble hearing. You have probably noticed yourself doing the same thing while wearing a mask. This comes across as aggressive or dominant, and will likely tire the muscles in your face quickly. Speaking slowly will help you conserve energy and will increase understanding (which means you won't have to repeat yourself!). An added benefit of talking slowly is that it conveys to your patient that you value the time you are spending with them and are not in a hurry to rush off to another patient.
8. Look for empathic opportunities. One way of thinking about communication styles is that they are either assertive or responsive. Assertive communication includes taking a strong stance on a topic and emphasizing expertise or credibility, whereas responsive communication involves offering help and being sensitive to the needs of others. While assertive clinicians may be seen as more competent, they are rarely considered more caring or trustworthy. A responsive communicator, who acknowledges empathic opportunities, is perceived by patients as competent and caring.
An empathic opportunity describes when a patient expresses an emotion, a challenge (e.g., negative experience or event), or progress (e.g., positive change or event). You should listen for empathic opportunities and view them as a prompt to respond using acknowledgment, praise, validation, or support: all forms of responsive communication. Learning to listen for these empathic opportunities can be particularly important when facial expressions are masked. You can also elicit these empathic opportunities by asking patients directly about their reactions/feelings when you are unable to read facial expressions.
9. Minimize dominant communication. Dominant communication involves controlling the conversation. These behaviors are associated with power, authority, and compliance-gaining, which can have negative impacts on patient outcomes. These behaviors intensify the perceived distance between you and your patient that already exists while wearing masks. Some dominant behaviors include standing during the visit, interrupting the patient, and making the patient wait for you without explanation.
10. Modify your communication to match your patient's. Communication accommodation refers to the extent to which two or more people match or differ the other person's verbal and nonverbal behavior during an interaction. Matching helps convey interest and relational closeness -- especially when both parties are wearing masks -- and is useful for developing trust. You should try to match your patient's behaviors including talk time, body position, speech rate, gesturing, nodding, and eye contact.
These communication behaviors are not necessarily unique to communication while wearing a mask. As educators we have been encouraging the use of these behaviors for years, and as researchers we know these behaviors are associated with positive relational and health outcomes.
Our hope is that these 10 strategies reassure clinicians who are feeling exhausted and frustrated by the communication challenges while wearing a mask that there are many ways to connect with patients when genuine smiles and sympathetic touch are restricted. Any combination of these strategies can help you provide compassionate care from behind a mask.
We followed-up with Gerth to see how her communication with patients was going after she had tried some of these strategies. She said she has found it useful to maintain a "relaxed, open, and forward leaning body posture" and use vocal inflection and eye movement to convey emotion. She explained that using gestures like a squint, smirk, and raised cheek bones may seem odd without a mask, but from behind a mask they give the impression of a "kind, inviting, loving smile." Of course, she also admitted to "lots and lots of nodding," which is a behavior that is affiliative and responsive and can minimize psychological distance created by a mask. We approve!
, is an assistant professor of Family Medicine at Ohio University Heritage College of Osteopathic Medicine in Athens.
, is a professor at the College of Journalism and Communications, College of Medicine, at the University of Florida in Gainesville.