The power of nonverbal communication in medical education

In 1356 BCE, Aristotle uttered the importance of the three pillars of communication: ethos, pathos and logos. Ethos is the speaker s personal character and according to Aristotle the most important of the three pillars because it establishes the speakers’ competence, good intention and empathy. This characteristic is conveyed mostly with nonverbal elements such as tone of voice, pitch, posture, etc. Pathos is the emotional aspect to be acknowledged in communication. Emotions are feelings that can influence one’s judgment and beliefs. Logos is the logical reasoning that should form the basis for assertions being made. It encompasses the ability to wisely connect the arguments and data for reasoning purposes (Braet 1992). In medicine, communication has also been depicted as a fundamental skill to be taught and learned. Nevertheless, the current approach to communication has mainly focused on developing one aspect of this competence, verbal communication proficiency. When evidence suggests 60% to 93% of what is communicated occurs nonverbally (DA 2011), teaching and learning nonverbal communication in medical school becomes an important consideration. This has implications both for faculty teaching in general and for education about communication skills in particular. Communications with patients and families about medical conditions are often complicated by strong emotional content and a context that is filled with stress. Pathos is built upon this emotional subtext and conveyed largely by nonverbal elements of communication. Therefore, it is imperative that the doctors have not only the mastery of the subject matter that will be discussed but nonverbal awareness of the emotional content and the anticipated and observed responses of those with whom one is speaking. Hence, for an effective communication, logos is necessary but not sufficient. The power of nonverbal communication for medical faculty is illustrated by the Dr. Fox effect, which relates to the impact of ethos and pathos even when the lecturer is not an expert on the subject matter presented. In fact, “Dr. Fox” was not a physician but a professional actor. In 1973, Dr. Naftulin et al. hypothesized and demonstrated that a charismatic lecturer (“Dr. Fox”), using proper nonverbal cues, could provide a positive learning experience even for expert medical educators, despite conveying meaningless content (Naftulin et al. 1973). This favorable outcome associated with certain kinds of nonverbal communication is achieved because an encouraging environment, one that conveys safety and support for the learner and enthusiasm and passion by the speaker, enables our brain to learn more and better, a concept termed constructive learning. This pathway increases not only our attention but also our memory consolidation, both of which are essential for learning. According to the neurological theories of learning, the primary motor cortex and the dorsolateral prefrontal cortex are primarily involved in the acquisition of knowledge and consolidation of memory respectively. Moreover, functional neuroanatomy suggests that the positive emotion associated with learning inhibits the prefrontal cortex, which encompasses the limbic system, our emotional gate, thereby increasing dopamine and acetylcholine release. This process leads to higher cognitive performance. The remaining question to be answered is: how does one use nonverbal communication patterns to foster learning in medical education without being an imposter? Educators outside the medical field have described nonverbal communication frameworks used by teachers. Nonverbal immediacy scales are validated and there are reliable tools to assess the effectiveness of a teacher’s nonverbal communication skills (Zhang et al. 2007). In addition, teacher immediacy has shown to be a predictor of teaching effectiveness by promoting higher cognitive and affective learning outcomes for students (Pribyl et al. 2004). Nonverbal immediacy techniques available to teachers include: eye contact, gaze, hand movements and gestures that are aligned with words, and a relaxed body position; tone of voice and a variety of vocal expressions; sitting, standing or moving closer to students while talking to them; talking to students in a cheerful manner, smiling, exciting facial expression and even respectful touching for encouragement (Zhang et al. 2007). Above all, these cues need to be related to the educator’s purpose; passion for one’s subject also plays an important role as well in the learning setting. These teaching behaviors combined with empathy for the learner inspire students to develop a growth mindset, the foundation of successful learning. When teaching communication skills, faculty should address similar nonverbal elements. Establishing a partnership with a patient, demonstrating empathy, responding to and validating emotion are all essential to successful communication in the clinical setting. Much of this is accomplished nonverbally.