Enhancing Doctor–Patient Communication Through Nonverbal Cues: A FACS-Based Study
About this article
Keywords:
doctor–patient interactions, facial action coding system, nonverbal communication, patient comfort, patient satisfactionAbstract
Background: Nonverbal cues are integral to clinical communication, yet there is limited anatomically precise quantification of clinician facial behaviour.
Objectives: To quantify clinician smiling during standardised consultations and determine its predictive value for patient-rated communication outcomes.
Methods: Fifty-two third-semester medical students conducted seven-minute simulated consultations with standardised patients. Certified coders scored facial Action Units (AUs) for duration and intensity, achieving high interrater reliability. Smiling AUs were compared between the speaking and listening phases using paired tests. Hierarchical regression analyses, controlling for clinician sex, evaluated smiling and additional facial movements as predictors of standardised patient ratings on global communication and comfort scales.
Results: Smiling occurred significantly more during speaking than listening. Smiling intensity and duration explained a substantial proportion of variance in patient-rated communication quality and comfort. Additional facial movements contributed further predictive value for communication quality but not for comfort ratings. Neither smiling nor other facial behaviours predicted clinician self-ratings or expert evaluations.
Conclusions: Clinician smiling, precisely quantified via Facial Action Coding System (FACS), robustly predicts patient perceptions of communication quality and comfort. Incorporating targeted nonverbal training into medical education may enhance patient satisfaction and trust.
References
Ekman, Paul, and Wallace V. Friesen. Facial Action Coding System. Environmental Psychology & Nonverbal Behavior (1978). Available online: https://doi.org/10.1037/t27734-000
Schneider, P., Zerbini, G., Reicherts, P., Reicherts, M., Roob, N., Hallmen, T., ... & Kunz, M. (2025). Smiling doctor, satisfied patient—the impact of facial expressions on doctor-patient interactions. Frontiers in Medicine, 12, 1518517. Available online: http://doi.org/10.3389/fmed.2025.1518517
Koech , B., Sikolia, G., & Macharia, N. (2023). Doctor Patient Nonverbal Communication and Tuberculosis Treatment Adherence in Kibera Infor-mal Settlement in Nairobi County, Kenya. International Journal of Communication and Public Relation, 8(4), 28–41. Available online: https://doi.org/10.47604/ijcpr.2166
Balashova, M. E., Ryaboshapko, A. I., Balashova, T. S., Akhmetkhanova, S. K., Amaeva, K. D., Adamov, M. M., & Erbieva, S. Z. (2025). Doctor-patient interaction at the outpatient stage: effective communication as a factor of treatment quality. Perm Medical Journal, 42(1), 105-111. Availa-ble online: https://doi.org/10.17816/pmj421105-111
Bommier, C., Mamzer-Bruneel, M. F., Desmarchelier, D., & Hervé, C. (2014). How nonverbal communication shapes doctor-patient relationship: from paternalism to the ethics of care in oncology. Journal international de bioéthique, 25(4), 29-49. Available online: https://shs.cairn.info/revue-journal-international-de-bioethique-2014-4-page-29?tab=resume
View more references (23)
Sudirman, I., Pasinringi, S. A., & Sidin, I. (2016). The role of demography in moderation the influence of nonverbal communication to patient’s satisfaction. International Journal of Medical and Health Sciences Research, 3(1), 10-23. Available online: https://ideas.repec.org/a/pkp/ijomah/v3y2016i1p10-23id2257.html
Waitzkin, H. (1984). Doctor-patient communication: Clinical implications of social scientific research. Jama, 252(17), 2441-2446. Available online: https://jamanetwork.com/journals/jama/article-abstract/395047
Robinson, J. D. (1998). Getting down to business: Talk, gaze, and body orientation during openings of doctor-patient consultations. Human com-munication research, 25(1), 97-123. Available online: https://doi.org/10.1111/j.1468-2958.1998.tb00438.x
Marcinowicz, L., Konstantynowicz, J., & Godlewski, C. (2010). Patients' perceptions of GP non-verbal communication: a qualitative study. The British journal of general practice: the journal of the Royal College of General Practitioners, 60(571), 83–87. Available online: https://doi.org/10.3399/bjgp10X483111
Kaul, P., Choudhary, D., & Garg, P. K. (2021). Deciphering the optimum doctor-patient communication strategy during COVID-19 pandemic. In-dian Journal of Surgical Oncology, 12(Suppl 2), 240-241. Available online: https://doi.org/10.1007/s13193-021-01301-z
Silverman, J., & Kinnersley, P. (2010). Doctors'non-verbal behaviour in consultations: look at the patient before you look at the computer. The Brit-ish journal of general practice : the journal of the Royal College of General Practitioners, 60(571), 76–78. Available online: https://doi.org/10.3399/bjgp10X482293
Roter, D. L., Frankel, R. M., Hall, J. A., & Sluyter, D. (2006). The expression of emotion through nonverbal behavior in medical visits. Mechanisms and outcomes. Journal of general internal medicine, 21 Suppl 1(Suppl 1), S28–S34. Available online: https://doi.org/10.1111/j.1525-1497.2006.00306.x
Zhang, X., Li, L., Zhang, Q., Le, L. H., & Wu, Y. (2023). Physician Empathy in Doctor-Patient Communication: A Systematic Review. Health Communication, 39(5), 1027–1037. Available online: https://doi.org/10.1080/10410236.2023.2201735
Kelm, Z., Womer, J., Walter, J. K., & Feudtner, C. (2014). Interventions to cultivate physician empathy: a systematic review. BMC medical educa-tion, 14(1), 219. Available online: https://doi.org/10.1186/1472-6920-14-219
Ortiz-Paredes, D., Adam Henet, P., Desseilles, M., & Rodríguez, C. (2024). Empathy in family medicine postgraduate education: A mixed studies systematic review. Medical Teacher, 47(2), 275–291. Available online: https://doi.org/10.1080/0142159X.2024.2328324
Pavlova, A., Wang, C. X., Boggiss, A. L., O’Callaghan, A., & Consedine, N. S. (2022). Predictors of physician compassion, empathy, and related constructs: a systematic review. Journal of general internal medicine, 37(4), 900-911. Available online: https://doi.org/10.1007/s11606-021-07055-2
Moya-Salazar, J., Goicochea-Palomino, E. A., Porras-Guillermo, J., Cañari, B., Jaime-Quispe, A., Zuñiga, N., ... & Contreras-Pulache, H. (2023). Assessing empathy in healthcare services: a systematic review of South American healthcare workers’ and patients’ perceptions. Frontiers in Psychi-atry, 14, 1249620. Available online: https://doi.org/10.3389/fpsyt.2023.1249620
Gonzalez-Tapia, G., & Lazzaro-Salazar, M. (2023). Medical empathy in the physician-patient relationship: A review from a cultural perspective. Re-vista Médica de Chile, 151(9). Available online: https://www.revistamedicadechile.cl/index.php/rmedica/article/view/10552
Tement, S., Ketiš, Z. K., Miroševič, Š., & Selič-Zupančič, P. (2021). The Impact of Psychological Interventions with Elements of Mindfulness (PIM) on Empathy, Well-Being, and Reduction of Burnout in Physicians: A Systematic Review. International Journal of Environmental Research and Public Health, 18(21), 11181. Available online: https://doi.org/10.3390/ijerph182111181
Andersen, F. A., Johansen, A. S. B., Søndergaard, J., Andersen, C. M., & Assing Hvidt, E. (2020). Revisiting the trajectory of medical students’ empathy, and impact of gender, specialty preferences and nationality: a systematic review. BMC medical education, 20(1), 52. Available online: https://doi.org/10.1186/s12909-020-1964-5
Derksen, F., Bensing, J., & Lagro-Janssen, A. (2013). Effectiveness of empathy in general practice: a systematic review. The British journal of gen-eral practice : the journal of the Royal College of General Practitioners, 63(606), e76–e84. Available online: https://doi.org/10.3399/bjgp13X660814
Roberts, B. W., Puri, N. K., Trzeciak, C. J., Mazzarelli, A. J., & Trzeciak, S. (2021). Socioeconomic, racial and ethnic differences in patient experi-ence of clinician empathy: Results of a systematic review and meta-analysis. PloS one, 16(3), e0247259. Available online: https://doi.org/10.1371/journal.pone.0247259
Gleichgerrcht, E., & Decety, J. (2013). Empathy in clinical practice: how individual dispositions, gender, and experience moderate empathic con-cern, burnout, and emotional distress in physicians. PloS one, 8(4), e61526. Available online: https://doi.org/10.1371/journal.pone.0061526
Kerasidou, A., & Horn, R. (2016). Making space for empathy: supporting doctors in the emotional labour of clinical care. BMC medical ethics, 17, 8. Available online: https://doi.org/10.1186/s12910-016-0091-7
KK Shyamala, Kulkarni, V. ., Shenoy, V. ., Bidhata Khatri, Thapashwi, TA, L. ., & Joseph , M. . (2022). Impact Of Communication Skills Training in Postgraduate Medical Education. National Journal of Community Medicine, 13(06), 359–363. Available online: https://doi.org/10.55489/njcm.13062022403
Adnan, A. I. (2022). Effectiveness of communication skills training in medical students using simulated patients or volunteer outpatients. Cureus, 14(7). Available online: https://doi.org/10.7759/cureus.26717
England, J. A., Howell, M., & White, B. A. A. (2020). Creating a culture of communication in undergraduate medical education. Proceedings (Bay-lor University. Medical Center), 33(3), 485–491. Available online: https://doi.org/10.1080/08998280.2020.1746156
Choudhary, A., & Gupta, V. (2015). Teaching communications skills to medical students: Introducing the fine art of medical practice. International journal of applied & basic medical research, 5(Suppl 1), S41–S44. Available online: https://doi.org/10.4103/2229-516X.162273