Part 3: Nonverbal Communication

A veterinary clinic's curb appeal does not stop at the clinic door. It extends all the way into the exam room and, most importantly,

Table 1.1 Examples of Average and Ideal expressions.

to the entire team! Every person our clients interact with will receive a “snap judgment” from his/her first impression. How long does this take? For years the general rule has been 7 seconds, but a few years ago a group of psy­chologists found that it takes about one-tenth of a second to form an impression of a stran­ger, simply from his/her face (Willis and Todorov 2006). They also found that longer exposure to the stranger does not signifi­cantly alter the impression; it only boosts confidence in the initial judgment.

What does this mean to a veterinary team? It means that we have a very, very small amount of time to make a positive impres­sion on our clients. This positive impression is not only essential from a business stand­point (you want them to come back!) but also from a medical one. Our clients need to trust us; they need to believe that we care about their pet the same way they do. Without the belief and trust that the client and the veteri­narian have the same desired outcome, trust and rapport will not be established, and the client may not accept the treatment plan that the veterinary professional team has offered. Which is, after all, the reason we are in busi­ness: to care for, treat, heal, and support animals.

Of course, the importance of body lan­guage or nonverbal communication is not a new concept. The “7-38-55 Rule” was first developed in 1971 by University of California, Los Angeles psychology professor Albert Mehrabian (Mehrabian 2009): 55% of what we convey when we speak comes from our body language, 38% from our tone of voice, and a mere 7% from the words we choose. This study has been widely misinterpreted by stating “97% of what we convey is nonverbal” instead of garnering a greater understanding of vocal (tone, cadence, etc.) and body lan­guage cues, which are inappropriately com­bined to come up with the “97%.”

Mehrabian more clearly states the follow­ing on his website:

Total Liking = 7% Verbal Liking + 38% Vocal Liking + 55% Facial Liking. Please note that this and other equations regarding relative importance of verbal and nonverbal messages were derived from experi­ments dealing with communications of feelings and attitudes (i.e., like-dislike). Unless a communicator is talking about their feelings or attitudes, these equations are not applicable.

Although this landmark study is riddled with criticism and misinterpretation, it remains an important and highly cited illustration of the value of nonverbal communication. Many other studies have arisen since, each with a new methodology and with the con­tinued conclusion that nonverbal cues are 3-4 times more influential than verbal cues.

Before we dive into the real content, it's important to understand that reading body language is not the same as mind reading. This is the difference between “observation” and “evaluation.” Reading someone's nonver­bal cues is about observation; we want to find natural tendencies in someone's physical behavior (called their “baseline”), then look for deviations from their baseline, and, finally, ask open-ended questions to find the root cause of the change.

For example, you may walk into a room and find two people seated; both have their arms crossed, while one has both feet flat on the floor and the other has her legs crossed at the knee. You might assume that the closed-off body postures mean they are both are upset, and perhaps the female is even more upset because her legs are crossed as well. This may be true, but prob­ably not. Jumping to conclusions so quickly and, for example, immediately putting your guard up or responding with your own closed-off body language may start you off on a bad foot (no pun intended) by eliciting defensive behavior from these clients. In this example, crossed arms might be this gentleman's natural baseline, and the female may simply be cold!

Remember, reading body language is about observing someone's baseline, finding where there are deviations from that baseline, and using powerful questions to find the underly­ing cause of the deviation.

The Basics

The basics of body language are pretty sim­ple. Across species lines, animals (human and nonhuman) use adaptations to increase or decrease their physical presence. A bear stands on his back legs to appear taller, cobras expand their hood when they are threatened, and the mantis lifts her front limbs while dis­playing a conspicuous eyespot to scare or distract a predator.

Humans present similar nonverbal “tells” by puffing their chest and standing taller when an attractive woman walks by or throw­ing both hands up in the air after accomplish­ing a huge milestone (even humans who have been blind since birth exhibit these behaviors).

The opposite is true as well; a dog cowers in the back of a cage or tucks his tail, an embarrassed child covers her face. We tend to minimize our physical presence when we want to disappear!

Each unique area of our body displays our emotions differently. The face is the most important when it comes to first impres­sions, and the feet most important when you want to know whether a negotiation is being tipped in your favor.

Personal Curb Appeal

When you want to make the most positive impression possible on a client, there are four main areas to consider: initial facial expres­sions, the introduction to the client, nonver­bal cues (aka nonverbals) while speaking, and physical appearance. Each of these areas has been proven to influence the impression someone has on another person.

Facial Expressions

Judgments based on facial appearance or expression play a very powerful role in how we get treated (Mehrabian 2009). In fact, in a court of law, it's been shown that “mature faces” receive harsher judicial outcomes than those with a “baby face,” and having a face that is thought to be “competent” (as opposed to trustworthy or likable) may be highly predictive of whether a person gets elected to public office (Zebrowitz and McDonald 1991). Also, like it or not, attractive people are more favorably viewed in general, leading to overall better outcomes in life, in addition to being thought of as more trustworthy (Subhani 2012).

What is a good way to use your facial expressions to improve your curb appeal? Smile. Yes, simply smile. Of course, we have all been subjected to the “fake smile” versus the “genuine smile”! This distinction has been researched for quite some time; so much so that a genuine smile is now described with the name “Duchenne smile” after the French physician Guillaume Duchenne, who studied the physiology of facial expressions in the nineteenth century (Harker and Keltner 2001).

The Journal of Personality and Social Psychology described the difference from the anatomical perspective (Harker and Keltner 2001):

1) The Duchenne smile involves both volun­tary and involuntary contraction from two muscles: the zygomatic major (raising the corners of the mouth) and the orbicu­laris oculi (raising the cheeks and produc­ing crow's feet around the eyes).

2) A fake smile involves the contraction of just the zygomatic major since we cannot voluntarily contract the orbicularis oculi muscle.

Interestingly, the fake smile is controlled by the motor cortex, while more complicated emotion-related expressions, like the Duchenne smile, are controlled by the limbic system.

Yes, our clients can tell the difference! A genuine, warm, sincere expression of happi­ness that conveys a welcoming greeting is related to emotion, while the cheesy grin is simply a forced muscle action. So make sure your greeter (whomever that might be) smiles because he/she is happy to be there, not because he/she is forced to!

The Nonverbals of Introduction

Upon being greeted with the warm, genuine smile, the customary introduction ensues. Even if this is a long-standing client, there is still a formal greeting ritual we all engage in. The first 7 seconds may be too long for a first impression, but it's the perfect amount of time for a good introduction.

In our current Western society, the hand­shake occurs first and, as long as it's a good one, is the universally accepted sign of pro­fessionalism, politeness, and confidence. A good handshake is an art! Whether you're the veterinarian or the support staff, make sure you initiate the handshake before the client does to show a confident welcome. Remember, clients are coming into your “home” (the clinic), and you want them to feel that you genuinely appreciate their pres­ence. Make hand contact palm to palm, web to web (the “web” is the flap of skin between your thumb and pointer finger), while keep­ing the angle of your hand either perpendicu­lar to the ground or palm facing slightly up. Palm down in a handshake indicates power. Don't squeeze too tightly, nor too loosely, and maintain consistent tension as you say your greeting. Also, make sure to shake eve­ryone's hand in the pet's family, not just the primary owner—even the children. (What a way to inspire a new generation of veterinarians!)

While shaking the client's hand, maintain good eye contact and introduce yourself, even if you believe he/she knows your name (but not with close friends, of course!). Clients may have forgotten your name since their last visit, and setting your clients up for success by knowing your name helps build their confidence.

Because the introduction is about 7 sec­onds long, make sure it's meaningful. Step in front of the receptionist's desk to shake the client's hand, use a two-handed handshake (both of your hands around their one hand), lean gently forward to show appreciation for the client coming in, and/or bend down to pet his/her dog (cats may not appreciate this, though!).

Nonverbals to Gain Rapport

After you've made an amazing first impres­sion, followed by a confident introduction, it's time to complete the circle so that the cli­ent builds the trust, rapport, satisfaction, and connection with the entire veterinary team. These skills all enforce the concepts of active listening, engaged interaction, and support­ing the client's concerns.

These concepts are broken into three ana­tomical areas: the top, middle, and lower body regions.

Body Language in the Top Third

Eye contact is incredibly important! But how much is too much? At what point does it start to become creepy? One study on the Royal Society Open Science website (Binetti et al. 2016) found that, when asked to stare at a video of an actor staring back at them, par­ticipants had a “preferred gaze duration” of 3.3 seconds (give or take 0.7 seconds). The authors also found that the rate of pupillary dilation (an automatic reflex) was a good indicator of how long people wanted to gaze; the longer their preferred gaze, the faster their pupils expanded. (Don't get too attached to this difference, however. The change was so subtle that it was only seen with eye­tracking software, which would be awkward to follow in real life!)

Make your eye contact consistent by look­ing only inside the imaginary triangle between the two points about 1 inch above each eye and the tip of the nose; going farther down to the mouth or chin is more indicative of a social or amorous relationship.

Aside from the eyes, do not bite, tense, purse, or conceal your lips. Janine Driver, renowned body language expert, says, “when we don't like what we see or hear, our lips dis­appear” (Lyintamer 2014). This is evidenced by turning both lips into our mouth, similar to spreading lip balm once it's been applied.

When nodding your head, a gentle, 1 sec­ond nod implies active listening, whereas faster head nods may tell your listener “hurry up, I don't have time for this.” Make your nods slow and small with a closed mouth (which indicates you are listening).

Hands and arms are the second compo­nent of this category. Many of us will find ourselves wringing our hands or picking at our fingernails at any given moment. This may increase when we are nervous and evolve from a normal, baseline behavior into what is considered “pacifying” behavior. This is a normal reaction to nervousness or dis­comfort. (Again, we don't know WHY some­one may be nervous or uncomfortable, but we can simply make the observation, then follow up with a powerful question.)

On the deeper meaning of hand positions, Adam Kendon, author of Gesture: Visible Action as Utterance, says (Kendon 2004):

Gestures of the Open Hand Prone or “palm down” family are used in contexts where something is being denied, negated, interrupted or stopped, whether explicitly or by implication. Open hand Supine (or “palm up”) family gestures, on the other hand, are used in contexts where the speaker is offering, giving or showing something or requesting the reception of something.

When auditing the body language of your own hands and arms, use open, offering palms when escorting a client to an exam room, offering to take their coat, or asking if there's “anything else you need?”

Body Language in the Middle Third

Where someone's torso is facing may be one of the most important indications of where they want (or don't want!) to be. The “belly button rule” dates back to the 1930s. Since then, numerous scientists and body language experts have reinforced the theory. Most notably, psychology professor Mehrabian has said, “the belly button rule is the most impor­tant indicator of reading a person's intention.”

During an introduction, face your belly but­ton toward them. This indicates genuine interest and engagement. While you're writ­ing in the patient's chart as the client actively describes his/her pet's history (or anything else he/she feels is important to you), you may turn your shoulders slightly away in recording notes, as long as your belly button remains mostly pointed toward the person talking.

Body Language in the Lower Third

Many experts feel that it's easier to read someone's feelings by looking at his/her feet than any other part of the body. In fact, this concept especially applies to interactions when one party is attempting to “convince” another, which can be the case when a veteri­narian (or anyone else on the team) is pre­senting an estimate to a client. Studies have actually shown that crossed legs can have a devastating effect on a negotiation.

In How to Read a Person Like a Book, authors Gerard Nierenberg and Henry H. Calero reported that the number of times settlements were reached increased greatly when both negotiators had uncrossed their legs. In fact, they found that out of 2,000 vid­eotaped negotiation transactions, not one resulted in a settlement when even one of the negotiators had his/her legs crossed (Nierenberg and Calero 1971).

So what is “good” body language in this lower part of the body? Because building a rapport with clients is our main goal, you want to be perceived as interested and actively listening. Uncross your legs, both feet flat on the ground, sit on the edge (but not too far forward) of the seat, and lean slightly forward. (This is a great stance to take when writing the clinical history while listening to the client.) For the best effect possible, don't jiggle your feet, wrap your toes around the edge of the chair, or cross your legs or your ankles. And if you see the client doing any of these unwanted behav­iors, it might be a good time to audit your own body language or other communication styles (tone or phrasing) to compensate for the potential misalignment. Of course the client might simply be cold!

Physical Appearance

You may not be into fashion or up on the lat­est trends, but that's not what having a “nice” appearance is all about. Being well dressed has everything to do with appearing put together, not being a mannequin for the lat­est crop top or fringe boots. Just as our cli­ents will judge the veterinarian's surgical skills by the neat row of sutures, they will also judge our entire team's knowledge, profes­sionalism, compassion, and overall trustwor­thiness by the way we choose to dress ourselves that morning.

We've all heard the saying “dress for the job you want” or “clothes make the man.” Well, those sayings have real research, and lots of it, to back them up! In 1955, a group of researchers had a man cross a city street against traffic (Lefkowitz, Blake, and Mouton 1955). When this man was dressed in a suit, 3.5 times as many people followed him as when he was wearing a “work shirt and trou­sers.” Regardless of background demograph­ics, a business suit is universally seen as a form of authority.

Taking this one step further, not only is being well dressed seen as a reason for others to follow you but also a reason for others to do what you ask them to do. In another study (Bickman 1974), an experimenter would stop someone on the street, point to a person about 50 feet away (this person far away was an accomplice), and say, “You see that guy over there by the parking meter? He's over parked but doesn't have any change. Give him a dime!” The experimenter would then leave. When dressed in a uniform (anything relating to authority), most people complied with the instruction to give the other person money. When dressed in regular clothes, however, compliance was less than 50%!

But how does this translate into the exam room? What about the white coat hyperten­sion we hear so much about? It appears this may be an overreaction, making it the excep­tion, not the norm. In a written survey in 2005, patients were asked to review pictures of physicians in four different dress styles, then answer questions relating to their pref­erence as well as their willingness to discuss sensitive issues (Rehman et al. 2005):

On all questions regarding physician dress style preferences, respondents significantly favored the professional attire with white coat (76.3%, P <.0001), followed by surgical scrubs (10.2%), business dress (8.8%), and casual dress (4.7%). Their trust and confidence was significantly associated with their preference for professional dress (P <.0001). Respondents also reported that they were significantly more willing to share their social, sexual, and psychological problems with the physician who is professionally dressed (P <.0001). The importance of physician's appearance was ranked similarly between male and female respondents (P =.54); however, female physicians' dress appeared to be significantly more important to respond­ents than male physicians' dress (P <.001).

The conclusion from this study was obvious: “Respondents overwhelmingly favor physicians in professional attire with a white coat. Wearing professional dress (i.e., a white coat with more formal attire) while providing patient care by physicians may favorably influence trust and confidence-building in the medical encounter”’ More recently, in 2015 a comprehensive international review of studies on physician attire was published on the British Medical Journal Open website, adding to the previous study's findings (Petrilli et al. 2015),. The authors confirmed the idea that, yes, most people prefer their doctor to be dressed for­mally, and they also stressed that how you feel about your doctor's attire can depend greatly on your age and/or culture. For exam­ple, in general, Europeans and Asians of any age, and Americans over age 50, trusted a formally dressed doctor more, while Americans in Generations X and Y tended to accept less-dressy physicians more willingly. Doctors in other roles, however, such as sur­gery or emergency, appear more insulated from this effect, and patients are much more willing to see their doctor in scrubs.