Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 142 No. 1920 (2012)

“Explicitly implicit”: examining the importance of physician nonverbal involvement during error disclosures1

  • Annegret F. Hannawa
Cite this as:
Swiss Med Wkly. 2012;142:w13576


QUESTIONS UNDER STUDY/PRINCIPLES: Medical errors are prevalent, but physicians commonly lack the training and skills to disclose them to their patients. Existing research has yielded a set of verbal messages physicians should communicate during error disclosures. However, considering the emotional message contents, patients likely derive much of the meaning from physicians’ nonverbal behaviours. The purpose of this study was to test the causal effects of physicians’ nonverbal communication on error disclosure outcomes.

METHODS: At a university hospital in the Southeastern United States, 318 patients were randomly assigned to three treatment groups. The first group watched a video vignette of a verbally and nonverbally competent error disclosure by a person acting as a physician. The second group was exposed to a verbally competent but nonverbally incompetent error disclosure. The third group read an error disclosure transcript. Then, all patients responded to measures of closeness, trust, forgiveness, satisfaction, distress, empathy, and avoidance.

RESULTS: The results evidenced that holding the verbal message content constant, physician nonverbal involvement was significantly associated with higher patient ratings of closeness, trust, empathy, satisfaction, and forgiveness, and with lower ratings of patient emotional distress and avoidance. These associations were not affected by patient predispositions such as sex, ethnicity, religion and previous experiences with medical errors.

CONCLUSION: The findings of this study imply that nonverbal communication has a significant impact on error disclosure outcomes and thus should be considered as an important component of future research and disclosure training efforts.


  1. Leape LL. The preventability of medical injury. In: Bogner MS, editor. Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates; 1994. p. 13–26.
  2. Kohn LT, Corrigan JM, Donaldson MS. To err is human: Building a safer health care system. Washington, DC: National Academy Press; 2000.
  3. Banja J. Medical errors and medical narcissism. Sudbury, MA: Jones and Bartlett Publishers; 2005.
  4. Schwappach DL. Frequency of and predictors for patient-reported medical and medication errors in Switzerland. Swiss Med Wkly. Forthcoming.
  5. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The quality in Australian health care study. Med J Aust. 1995;163:458–71.
  6. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: Preliminary retrospective record review. Br Med J. 2001;322:517–9.
  7. Schioler T, Lipczak H, Pedersen BL, Mogensen TS, Bech KB, Stockmarr A, et al. Incidence of adverse events in hospitals. A retrospective study of medical records. Ugeskr Laeger. 2001;163:5370–8.
  8. Reason J. Human error. Cambridge, MA: Cambridge University Press; 1990.
  9. Hannawa AF, Roter DL. TRACEing the roots: a tool for retrospective analysis of critical events. Milbank Q. Under review.
  10. Wu AW. Handling hospital errors: Is disclosure the best defense? Ann Intern Med. 1999;131:970–2.
  11. Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE. Disclosing medical errors to patients: Attitudes and practices of physicians and trainees. J Gen Intern Med. 2007;22:988–96.
  12. Levinson W. Disclosing medical errors to patients: A challenge for health care professionals and institutions. Pat Educ Couns. 2009;76:296–9.
  13. Gallagher TH, Studdert LL, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356:2713–9.
  14. Lamb RM, Studdert DM, Bohmer RM, Berwick D, Brennan TA. Hospital disclosure practices: Results of a national survey. Health Aff. 2003;22:73–83.
  15. American Medical Association (2001). Principles of medical ethics: Revised June 17, 2001. Available from:
  16. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. J Am Med Assoc. 2003;289:1001–7.
  17. Mizrahi T. Managing medical mistakes: Ideology, insularity and accountability among internists-in-training. Soc Sci Med. 1984;19:135–46.
  18. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? J Am Med Assoc. 1991;265:2089–94.
  19. Gallagher TH, Garbutt JM, Waterman AD, Flum DR, Larson EB, Waterman BM, et al. Choosing your words carefully: How physicians would disclose harmful medical errors to patients. Arch Intern Med. 2006;166:1585–93.
  20. Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen A, Schneider E, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933–40.
  21. Hobgood C, Peck CR, Gilbert B, Chappell K, Zou B. Medical errors – what and when: What do patients want to know? Acad Emerg Med. 2002;9:1156–61.
  22. Mazor KM, Simon SR, Yood RA, Martinson BC, Gunter MJ, Reed GW, et al. Health plan members’ views about disclosure of medical errors. Ann Intern Med. 2004;140:409–18.
  23. Mazor KM, Goff SL, Dodd K, Alper EJ. Understanding patients’ perceptions of medical errors. J Commun Hlthc C. 2009;2:34–46.
  24. Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? Arch Intern Med. 1996;156:2565–9.
  25. Chan DK, Gallagher TH, Reznick R, Levinson W. How surgeons disclose medical errors to patients: A study using standardized patients. Surgery. 2005;138:851–8.
  26. White AA, Gallagher TH, Krauss MJ, Garbutt J, Waterman AD, Dunagan WC, et al. The attitudes and experiences of trainees regarding disclosing medical errors to patients. Acad Med. 2008;83:250–6.
  27. Levinson W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med. 1993;8:318–24.
  28. Burgoon JK. Nonverbal signals. In: Knapp ML, Miller GR, editors. Handbook of interpersonal communication. 2nd ed. Thousand Oaks, CA: Sage; 1994. p. 229–85.
  29. Ekman P, Friesen WV. The repertoire of nonverbal behavior: Categories, origins, usage, and coding. Semiotica. 1969;1:49–98.
  30. Birdwhistell RL. Background to kinesics. Rev Gen Seman. 1955;13:10–8.
  31. Mehrabian A, Ferris SR. Inference of attitudes from nonverbal communication in two channels. J Couns Psychol. 1967;3:248–52.
  32. Philipott JS. The relative contribution to meaning of verbal and nonverbal channels of communication: A meta-analysis. Unpublished master’s thesis, Univ of Nebraska, Lincoln; 1983.
  33. McGowan JF, Schmidt LD. Counseling: Readings in theory and practice. New York: Holt, Rinehart & Winston; 1962.
  34. Haase RR, Tepper DT. Nonverbal components of empathic communication. J Couns Psychol. 1972;19:417–24.
  35. Tepper DT, Haase RE. Verbal and nonverbal communication of facilitative conditions. J Couns Psychol. 1978;25:35–44.
  36. Seay TA, Altekruse MK. Verbal and nonverbal behavior in judgments of facilitative conditions. J Couns Psychol. 1979;26:108–19.
  37. Griffith C, Wilson JF, Langer S, Haist SA. House staff nonverbal communication skills and patient satisfaction. J Gen Intern Med. 2003;18:170–4.
  38. Schmid-Mast M. On the importance of nonverbal communication in the physician-patient interaction. Pat Educ Couns. 2007;67:315–8.
  39. Hall JA, Harrigan JA, Rosenthal R. Nonverbal behavior in clinician – patient interaction. Appl Prev Psychol. 1995;4:21–37.
  40. DiMatteo MR, Hays RD, Prince LM. Relationships of physicians’ nonverbal communication skill to patient satisfaction, appointment non-compliance, and physician workload. Health Psychol. 1986;5:581–94.
  41. Robinson JD. Nonverbal communication and physician–patient interaction: Review and new directions. In: Manusov V, Patterson ML, editors. The Sage handbook of nonverbal communication. Thousand Oaks, CA: Sage; 2006. p. 437–60.
  42. DiMatteo MR, Taranta A. Nonverbal communication and physician – patient rapport: An empirical study. Prof Psychol. 1979;10:540–7.
  43. Ben-Sira Z. The function of the professional’s affective behavior in client satisfaction: a revised approach to social interaction theory. J Health Soc Beh. 1976;17:3–11.
  44. Ambady N, Koo J, Rosenthal R, Winograd C. Physical therapists’ nonverbal communication predicts geriatric patients' health outcomes. Psychol Aging. 2002;17(3):443–52.
  45. Spitzberg BH, Cupach WR. Interpersonal skills. In: Knapp ML, Daly JA, editors. Handbook of interpersonal communication. Thousand Oaks, CA: Sage; 2002. p. 564–611.
  46. Zoppi K, Epstein RM. Is communication a skill? Communication behaviors and being in relation. Fam Med. 2002;34:319–24.
  47. Cegala DJ, Coleman MT, Turner JW. The development and partial assessment of the Medical Communication Competence Scale. Health Commun. 1998;10(3):261–88.
  48. Cegala DJ, McGee DS, McNeilis K. Components of patients’ and doctors’ perceptions of communication competence during a primary care medical interview. Health Commun. 1996;8(1):1–27.
  49. Hannawa AF. Shedding light on the dark side of doctor–patient interactions: Verbal and nonverbal messages physicians communicate during error disclosures. Pat Educ Couns. 2011;84:344–51.
  50. Gallagher T. Criteria of effective error disclosure. Unpublished coding scheme; 2010.
  51. Guerrero LK. Observer ratings of nonverbal intimacy and involvement. In: Manusov V, editor. The sourcebook of nonverbal measures. Mahwah, NJ: Lawrence Erlbaum Associated; 2006. p. 221–38.
  52. Aron A, Aron EN, Smollan D. Inclusion of other in the self scale and the structure of interpersonal closeness. J Pers Soc Psychol. 1992;63:596–612.
  53. Anderson L, Dedrick RF. Development of the Trust in Physician Scale: A measure to assess interpersonal trust in patient physician relationships. Psychol Rep. 1990;67:1091–100.
  54. Berry JW, Worthington EL, O’Connor LE, Parrott L, Wade NG. Forgivingness, vengeful rumination, and affective traits. J Pers. 2005;73:1–43.
  55. McCullough ME, Worthington EL, Rachal KC. Interpersonal forgiving in close relationships. J Pers Soc Psychol. 1997;73(2):321–36.
  56. Hausknecht D. Measurement scales in consumer satisfaction/dissatisfaction. J Consum Sat, Dissat Complain Behav. 1990;3:1–11.
  57. Coke JS, Batson CD, McDavis K. Empathic mediation of helping: A two-stage model. J Pers Soc Psychol. 1978;36:752–66.
  58. McCullough ME, Root LM, Cohen AD. Writing about the personal benefits of a transgression facilitates forgiveness. J Consult Clin Psychol. 2006;74:887–97.