Paths to Improved Patient Engagement

Building Relationships with Patients: A Cornerstone of Patient Engagement

Research reflects that building relationships with patients through communication and patient-centeredness has a strong impact, which includes improving patient and provider satisfaction, improving adherence to medication, and decreasing resource utilization, costs and malpractice. The major skills in building a relationship and patient-centeredness include attentiveness and warmth, empathy, respect, support and partnership.

Attentiveness and Warmth

Attentiveness and warmth, which is the foundation of relationship building, is demonstrated by both non-verbal and verbal behaviors. Important actions include eye contact, voice tone, nods and uh-huh’s, responsive facial expressions and forward posture. Attentive silence can have a powerful positive impact, as well. An emerging body of research supports these contentions. Doctors who establish appropriate eye contact are more likely to detect emotional distress in their patients. Doctors who perform better on tests of nonverbal sensitivity have patients who are more satisfied. Doctors who lean forward and have a forward head lean and open body posture also have more satisfied patients.

Patients’ nonverbal behaviors are keys to their emotional lives. Most patients express their emotional state through facial expression, body posture, movement, tone of voice, inflection and physical manifestations of autonomic nervous system reactivity (sweaty palms, flushed face, etc.). Clinicians interested in understanding their patients’ emotional states will look for these signs and consider their importance at every stage of the communication process.

Thoughtful attention to the use of space also facilitates rapport. Vertical space between doctor and patient should be minimized (e.g., not standing while the patient sits) and horizontal space should be carefully planned (e.g., not too close or too far).

Verbal demonstration of attentiveness is largely through active listening, which includes continuers (encouraging comments), such as “Please tell me more,” and reflection (repetition) of key phrases used by the patient (“I see …the pain was severe”).

Attentiveness is not just listening but rather authentic engagement with patients and their verbal and non-verbal cues. Physicians do an excellent job of asking questions about symptoms; however, other questions stemming from active listening and empathic comments alert patients that the doctor is attending to the person, not the disease.


Empathy is a term indicating one person’s appreciation, understanding and acceptance of someone else’s emotional situation, inner experience and perspectives. When a clinician communicates this understanding, the patient feels heard, understood and accepted.

The communication of empathy is one of the most helpful, meaningful and comforting interventions one person can have with someone else. A clinician can build rapport and respond to patients’ emotions best by the communication of empathy. Sometimes clinicians are reluctant to encourage the patient to express feelings more deeply. They may feel that this will open a “Pandora’s box” of emotions or that empathic comments will “push” patients to express feelings that they might otherwise wish to keep private.

Research suggests that it is helpful and supportive to allow patients opportunities for the ventilation of feelings. Such interventions help develop rapport and trust. And contrary to the worry that expressions of empathy can unnecessarily prolong the interview, there is evidence that empathic statements can make interactions with patients more efficient.

Nonverbal behaviors can sometimes communicate empathy more effectively than statements. A sympathetic look, attentive silence and a hand on the shoulder can let the patient know that the clinician is emotionally in tune with the patient’s distress. Genuine interest in the patient’s life, feelings, worries, expectations and hopes communicate empathy.


Attentive listening, nonverbal signals, eye contact, and genuine concern show that the clinician respects the patient and his or her problems. Making explicit respectful comments further builds rapport, improves the relationship and helps the patient cope with difficult situations.

Statements of respect, which validate patient behaviors, will, in general, tend to reinforce the behavior, and make it more likely to happen again. Frequent demonstrations of respect will foster a positive relationship and promote the patients’ capacity for coping.

Clinicians usually can find something to praise in all their patients. Most everyone does something well. This holds true even for patients with troubling or difficult behaviors. Doctors can help their patients by focusing on one or more of their patient’s successful coping skills. An example might be, “How much do you help your kids” or “How have you’ve been able to go through all the tests we’ve ordered?” etc.

This will improve patient satisfaction and adherence.

Statements of respect must be honest or they will be more destructive than helpful. Statements that reflect true sentiments and feelings of the clinician are powerful facilitators of improved communication and rapport between doctors and patients.

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The clinician should make explicit statements that express that he or she is there, personally, for the patient and wants to help. Again, this must be an honest statement or it will not be effective. The assurance of direct personal support is particularly important when situations are changing rapidly or in those situations where there is considerable uncertainty about diagnosis or treatment or where anxiety or tension or conflict is paramount. A statement of personal involvement means a lot to the patient and leads to improved rapport and solidification of the doctor-patient relationship.


Patients are more satisfied with clinicians and are more likely to adhere to treatment recommendations when their clinicians assure them that they are working in close partnership. However, working together as partners cannot occur unless the clinician and the patient agree on an understanding of the task in hand. The first task is the process of the interview itself. It may be helpful for the clinician to offer brief explanations in advance of certain components of the interview, such as the inquiry into personal and social factors. An example might be, “It would be helpful to know a bit about your personal circumstances because sometimes this has a bearing on how best to sort out your problem.”

Increasing the participation of the patient in his or her own treatment improves the patient’s coping skills and improves the likelihood of good outcome from illness processes. Clinicians’ work is much easier when patients sense a clear joining together to find the best solutions, especially for thorny and difficult problems.

By exhibiting attentiveness and warmth, empathy, respect, support and partnership, clinicians can build a strong relationship with their patients, which can have a substantial impact, not only on the patient, but on the clinician, as well.

Editor’s Note: The content of this article is excerpted from DocCom Module 6, which is available for free at and includes an Empathy Test. Barbara can be reached at for a free 30-day trial subscription to DocCom.


Barbara Lewis, MBA Barbara Lewis, MBA is the Managing Editor of DocCom, a non-profit on-line communication skills learning system launched in 2005 to help medical students become better communicators. Today, the fastest growing segment of DocCom’s subscribers is residency programs. Translated into three languages, DocCom ( has subscribers in eight countries. Barbara is a former journalist and marketing consultant.

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