establishing good communication , either verbal or nonverbal , with patient is an essential and important component to develop a good doctor - patient relation .
face - to - face interaction ( including facial expressions and eye contact ) , expressive touch , body language , paralinguistics ( vocal communication which is discrete from actual language ) , interpersonal proximity , physical appearance , and eloquent gestures all make verbal conversation more expressive and meaningful .
evidence shows that physician 's nonverbal behavior leads to higher patient satisfaction , but this is affected by a number of factors , including gender of the doctor as well as of the patient [ 3 , 4 ] .
a study , from switzerland , showed both male and female doctors should display different set of nonverbal behavior to maximize patients satisfaction .
nonverbal communication has been shown to be important in dealing with pediatric age groups   and with those recovering from disabilities [ 79 ] .
eye contact and physical touch are commonly used as effective tools in nonverbal communication [ 1 , 10 ] .
general practitioners may feel reluctant to use touch other than procedural touch , because of the fear of misinterpretation of such behavior however , many patients believe that , particularly in distressing situations , expressive touch is acceptable .
a study conducted in canada on female patients concluded that , as compared to males , females were more tolerant of comforting touch .
eye contact is another important nonverbal behavior and is especially essential for building good rapport with elderly individuals .
it is mostly taken as a sign of respect , care , and attention from a doctor . however
, if eye contact is coupled with attentive listening it inclines the interaction towards more patient - centered communication . nowadays , the use of computers and especially the electronic health records ( her ) , during medical interviews , is a big obstacle in using eye contact as an effective way to communicate .
we therefore directed our study to explore the expectations and perceptions of patients , in a developing asian country , regarding touch and eye contact by physicians during consultancy , as most of studies on nonverbal communication were conducted in west and we consider that responses in our part of the world would differ .
this cross - sectional study was conducted at the community health centre ( family practice clinic ) , at the aga khan university hospital , karachi , pakistan ( akuh ) , during the months of january to march 2012 .
akuh is one of the major , tertiary care teaching hospitals in karachi , with state - of - the - art family practice clinics . on an average
, 200 family practice patients with mostly primary and secondary care level problems were seen daily by 1216 family physicians at the clinics .
an interview based questionnaire was developed by the researchers through literature search ( for validated questions ) , input from colleagues and from experts in the field of family medicine .
the questionnaire was then translated from english version to urdu language and was back translated in english to check for reliability and any discrepancies found were removed .
the questionnaire was pretested on 10 participants ( data not included in the results ) before finalizing it . interviewers ( two medical graduates ) were trained for data collection and on the use of the questionnaire to ensure uniformity of application .
the questions were asked in english and in urdu depending on the participant 's ease with the language .
patients were chosen randomly and interviewed in the waiting area , before their consultancy with the physician , irrespective of their age , gender , educational status , and the reason for their visit .
those who were willing to participate did not receive any monetary compensation and were asked to sign a written consent form and the provision of confidentiality was ensured to them .
section 1 included demographics like age , gender , religion , education , marital status , and occupation . in section 2
the questions were focused on the nonverbal communication modes of touch and eye contact only , exploring the patient 's expectations about willingness , comfort , and perceptions regarding the two modalities .
other questions were directed to know which part of the body they would allow the physician to touch and the duration of eye contact . the study was reviewed and approved by the dow university of health sciences , karachi .
the data was entered on statistical package for social sciences ( spss ) version 16 .
proportions were calculated for all the variables of interest and chi - square test was used to assess relations of gender and educational level with nonverbal communication modalities . a p - value of < 0.05 was considered statistically significant throughout the study .
a total of 133 patients were approached , out of which 120 patients agreed to participate and were interviewed .
the mean age of the participants was 34.9  10.9 years , out of which 32.5% were between 2030 years of age and 39.2% were 3040 years .
eighty - three respondents were married with 80.1% ( 96 ) having grade ten or more education ( table 1 ) . in the study 62.6% ( 62 ) males and 37.3% ( 37 ) females formed a total of 99 participants who stated that a physician should use touch during their visits ( p - value : 0.03 ) ( table 2 ) ; however there was no statistical significance in relation to their educational level ( p - value : 0.28 ) , religious beliefs ( p - value : 0.63 ) , and marital status ( p - value : 0.61 ) .
about 75.8% of 120 patients said that they can be tapped at their shoulder , 38.3% on their upper back , and 14.2% on their hands ; however 59.1% do not want to be touched on either knee ( figure 1 ) .
if tapped on their shoulder , 35.8% would take it as a gesture of comfort and 24.1% would take as respect followed by 21.6% as healing and 19.1% as a way to increase mutual understanding ( p - value : 0.001 ) ( table 3 ) . the desire to have eye contact was not statistically significant to gender ( p - value : 0.08 ) , religion followed , or literacy level . however , 95.8% ( 115 ) patients felt comfortable if eye contact was established by the clinician in order to develop the patient - doctor relation ( table 2 ) .
eighty - six percent of the respondents felt that this is a sign that the doctor is paying attention to their complaints .
forty - six percent felt that this was done to gain confidence in communication . according to 54.1% , eye contact should be brief but regular rather than only when patient is talking about symptoms ( 1.7% ) .
long stares ( 36.7% ) and objects in the surrounding environment , like computers ( 19.1% ) make them uncomfortable during eye contact ( table 4 ) .
this is a pioneer study from the south asian region to assess patient 's attitudes towards nonverbal communication through touch and eyecontact during consultations
. the outcomes from this study should reassure many medical practitioners regarding the use of comforting touch to patients , as 82.5% of respondents wanted sympathetic touch , especially in distressing situations .
however , as opposed to more distal touch , this study reveals that touch on the shoulder ( 75.8% ) or upper back ( 38.3% ) is more acceptable , when compared to touching on the hands ( 14.2% ) .
yet there exists some gender bias , as patients ( of both sexes ) are more comfortable to touch from a female doctor as compared to that from a male .
our results are consistent with study by street and buller , who studied the nonverbal communication in patient - doctor interactions and they also found no statistically significant correlation between the level of education of patients and their perceptions regarding physician 's touch , whereas a study from john hopkins has shown contrasting results that physician 's touch can be  dominating or controlling  to people , but as our results highlight it is also taken as a gesture of comfort or respect and as healing , which is in agreement with osmun et al . .
a good physician begins to care for the patient as soon as he / she looks at him . in this present study ,
86.1% of the patients eagerly wanted the doctor 's attention through his / her eye contact as pointed out by marcinowicz et al . .
even a simple gesture of frowning can have a positive impact on the patient 's satisfaction .
we also found that in the opinion of 54.1% participants , a regular but brief visual interaction is more effective , rather than long durations of eye contact .
the use of the computer for keeping electronic records has been a hindrance in developing a good patient - doctor relation , as in this study 19.1% people are distracted from objects in the clinical environment and feel that less attention is being directed to them .
this has been acknowledged by many general practitioners ( gps ) as there was a drastic decrease ( from 2001 to 2008 ) in the use of computer by gps during consultancy .
observing the patient together with listening and informative responses makes a medical interview more patient centered and thus results in better therapeutic outcome .
this research is a first step in exploring the importance of nonverbal communications among physicians in the south asian region , but it does have many limitations .
first , the study was conducted at a single , privately governed hospital and needs a larger sample size to generalize the results to all private or to public sector hospitals .
secondly , only two nonverbal modalities have been evaluated in this study , rather than exploring all nonverbal means of communication .
fourth , online literature search revealed a study by stepanikova et al .   who concluded that racial backgrounds do play a role in influencing nonverbal communication and this aspect is not covered in the present study .
positive , effective , and sensitive nonverbal behavior helps to strengthen the doctor - patient bond .
this study does require further clarification and elaborations , but the results do demonstrate the importance of touch and eye contact during the physician 's consultancy .
patients do require , from their doctors , a comforting touch on shoulder and regular but brief eye contacts to demonstrate his / her attention towards the patients .
we believe further research on this important subject , which could be multicentric , should be further explored , with larger sample populations and covering all aspects of nonverbal communication . moreover , researches investigating physician 's perspective regarding nonverbal means of communication during consultancy are warranted to enhance the importance of this ignored yet eminent topic . 

annex : questionnaire 
 
 name ( optional):age : gender :  male  femalereligion : education :  illiterate  can read and write  primary  secondary ( grade viii )  grade 10  higher secondary  graduate  postgraduatemarital status :  married  unmarriedoccupation :  private job  government job  self - employed  retired 
  the following questions are designed to assess the preferences for touch and eye contact during consultations .
you may decide not to participate or if you decide to participate , you are free to withdraw from the study at any time .
results of the survey will only be reported in the aggregates ; individuals will not be identified in any way in the reports .
your data will be coded under a random identifier that can not be linked to you .
signature :   date : (1 ) do you want physical touching of your body by doctor during consultation ?  ( a ) yes 
( b ) no  ( c ) do n't know(2 ) do you approve physical touching of your body by doctor during consultation ?  ( a ) yes  ( b ) no  ( c ) do n't know(3 ) do you feel comfortable with physical touching of your body by doctor during consultation ?  ( a ) yes 
( b ) no  ( c ) do n't know(4 ) you would take a touch from a doctor during consultation as a gesture of ?  ( a ) empathy  ( b ) cure  ( c ) respect  ( d ) comfort  ( e ) communication with doctor  ( f ) other (5 ) which part of your body you would comfortable with ?  ( a ) hand  ( b ) head  ( c ) shoulder  ( d ) knee  ( e ) upper back  ( f ) other (6 ) which part of your body you will not be comfortable with ?  ( a ) abdomen  ( b ) thigh  ( c ) others (7 ) do you feel comfortable with his / her eye contact ?  ( a )
yes  ( b ) no  ( c ) do n't know(8 ) for how long should an eye contact be ?  ( a ) should be throughout consultation  ( b ) should be brief but regular  ( c ) should be more at beginning less in the end  ( d ) should be more at endless in the beginning  ( e ) others (9 ) what do you feel when a doctor makes an eye contact ?  ( a ) confidence in yourself  ( b ) confidence in communication  ( c ) secure  ( d ) attended  ( e ) much more important  ( f ) other (10 ) what are the things which would make you uncomfortable during eye contact ?  ( a ) long stare  ( b ) smiling eyes  ( c ) frequent blinking 
( d ) others(11 ) what do you feel if a doctor does not make an eye contact ?  ( a )
religious  ( b ) less confident  ( c ) short attention span  ( d ) liar  ( e ) lack of interest 

 
 background . nonverbal behaviors have a significant impact on patients during consultations . 
 this study was undertaken to find out the attitudes and preferences of the patients regarding nonverbal communication during consultations with physicians , in a tertiary care hospital . 
 methods . 
 a questionnaire based cross - sectional study was carried out at the aga khan university hospital , karachi , pakistan , during the months of january to march 2012 . 
 all patients ( > 18 years of age ) coming for consultancy in the family medicine clinics were approached ; out of 133 , 120 agreed to participate . 
 the subjects were asked questions regarding physician 's comforting touch and eye contact and their responses were noted . 
 the data were analyzed using spss and chi - square test was used to identify corelations . results . 
 overall , 120 patients were enrolled . 
 about 58.3% were men and 41.7% were women with a mean age of 34.9 
  10.9 years . 
 95.8% were muslims and 57.6% had more than 12 years of education . among females 74% wanted supportive touch from doctors , used to comfort the patient ( 45% ) or to show respect ( 27.5% ) or as healing ( 30% ) . 
 86.1% of the respondents believe that establishing eye contact with the patient shows that the doctor is attentive towards his / her patient . 
 the eye contact should be brief but regular ( 54.1% ) and prolonged staring ( 36.7% ) makes them uncomfortable . 
 conclusion . 
 nonverbal communication helps to strengthen the doctor - patient relation as patients do appreciate positive touch and eye contact from their physicians . 
1. Introduction
2. Methods
3. Results
4. Discussion
5. Conclusion