In medicine, it is critical that clinicians demonstrate both empathy (perceived as warmth) and competence. Perceptions of these qualities are often intuitive and are based on nonverbal behavior. Emphasizing both warmth and competence may prove problematic, however, because there is evidence that they are inversely related in other settings. We hypothesize that perceptions of physician competence will instead be positively correlated with perceptions of physician warmth and empathy, potentially due to changing conceptions of the physician’s role. We test this hypothesis in an analog medical context using a large online sample, manipulating physician nonverbal behaviors suggested to communicate empathy (e.g. eye contact) and competence (the physician’s white coat). Participants rated physicians displaying empathic nonverbal behavior as more empathic, warm, and more competent than physicians displaying unempathic nonverbal behavior, adjusting for mood. We found no warmth/competence tradeoff and, additionally, no significant effects of the white coat. Further, compared with male participants, female participants perceived physicians displaying unempathic nonverbal behavior as less empathic. Given the significant consequences of clinician empathy, it is important for clinicians to learn how nonverbal behavior contributes to perceptions of warmth, and use it as another tool to improve their patients’ emotional and physical health.

Introduction

We define empathy as a social-emotional ability having two distinct components: one affective: the ability to share the emotions of others, and one cognitive: the ability to understand the emotions of others. This definition is supported by evidence that these two components have dissociable neurological substrates [1, 2]. This approach is broad enough to encompass elements of various components of empathy that have been proposed [3, 4]—e.g. sympathy (or shared emotions) [5], perspective taking [6], and accurate interpersonal perception [7, 8]—while distinguishing basic cognitive processes underlying them. It is necessary for an operational definition of empathy to focus on the cognition of the empathic subject (i.e. the person expressing empathy, such as a physician), but because empathy is fundamentally a relational ability, it is also useful to understand the cognition of the empathic object (i.e. the individual whose emotions are being empathized with, such as a patient). There is extensive evidence that empathy (expressed by the subject) is perceived (by the object) as warmth [e.g. 9]. In this paper, we therefore discuss empathy and warmth as two sides of the same coin (i.e. “empathy/warmth”), in that they are functionally linked in the context of social interaction.

Empathy is particularly important in the context of medicine, where evidence suggests it is related to numerous positive outcomes [for a review, see 10] including increased patient satisfaction [11], good patient rapport [12], increased adherence to treatment [13], increased diagnostic accuracy [14], reduced medical errors [15], and positive health outcomes [16–18] (though see [19]; an intervention of care-giver investment does not alter diabetes outcomes). Other explorations of how physicians are perceived have further differentiated perceptions of empathy, distinguishing two dimensions: caring (similar to high empathy) and dominance (similar to low empathy) [20]. Conveying competence is also important in medicine, as the literature on “medical professionalism” demonstrates [21, 22]. There have even been attempts to institutionalize professionalism through, for example, the doctor’s “white coat” [23]. The white coat has traditionally played a significant part in physician identity formation during medical training [24–28] as well as role identity in clinical settings. Empathy (perceived as warmth) and competence are not only important in medicine, but are two frequently-used dimensions of person perception across many contexts [29].

While ratings of empathy are positively correlated with perceptions of warmth both in the lab [e.g. 30] and in clinical contexts [e.g. 31, 32], there is evidence that perceptions of warmth and competence can be inversely related in some contexts [33–37]. Four mechanisms of the warmth/competence tradeoff are particularly relevant here. First, people can exhibit compensatory judgments of warmth and competence [38] particularly when they are under threat [39]. Because high status and wealth are associated with high ratings of competence [40] and physicians are often considered high status, patients who are threatened by an upward social comparison may be biased to perceive their physicians as less warm. Second, though warmth and competence can be positively related in judgments of individuals, they are more likely to be negatively related in judgments of groups [37]. To the extent that a patient sees a clinician as a member of an outgroup—such as the “upper class,” but also in terms of other social group categories, e.g. gender or ethnicity—they may be more likely to exhibit compensatory judgments of warmth and competence. Third, when comparing two others, people see one individual or group as high on one dimension and low on the other, and the inverse for the object of comparison (e.g. among women [34], businesses [41], and immigrant groups [42]). Patients who are comparing their current clinician experience with others in the past therefore may perceive warm clinicians as less competent and vice versa. Finally, when being perceived, people engage in impression management, downplaying one dimension to highlight the other [36]. Clinicians who are trying to convey empathy, therefore, may downplay their competence.

The field of medicine therefore faces a dilemma: if empathy (perceived as warmth) and competence are both important, but are inversely related in patients’ perceptions, which should be emphasized? Indeed, some have argued that an emphasis on empathic clinician behaviors could negatively impact patient perceptions of clinician competence [43] while others argue that the white coat might emphasize professionalism at the cost of humanism [44, 45]. However, “competence” in the medical context embodies both technical competence (i.e. skill in medical procedures and biological knowledge) and interpersonal competence (i.e. skill in medical social interactions). Given that patients consider interpersonal competence to be crucial in their evaluations of clinicians, one might expect that competence and empathy/warmth would be positively correlated because empathy is increasingly becoming a component of successful medical care or interpersonal competence [46]. This distinction and trend in the understanding of medical competence is consistent with the movement of patient-centered care [47] (and more recently, relationship-centered care [48]), which emphasizes patient experience with and understanding of treatment (including emotional and social implications). Patient- or relationship-centered care models have demonstrated both increased efficiency in treatment and better health outcomes [49, 50]. We therefore predicted that empathic nonverbal behavior will increase perceptions of clinician warmth and competence.

Empathy is communicated through both verbal and nonverbal behaviors [51], though the power of nonverbal communication of empathy may be underestimated, as nonverbal behavior can communicate emotional states subtly [52] and automatically [53]. Further, the literature on “thin slicing,” demonstrates that we rapidly make judgments of others [54, 55]. In medical education, emphasis has traditionally been placed on training clinicians in verbal communication [56], with relatively little attention paid to nonverbal communication [57, 58]. The nonverbal behavior literature provides widespread support for the claim that good nonverbal behavior is crucial to patient-centered care in medicine [59, 60], and identifies a number of specific nonverbal behaviors that influence patients’ perceptions of clinicians [58, 61–63]. For example, open body posture (uncrossed arms), eye contact, smiling, and touch express positive affect, involvement, availability, attention, warmth, encouragement, respect, understanding, empathy, and affiliation with the patient [56, 58, 64–68]. Further, nonverbal communication is also related to positive health outcomes, such as increased pain tolerance [69]. In medical practice, humanistic concern for patient well-being—which can be expressed via these nonverbal behaviors—drives the standard of care forward and incentives for quality care have grown as healthcare reimbursement from third-party payers is now often tied to patient satisfaction surveys [64, 70]. There is relatively less research on nonverbal communication of clinician competence in general [71], and perceptions of the white coat in particular [72]. Because there is a growing debate about the effects of the white coat [68, 73–79], we thought manipulating its presence would be a particularly interesting test of the nonverbal communication of competence.

In the present study, we test whether a warmth/competence trade-off will occur in response to clinicians’ nonverbal behavior. We also test for interactions of participant gender with our independent variables as previous findings have indicated gender differences in judgments of warmth and competence [80–83]. Specifically, while both men and women judge traits related to warmth to be more important than traits related to competence in their formation of impressions of others, women judge the relative importance of traits related to warmth to be significantly more important [84]. There is a gender-role stereotype that women are warmer than men, and these findings might be partially explained by women internalizing this stereotype which transfers to their perception of others [81]. Finally, we wanted to ensure that any effect we found was not driven by mood, such that our manipulations put participants in a positive or negative mood, which then influenced their perceptions of clinicians [85]. Therefore, we included participant mood as a covariate in our analyses to ensure that participants’ ratings of clinicians are attributable to our manipulations. We provide preliminary evidence that nonverbal empathic behaviors increase patient perceptions of clinician empathy, warmth, and competence. We find that this effect may be stronger for women, cannot be attributed to mood, and that there is no effect of the white coat.