Intended for healthcare professionals

  1. Xuemin Yan, associate chief physician,1,
  2. Jun Li, associate professor of linguistics and sociology2
  1. 1Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
  2. 2Department of Language and Culture in Medicine, Peking University School of Health Humanities, Beijing, China

Cultural norms shape doctors and patients’ perceptions of effective communication, say Xuemin Yan and Jun Li

Newton’s third law of motion dictates that bodies exert forces upon each other.1 The same can be true for doctor-patient interactions. Effective communication between doctors and patients, which accurately conveys intent and meaning and reduces misunderstandings, can improve patient prognosis.23 Communication is both verbal and non-verbal, with non-verbal communication, such as eye contact, voice modulation, and posture, constituting up to 80% of people’s daily interpersonal interactions.4 Even simple actions, like maintaining eye contact with a patient or sitting at their bedside, can improve the quality of communication between clinicians and patients.56

Iyer and colleagues have completed a single centre, double blind, randomised controlled study in Texas, US to evaluate the impact of convenient chair positioning on doctors’ sitting behaviour and patient experience.7 They found that convenient chair placement was not associated with time spent in the room (10.6 minutes for chair intervention vs 10.6 minutes for usual care) and perception of time in the room for physicians (9.4 minutes vs 9.8 minutes) or patients (13.1 minutes vs 13.5 minutes). Convenient chair placement was, however, associated with slightly higher patient satisfaction scores.

Based on these findings, the authors argue that this intervention is a no cost, low tech method of influencing physician behaviour to improve patient experience. This study provides additional favourable evidence that proficient non-verbal communication can enhance patient satisfaction, but can it be applied to different countries and cultural contexts?

Different settings and cultural norms

China has a population of around 1.4 billion people, but only 2.2 doctors for every 1000 people.8 Three or more patients will typically occupy one room in hospitals in China, complete with beds and chairs. Consequently, in depth, private conversations are less likely to happen regularly, particularly for busy physicians. It’s important to note that the healthcare structure in other lower resource settings may more closely resemble China’s than the US’s, making the possibility of lengthy conversations—such as the 10 minute long interactions that happened in Iyer’s study—less likely.

An important caveat to the study is that the habits and conventions of a society can influence the interactions of doctors and patients in medical encounters. The role of authority and who possesses it, as well as expected mannerisms, influence communication differentially by culture.9 Sitting down with patients so that the two parties interact at an equal height (and footing) symbolises empathy and an equal exchange of ideas. But some cultures place a greater emphasis on authority.

We know that China and other societies have a clearer delineation of hierarchical roles and etiquette for observing authority. In China, for example, members of the imperial court weren’t allowed to sit down to discuss state affairs with emperors since the North Song Dynasty (960AD-1127AD).10 These attitudes to authority led to physicians with a more dominant, authoritative position in medical encounters until recent decades, when China embraced more western philosophies of healthcare roles. Etiquette also differs between western and eastern cultures—for example, when it comes to people’s perception of the appropriate amount of eye contact.11

Other factors should be considered in future studies on this topic. Doctor-patient communication and each party’s expectations can be influenced by entwining socioeconomic factors, such as cultural norms, educational attainment, gender, age, ethnicity, setting, and the patient’s severity of illness.121314151617181920 Further cross-cultural research is needed to untangle these complexities and consideration should be given to how these unique factors can shape communication.

There’s no one size fits all solution to creating satisfying physician-patient interactions. However, if the convenient placement of a chair at almost no extra cost can nudge the clinician to sit with their patient and result in higher patient satisfaction scores, then this kind of small behavioural change could be a worthwhile endeavour.


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned, not externally peer reviewed.