Early impressions are hard to eradicate from the mind. When once wool has been dyed purple, who can restore it to its previous whiteness?—Saint Jérôme
The first 30 seconds can be critical to the success or failure of any consultation. Research and experience lead us to the incontrovertible conclusion that people make up their minds almost instantaneously. Reasoning comes later—and that may be too late.
The instant your patient lays eyes on you, he has already begun to form an opinion, assembled unconsciously and at near-light speed, from the way you are dressed, your posture, facial expression, eye contact, and body movements. Within the first few words you speak, the impression is all but fixed.
The phenomenon, extensively studied by psychologists as ‘thin slicing’133 and introduced to the general public by science and psychology writer Malcolm Gladwell in his highly readable book, Blink, is familiar to everyone in both social and professional settings. How many times have you taken an instant liking to someone you met at a party? Within minutes, you felt as if you’d known them ‘forever’. How many times have you ‘just known’ something was wrong with the person on the other end of a telephone conversation, even though nothing specific was said?
Aside from the spoken word, people leak information at every turn. This includes eye movements; facial expression; physiology; gestures; tics and mannerisms; vocal qualities; breathing patterns; changes in skin color and muscle tone. Most of this is absorbed below the threshold of consciousness, but it is absorbed. And, once absorbed, it acquires meaning through some of the processes we will discuss below.
The speed with which information is transmitted and received is staggering. Paul Ekman has identified micro-expressions of emotions, such as anger, fear, disgust, happiness, and sadness, lasting as little as 1/500th of a second and shared by cultures throughout the world.134
Harvard University’s Nalini Ambady and fellow experimental psychologist Robert Rosenthal have demonstrated that 30-second snatches of soundless videos of lectures are all observers needed accurately to predict the qualities of teaching as measured over an entire semester. 135
Awareness that these processes are at work and understanding how to engage with patients at the most productive level can give rise to a set of skills that allows the practitioner to achieve maximum engagement with the patient. This, in turn, improves both concordance between patient and practitioner and adherence to treatment plans, while avoiding, as far as possible, accidental and damaging disconnects.
Lack of warmth and friendliness has been found to be one of the most significant variables adversely affecting patient satisfaction and concordance. Many busy practitioners underestimate how much their attention shifts from the patient to other concerns (computer screens, notes, calls, etc), and overestimate the time they give to listening, eliciting unexpressed concerns, and giving information.136
In order to get the feeling for this, imagine for a moment that you are a patient visiting a doctor you have never met before. As you enter the examination room, she is tapping at the keyboard on her desk, eyes fixed on the screen. Without looking up from your electronic records, she says,
‘What’s the problem?’
‘Well, doctor, I have this headache and it’s worrying me because—’
‘When did it start?’ The doctor pauses, fingers hovering above the keyboard, still not looking up.
‘About three weeks ago, but—’
‘Whereabouts in your head is it?’
‘Well, it’s actually more a kind of pressure at the back. I’m worried about—’
‘Is the pain sharp or dull?’
‘Um—like I said, it’s more a kind of…pressure, but I think it’s—’
And, so it goes.
For you, as the patient, a number of things are happening, aside from your symptoms and any frustration, confusion or irritation you may be feeling at the repeated interruptions.
The first is a ‘gut feeling’ that something is not right. At this stage (and, had you been alert enough, you might unconsciously have noticed it the instant the physician failed to look at you when you entered his space), you will not have attached any words to the experience. In Korzybski’s model, it occurs at the Object level—a kinesthetic internal experience that has qualities, such as heat, weight, movement, and intensity. It is highly unlikely that it will feel good.
In NLP terminology, this is an ‘internal kinesthetic’. Neuroscientist Antonio Damasio calls it a ‘somatic marker’, and he believes that it is a learned response that serves as an automated alarm, a psychophysical signal communicating either ‘Danger!’ or ‘Go for it!’137
Somatic markers are ‘paired’ experiences, he adds. In other words, we learned to feel one way if Dad never praised us for our accomplishments, or another way if Mom gave us a particularly sunny smile every time she saw us. As we navigate through life, we link various experiences, or ‘states’, into groups or chains according to the characteristics they share. Each of these is experienced as a distinctive kinesthetic or somatic marker. And each of these markers, in turn, may be triggered at any later stage by a word, a look, a tone of voice—any stimulus, in fact, that is a broad pattern-match to the one that set up the original response.
The stimulus may occur unexpectedly, and at any time, long after the original experience has been forgotten. Only later (often much later, and sometimes in front of a lawyer) does cognition kick in and we try to explain the reasons for feeling the way we did. ‘She just didn’t seem to care’; ‘She was too busy to listen’; ‘I tried to tell her my sister had died but she kept cutting me off’. (Some lawyers are extremely skilled at helping clients ‘translate’ these somatic markers into the language of litigation—so be warned.)138
This automated stimulus-response is known in NLP as an ‘anchor’, and it is impossible to know how many have been set up over the years. It follows, then, that we need to do whatever we can in order to minimize adverse responses in the people we hope to help. Entirely avoiding responses that bubble up from the patient’s hidden past may be an impossible task. However, the probability of a mutually rewarding consultation is significantly increased if three propositions are borne in mind:
Our contention—and the balance of research that we present in this book—is that a major part of effective consultation is a mutually respectful emotional and working relationship between patient and practitioner, and that, once set up, is maintained and measured through the medium of communication. What follows from this point on, then, is a collection of principles and techniques modeled from particularly effective communicators, reinforced by research projects, and verified by patients satisfied with the healthcare they have received.
We have also gleaned useful nuggets from less orthodox sources, including: information technology; Game Theory; Contingency Planning; successful business consultants; effective salespeople; presenters; observations made by us or our colleagues; personal experience; and, common (Korzybski would say ‘un-common’) sense.
Together, these form the basis of the Engagement phase of the three-part Medical NLP Consultation Process. Integrating them into your normal consultation style takes little or no extra time and increases your sense of control in potentially problematical or challenging situations.
Appearance is a significant factor in creating good first impressions. Although the results of studies on physician attire are inconclusive regarding the white coat versus no white coat debate, communication experts agree that patients expect health professionals to be well dressed and smartly groomed. The consensus is well-fitting suits, plain shirts and ties for men, neat suits or jacket and skirts for women. Both sexes should avoid overly strident patterns or colors, excessive jewelry, and unpolished shoes. Many patients react particularly adversely to extravagant hair styles or overly trendy cuts.
Most of us take the voices we were ‘born with’ for granted—until we hear ourselves for the first time in a recording. Even that is often not enough to prod us into taking charge of one of our most fundamental tools of communication. Well, consider this: within less than a minute, your voice can reveal your height, weight, build, gender,140 age, occupation,141 and even your sexual orientation,142 sight unseen.
As sociologist Anne Karpf comments in her book, The Human Voice, we are doing something ‘terrifyingly intimate’ every time we speak, even if all we’re doing is to read out a list of rules and regulation about waste disposal.143 Such a powerful tool needs to be cared for and protected if it is to do its job effectively.
If you are unsatisfied with the quality of your speech and are unable to correct it by applying some of the suggestions below, we urge you to consult a qualified professional to improve your presentation and to prevent damage to your vocal chords. Vocal coach and therapist Janet Edwards identifies two factors particularly damaging to the voice: inadequate breathing and dehydration.
‘If you don’t breathe into your abdomen, your voice has no support and lacks power,’ she says. ‘This is also a great drain on energy.’ She also suggests a minimum of two to three pints of water (‘not soft drinks, tea, or coffee’) sipped over a day to ensure adequate hydration.
Another recommendation often given to professionals who use their voices over sustained periods is to locate their unique ‘key’. Broadly speaking, key refers to the most comfortable series of notes you can produce while still retaining a wide range of ‘highs’ and ‘lows’. By identifying the key of your speaking voice—which changes from day to day according to energy levels, the amount of talking you do, your physical and emotional state at the time—you can inject variation into your speech and sustain interest while avoiding strain.
We suggest one of the following ways to ‘set’ your key before starting any sustained period of speaking. The first is to sing (probably best when no-one else is around to witness your efforts) the lowest note you can produce. Then, sing five notes up the scale (‘soh’ on the doh-re-mi scale). This is the mid-point of your range, giving you flexibility to move up and down while still retaining a ‘natural’ sound.
If you prefer not to sing, or are not familiar with the notes of the musical scale, take a deep breath, imagine you are sitting down after a long and tiring period on your feet, and make that ‘comfort sound’ we all know so well—hunh! The hunh sound is the mid-point of your current vocal range.
Communicating with purpose requires an understanding of how the ‘shape’ and rhythm of language can affect the listener as much as the words that are used.
As a general rule, only questions should inflect upwards (the voice going up at the end of the sentence), whereas neutral statements tend to be uninflected, and commands, orders or important information are all downwardly inflected (the voice going down at the end of the sentence).
Some nationalities (Australian and Welsh in particular) have a tendency to inflect upwards whether or not a question is being asked. Women in the West sometimes follow the same pattern in the belief that it is a friendlier, more empathetic approach. However, this may sometimes be interpreted as a lack of certainty.
Effective communicators and presenters tend to share two qualities—credibility and approachability—both of which have distinctive vocal patterns (see Figure 8.1). It is important to distinguish between the two styles, and to know when to apply them.
Approachability (often associated with ‘friendliness’ and ‘likeability’) is an aid to gaining rapport, gathering information, and encouraging disclosure. It is marked by variability in pitch, tone, and rate of speech (what Edwards calls ‘color’). The voice is animated, rising and falling naturally. Laughing and joking (if appropriate) and moving or gesturing while talking are also permissible in the approachable phase.
Setting your ‘key’, as mentioned above, helps facilitate the vocal flexibility that characterizes approachability.
Approachability alone, however, may be counter-productive when important information or instructions need to be given. Patients may like an approachable practitioner, but will not necessarily accept his advice as authoritative. This is where ‘credibility’ will improve concordance and adherence.
Credibility (being authoritative but not overbearing) serves analogically to ‘mark out’ the importance of a statement from the general ‘noise’ of conversational exchanges. This alerts the patient, consciously and unconsciously, to pay particular attention to what is being said, while also helping to increase memory and adherence.
Credibility and authority are dependent not on volume, but on vocal style. When striving to be credible, your voice should be less varied, and your movements and gestures more restrained. Information and instructions are delivered with a downward inflection at the end of a sentence. Eye contact should be steady throughout the statement, without being intimidating.
| Purpose | Tone | Pitch | Eye contact |
Physical movement |
|
| Approachable | Rapport Concordance Information | Variable | Variable | Variable | Some |
| Credible | Instructions Advice Adherence |
Monotone | Drop at end of sentence |
Fixed | Restrained |
Figure 8.1 The vocal patterns of approachability and credibility
Both men and women may initially find it challenging to allow their voices to move up or down into registers they do not normally use. This is a common response, but one that usually disappears with practice.
It is also important to note that in British and American cultures, the ‘meaning’ of head-nodding can differ between the sexes. To generalize, men tend to nod when they agree with a statement, while women often nod to show they are listening. There is potential for confusion in both personal and professional settings (‘But the doctor thought it was okay for me to keep drinking’; ‘But you agreed when I said I wanted to play golf on Saturday instead of visiting your mother’). We suggest, therefore, that, as far as possible, both male and female practitioners inhibit nodding and affirmative phrases unless they intend to confirm or reinforce a statement or opinion.
In a time-starved working world, you can carve out 30 vital seconds simply by getting up and going to fetch your patient (supposing that he or she is ambulatory, and that you are, too).
During the walk back to your office, you can lock in two essential requirements for effective communication: rapport and concordance. Much is made of ‘rapport’ in communication courses and NLP texts and trainings, and the usual means of accomplishing it is ‘mirroring’—reflecting the subject’s physical postures and movements. This kind of phase-locked ‘dance’ can be seen anywhere two people are in close accord. Watch out in restaurants and public places for those couples who unconsciously reflect each other’s moves: one picks up a drink, the other follows; one sits forward and folds his or her arms, the other follows.
We have some reservations about this single-technique approach to rapport-building. First, it takes considerable practice to lock in to another person, and the risk of detection is always present. Second, it takes time to achieve that level of mirroring, and, time, as we have agreed, is in short supply. Third, our suspicion is that ‘phase-locking’ can be the result, rather than the cause, of two people gaining rapport. And, fourth, according to psychologist James Pennebaker, author of The Secret Life of Pronouns, this kind of mirroring may mean nothing other than the people concerned are focusing on each other, not necessarily that they are in accord.144
The following method is easy and almost instantaneous, and has proved successful with hundreds of practitioners incorporating it into the ‘meet-and-greet’ phase of the consultation. Four steps, performed almost simultaneously, are involved.
Handshakes should be avoided if:
Other caveats include the following: do not present your hand with the back facing upwards (signaling dominance) or downwards (signaling submission) and do not touch the patient’s forearm, upper arm, or shoulder with your free hand while shaking hands at first encounter. This is sometimes interpreted as patronizing or manipulative if occurring in the opening stage of a meeting.
The following four-part approach is derived from the field of social psychology and the work of Milton Erickson, whose expertise in gaining concordance with his patients was unparalleled. Erickson’s language patterns, known in NLP as the Milton Model, were elegant, persuasive, and respectful of his subject’s needs. Since his medium was hypnosis, and ‘hypnotizability’ may be equated with a willingness to follow instructions, his methods were also designed systematically to predispose the subject towards a cooperative mindset.
Erickson knew from long experience that the more agreement he could extract from the patient, the more acquiescent the patient would become. Truisms—statements that cannot be denied—were his vehicle of preference. The process of asking questions that can only be answered affirmatively are known as yes-sets, and three seems to be the magic number. Yes-sets are bundled as conversation or ‘small talk’—for example:
‘So you managed to get an appointment today?’ (Yes)
‘Good. And, you found your way here okay?’ (Yes)
‘It looks like it’s still raining outside…’ (Yes)
Note: Effective yes-sets should be incontrovertible. Avoid statements that can potentially be denied. ‘It’s raining’ cannot be denied (assuming there’s a window nearby), whereas ‘It’s a nice day, isn’t it?’ can be—especially if the patient is feeling depressed. Also, take care when using names as a yes-set (‘You’re Mrs Peterson, aren’t you?’) unless you’re absolutely sure you have the correct details at hand.
At this point, some subjects may unconsciously feel they have been too agreeable, so we depotentiate with another linguistic device called a ‘negative frame’. This is a language pattern that prompts a negative response while still maintaining agreement. For example:
‘Well, let’s go right through because we wouldn’t want to keep you waiting any longer, would we?’ (No—meaning, ‘I agree’.)
Some languages, such as French, Russian, and Afrikaans, employ negatives in pairs. Unlike in English, they are still regarded as negative. So, if adapting these techniques to such a language, the pattern can still be used.
A joke. A rather pompous professor of linguistics told his class, ‘In English, a double negative forms a positive. In some languages, a double negative is still a negative. However, there is no language in which a double positive can form a negative.’
A bored voice piped up from the back of the room, ‘Yeah, right.’
The formula for the yes-sets and negative frames is as follows:
1. Truism + 2. Truism + 3. Truism + Negative frame
A negative frame is, in turn, constructed as follows: begin with something that is desirable (‘go right through’), add the word ‘because’, and follow this with something that is not wanted and is negatively expressed (such as ‘we don’t want to wait any longer’), then add the rhetorical tag-line: ‘do we?’, or ‘would we?’.
Desired action + ‘because’ + undesired (negated) action + rhetorical tag
The word ‘because’ acts as a powerful releaser of decision or action—often regardless of what that decision or action might be.
Harvard social psychologist Ellen Langer once conspired with her university librarian to shut down all but one photocopying machine. As a long line formed, Langer sent in one group of confederates to go to the head of the queue and ask permission to use the machine, giving no explanation. Around 60% of students allowed the confederates to go ahead of them.
A second group of confederates asked to use the machine, giving explanations such as, ‘I’m late for class.’ The percentage given permission jumped to 94.
Then Langer had a brilliant idea. She had another group go to the head of the queue and make bogus requests to use the machine, explaining, ‘… because I want to make some copies’. Contrary to all expectations, the requests went largely unchallenged. Almost nobody said, ‘Of course you do. We’re all here to make copies, so wait your turn.’ The success rate dropped only one percentage point.145
This, along with a number of subsequent studies, gives rise to the (slightly discomforting) realization that many of us respond to linguistic patterns almost as readily as to the content or meaning of certain statements and requests…so long as there’s a reason. Any reason.
What this suggests is that our cognitive functions are often in ‘park’ mode. As mentioned in the previous chapter on cognitive bias, people respond to the ‘shape’ of things rather more than what the things mean. In contrast to algorithmic thinking (the application of predetermined ‘rules’ to arrive at conclusions), this form of processing is ‘heuristic’.
For our purposes, heuristics may be thought of as mental ‘tools’ we use in order to conserve brain power, or as ‘shortcuts’ that aim to get more thinking done with minimum effort. Although the shortcomings of heuristic thinking are evident from the examples given above, heuristics themselves, as we will suggest later, can also be valuable tools if consciously and contextually applied as a means to an end.
Our hope, then, by presenting some of the evidence surrounding the issues of first impressions and decision-making, is to sensitize you to the fact that more—much more—is happening than simply inviting your patient to sit down.
The overall object of the Engagement phase of the Medical NLP Consultation Process is to increase a productive sense of ‘connectedness’ with the patient, and to reduce, as far as possible, the risk of avoidable mishaps and misunderstandings. The starting point of a safe, productive and mutually satisfying first contact is the congruence of the practitioner—that is, an alignment of attitude, intention, communication style, and behavior. And, it’s best to bear in mind that, while you are assessing the patient, the patient is assessing you. Diagnosis, for better or worse, is a two-way street.
1. Yes-sets are key skills to master in this section. Review the four-part structure, and then create sets of your own. The challenge is to make them naturally conversational, but still based on truisms. Test these for effectiveness.
2. Read aloud any three paragraphs from the chapter above. At the end of each sentence, practice inflecting downwards. You may record this for learning purposes if you wish.
3. Rehearse giving lifestyle advice to a patient:
i. with an ‘approachable’ delivery only;
iii. with an appropriate combination of the two.
ii. with a ‘credible’ delivery only;
4. Practice the ‘rapid rapport’ method with the next 20 people you meet.
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134. Ekman P, Frieson WV (2003) Unmasking the Face. Cambridge, MA: Major Books.
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