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continued from page 23 angry about their care, their diagnosis, the results of a surgery, or other issues. These cases pose a possibility of miscommunication, loss of a good working relationship with the patient, or in advanced situations, litigation, Dr. Stulting said, and as a result require a great deal of empathic care. "These communications are all about the astute and skillful shaping and maneuvering and choreographing of the emotional atmosphere," Dr. Banja said. Physicians need to match their behavior to the situation. For instance, if the situation is serious, the physician should be serious. People's natural inclination is often to avoid such situations, Dr. Banja said, but this can worsen the issues. "It's very important for health professionals to recognize that, in these unpleasant situations, you will be very tempted … to make the conversation end as soon as possible," Dr. Banja said. However, people who are effective at communicating continue the discussion, even when uncomfortable. Physicians should put themselves in their patients' position for a moment, Dr. Banja said, imagining how they feel when angry or disappointed. They should remember how they act in those situations, specifically how their tone of voice changes, how their vocal speed changes, whether they talk more or less, interrupt more or less, and if they become defensive. "A skillful communicator will always be monitoring his or her communication," Dr. Banja said. "The way you're going to be monitoring it is [to watch] how this is going down on the listener's end. If the listener interrupts you, you should stop talking immediately. If the listener looks away from you, you should stop talking. If the listen- er asks you questions, you should respond to those questions." Dr. Stulting said when informing patients of medical errors, body language should "convey honesty, apology, desire to avoid similar errors in the future, willingness to rectify error, openness to accept comments from the patient." Dr. Mamalis said it is vital for physicians to give patients—especially those that are angry—their undivided attention. They should put the computer, chart, and other apparatus away, and make direct eye contact with patients. This is key in not only communicating well, but also in noticing how the patient is acting. "You want to be aware of patients' body language because body language can tell you if they're having problems, or if they're angry, or if they're defensive. You need to look at them to be able to do that," he said. More tips Drs. Stulting, Mamalis, and Banja have additional tips for maintaining good communication with patients: • Don't close your body by folding your arms or turning away. • It is OK to touch the patient's hands and arm below the elbow, if warranted. • Facial expressions with the brows, lips, and jaw should show contriteness and empathy. • Do not furrow the eyebrows, purse the lips, or clench the jaw, which can portray anger and irritation. • Speak slowly and softly, modulating your tone to the patient's hearing ability. • Ask patients if they understand medical information, especially if they have a puzzled expression or appear to have stopped listening. • Use language and terms that patients can understand. • Practice empathetic skills regularly. • Be humble. • Listen. 24 Ophthalmology Business • December 2013 • Validate the patient's response. If all else fails and the situation is not working for either the patient or physician, Dr. Banja suggested referring the patient to another physician. Body position In addition to these tips, body position while speaking with a patient is of vital importance. "Sit rather than stand, and adjust eye level to slightly lower than that of the patient, so as not to imply superiority," Dr. Stulting said. "Lean slightly forward, with shoulders slumped, knees apart, forearms on legs, hands open, expressing attention to the situation and willingness to listen." Dr. Mamalis said that when faced with difficult patients, physicians sometimes get defensive and lean back. He recommended that physicians be aware of their posture and how it might impact the patient, and lean forward in more volatile situations. He sits on a rolling stool, which gives him the opportunity to slide closer to the patient based on the patient's response and body language. "You need to sit at the same level as the patient," Dr. Mamalis said. "A lot of doctors will stand up or they'll lean against one of the writing surfaces, but it's important that you're looking at the patient at the same level, instead of looking down at the patient." OB Editors' note: The doctors have no financial interests related to this article. Contact information Banja: jbanja@emory.edu Mamalis: nick.mamalis@hsc.utah.edu Stulting: dstulting@woolfsoneye.com