Thin slices: A doctor’s first words to a patient

Doctor greeting patientby Daniel Wolpaw, MD and Daniel Shapiro, PhD

Our article, The Virtues of Irrelevance, was published in the April 3, 2014 issue of the New England Journal of Medicine.  The article grew out of a conversation about some things we find important in healthcare communication, things that are often overlooked or even inadvertently sabotaged in medical school curricula. We focused on the very first things we say to patients.  Both of us have noticed that experienced, humanistic physicians and health care professionals will frequently avoid diving directly into medical or “relevant” questions when we first meet a patient.  Instead, the first spoken words are often about earrings, an article of clothing advertising a sports team, or some other specific observation about the individual patient that sounds more neighborly than medical.

We found support for these “irrelevant” comments not only in our own observations and experience, but also in the literature on “thin slices,” particularly the work of Nalini Ambady. Our parents noted the importance of first impressions when raising us, and it turns out that there is convincing experimental evidence that they do make a difference.  And we believe that in the healthcare setting this goes beyond how our patients view us. Opening with natural conversation levels the relationship, deepens our perspective, relaxes patients, encourages their sense of agency and identity, and lays the foundation for an authentic therapeutic relationship.  When this first exchange focuses on even a minor uniqueness, it communicates that we are attending to them as people and not just another in a long stream of faceless objects or problems.

It is also important to think about these opening moments in the context of medical education. Efforts to standardize and objectify clinical skills such as communication frequently lead to reductionist checklists. Medical students tend to obsess over these lists, losing the opportunity for engaging in the natural flow and interest of getting to know a person.  While specific process and content targets may sometimes be helpful in education, there is always the risk of losing track of the goal that we are really interested in – a provider who truly connects with her/his patients and is able to build on this relationship to offer the best possible care.

Becoming distracted by intermediate endpoints occurs all too frequently in medical education as well as many other fields. In looking at the virtues of seemingly irrelevant, neighborly comments, we are attempting to shed some light on what is important, possibly most important, when we are getting to know our patients and their stories.

Our hope is to begin a conversation about things many of us know, but have not always advanced with public discussion and educational focus. The most common responses we have received to the article reflect the importance of this validation – “I have been doing this for years – I am glad someone finally wrote about it!” or “This article was practice changing for me.”  As healthcare professionals who are dedicated to improving physician-patient relationships, we hope to continue and expand this essential dialogue. Comment below and let us know — How do you usually greet your patients?

Daniel WolpawDaniel Wolpaw, MD is the Director for the Kienle Center for Humanistic Medicine at Penn State College of Medicine.   He has a longstanding interest in Humanism and Medical Education, publishing in journals such as Academic Medicine, Medical Education and the New England Journal of Medicine and presenting extensively nationally and internationally.


Dan ShapiroDaniel Shapiro, PhD is a Gold Professor and the Chair of the Humanities Department at Penn State College of Medicine.  He is the author of three books and his writing has also appeared in the New York Times, JAMA, and the Chronicles of Higher Education.