Presence in the Clinical Encounter: Screens, Attention, Silence and Nonverbal Communication

Presence is not the absence of technology

Modern clinical work requires screens.

The electronic record may contain medication history, test results, previous notes, decision support and the documentation needed for safe care.

The problem is not that a clinician looks at a computer.

The problem is when the patient cannot tell whether the clinician is still with them.

Presence is therefore less about eliminating technology and more about managing attention visibly.

Patients read attention through several channels

People notice:

• where the clinician is looking;
• whether they are interrupted;
• whether pauses are allowed;
• tone of voice;
• posture and orientation;
• whether the clinician keeps typing during emotionally important moments;
• whether the screen is shared or becomes a barrier;
• and whether something the patient said changes the clinician's behaviour.

None of these cues is universally interpreted in the same way.

Culture, disability, neurodiversity, hearing, vision, trauma history and personal preference all matter.

That is why presence should not become a checklist of gestures.

The screen can support or compete with the conversation

Research on electronic-record use has found mixed effects.

Screens can support communication by making information visible, helping answer questions and allowing clinician and patient to review results together.

They can also reduce eye contact, interrupt conversational flow and compete with emotional cues.

The practical question is:

Is the screen functioning as a shared clinical tool—or as a third participant that has taken over the encounter?

Useful habits include:

• acknowledge the patient before turning to the record;
• explain what you are doing when screen use will take time;
• share the screen when it helps;
• pause typing during sensitive or emotional disclosures;
• and periodically reorient toward the patient.

Narrate invisible work

Typing can look like inattention even when the clinician is doing important work.

A short explanation can make the process visible:

“I’m going to look back at your previous scan while you’re telling me this.”

or:

“I’m writing down what you just said because I do not want to lose that detail.”

The task has not changed.

The meaning of the task has.

Silence is part of attention

Clinicians often fill silence because silence feels inefficient or uncomfortable.

But after difficult information, a patient may need a few seconds before they can formulate the next question.

Silence can communicate:

You do not need to hurry your reaction for me.

That does not mean every pause must be prolonged.

The skill is noticing whether speech is serving the patient or relieving the clinician's discomfort.

Nonverbal cues should be checked, not diagnosed

A patient looks away.

A caregiver becomes quiet.

Someone crosses their arms.

These observations may matter.

Their meaning is not self-evident.

Avoid:

“You seem resistant.”

Prefer:

“I noticed you became quiet when we talked about that. What is going through your mind?”

The same principle applies to tone, facial expression and posture.

Notice first.

Interpret cautiously.

Check when it matters.

Eye contact is not a universal empathy rule

Sustained eye contact may communicate attention in one context and feel intrusive in another.

People with autism, trauma histories, cultural preferences, visual differences or simple personal habits may engage differently.

Do not evaluate empathy by whether someone follows one preferred nonverbal style.

The aim is responsive communication, not performance.

Presence under time pressure

When the clinic is running late, attention often becomes compressed.

Speech speeds up.

Interruptions increase.

The clinician begins thinking about the next task while still in the current one.

The solution is not pretending time pressure does not exist.

It can be more honest to say:

“We have limited time, and I want to make sure I understand the most important thing before we finish.”

That can restore a shared focus without promising unlimited availability.

Transitions are high-value moments

Presence is especially visible at transitions:

• entering the room;
• moving from history to examination;
• returning to the screen;
• delivering important results;
• changing from explanation to decision;
• and ending the visit.

A brief reorientation at those points can keep the patient from feeling that the encounter has moved on without them.

For example:

“Before we finish, I want to come back to the concern you raised at the beginning.”

A practical self-audit

After a few consultations, ask:

Arrival: Did I acknowledge the person before the task?

Screen: Did I explain or share what I was doing when the computer took my attention?

Emotion: Did I stop typing when the conversation became important enough to deserve undivided attention?

Silence: Did I allow enough space for the patient to respond?

Nonverbal cues: Did I check important cues rather than assuming what they meant?

Ending: Did the patient have a clear opportunity to raise what still mattered?

The central idea

Presence is not a theatrical bedside manner.

It is the repeated experience that the clinician is available enough to notice what matters and responsive enough to show that they noticed it.

Technology, documentation and time pressure make that harder.

They do not make it impossible.

Selected evidence

Alkureishi MA, Lee WW, Lyons M, et al. Impact of electronic medical record use on the patient-doctor relationship and communication: a systematic review. Journal of General Internal Medicine. 2016.

Shachak A, Reis S. The impact of electronic medical records on patient-doctor communication during consultation: a narrative literature review. Journal of Evaluation in Clinical Practice. 2009.

Henry SG, Fuhrel-Forbis A, Rogers MAM, Eggly S. Association between nonverbal communication during clinical interactions and outcomes: a systematic review and meta-analysis. Patient Education and Counseling. 2012.

National Institute for Health and Care Excellence (NICE). Patient experience in adult NHS services. Clinical guideline CG138.