Culture and nonverbal expressions of empathy in clinical settings: A systematic review.
To conduct a systematic review of studies examining how culture mediates nonverbal expressions of empathy with the aim to improve clinician cross-cultural competency.



We searched three databases for studies of nonverbal expressions of empathy and communication in cross-cultural clinical settings, yielding 16,143 articles. We examined peer-reviewed, experimental or observational articles. Sixteen studies met inclusion criteria.



Nonverbal expressions of empathy varied across cultural groups and impacted the quality of communication and care. Some nonverbal behaviors appeared universally desired and others, culturally specific. Findings revealed the impact of nonverbal communication on patient satisfaction, affective tone, information exchange, visit length, and expression decoding during cross-cultural clinical encounters. Racial discordance, patients' perception of physician racism, and physician implicit bias are among factors that appear to influence information exchange in clinical encounters.



Culture-based norms impact expectations for specific nonverbal expressions within patient-clinician dyads. Nonverbal communication plays a significant role in fostering trusting provider-patient relationships, and is critical to high quality care.



Medical education should include training in interpretation of nonverbal behavior to optimize empathic cross-cultural communication and training efforts should accommodate norms of local patient populations. These efforts should reduce implicit biases in providers and perceived prejudice in patients.
Massachusetts General Hospital/Harvard Medical School, Empathy and Relational Science Program, Department of Psychiatry, Boston, MA, USA.
Áine
Á
Lorié
Massachusetts General Hospital/Harvard Medical School, Empathy and Relational Science Program, Department of Psychiatry, Boston, MA, USA; New York University, Department of Psychology, New York, NY, USA.
Diego A
DA
Reinero
Massachusetts General Hospital/Harvard Medical School, Empathy and Relational Science Program, Department of Psychiatry, Boston, MA, USA.
Margot
M
Phillips
Massachusetts General Hospital/Harvard Medical School, Empathy and Relational Science Program, Department of Psychiatry, Boston, MA, USA.
Linda
L
Zhang
Massachusetts General Hospital/Harvard Medical School, Empathy and Relational Science Program, Department of Psychiatry, Boston, MA, USA. Electronic address: hriess@mgh.harvard.edu.
Helen
H
Riess
D003142:Communication; D054521:Cultural Competency; D003469:Culture; D004645:Empathy; D006801:Humans; D009042:Motivation; D009633:Nonverbal Communication; D017060:Patient Satisfaction; D010465:Perception; D011787:Quality of Health Care
Culture; Empathy; Nonverbal; Patient-physician relationship; Systematic review