First Impressions: Setting the Stage for Better Relationships

Social settings are stages; every encounter is a theatrical act performed in front of an audience. Introduced in 1956 by American sociologist Erving Goffman, the theory of dramaturgy describes social interactions through the analogy of theater. Whether eating at a restaurant, exercising, or talking to someone on the phone, people can be thought of as “performing” to an audience. Even if no one is present to view these “performances,” Goffman writes that the “lively belief that an unseen audience is present” affects our actions and how we portray them to the world.1 Goffman’s theory is helpful in explaining the importance of first impressions, which can be thought of as the “opening act” of performances. Carrying the potential to influence audience perceptions for the rest of the show, a successful opening act is crucial. As the “opening acts” of relationships, first impressions set the tone for future social interactions. People use first impressions to determine their primary judgments, perceptions, and social characteristics of others, and the importance of these impressions is magnified by the short duration during which they can be determined: as little as 100 milliseconds.2 Given how impactful they can be, understanding what makes a first impression memorable is vital for those hoping to make the most of social interactions. Such interactions are particularly relevant to the field of medicine. Physicians take on many roles in their communities. As caretakers, team leaders, and network builders, the relationships they form have a substantial impact on the quality of care they provide. Consequently, first impressions play a notable part in their work. By learning how to interpret and project a positive first impression, physicians may be able to improve their relationships with their patients. This article will provide an overview of the main factors that form first impressions, the specific actions that can lead to positive first impressions, and how this knowledge can be applied to patient-physician relationships. COMPONENTS OF A GOOD FIRST IMPRESSION First impressions have three major qualities: trustworthiness, dominance, and presentation.3 Each of these values is closely related to leadership and similarly useful social traits. Understanding why these qualities play such outsized roles in the formation of first impressions requires an examination of human history. The evolutionary-contingency hypothesis provides an answer by explaining how environmental pressures and community needs in early human societies (before the invention of writing systems) shaped perceptions of leadership and its associated qualities.4 Each trait is described in brief below, along with an explanation of its evolutionary origins. Trustworthiness is associated with diplomacy and peace. In early human society, leaders with this trait were perceived to avoid conflict and promote cooperation among their followers. Studies have shown that voters seeking peace prefer candidates who appear trustworthy.5 Dominance, on the other hand, is associated with assertiveness and leadership. The physical capabilities tied closely to dominance can be explained evolutionarily by their crucial roles in resolving conflict.6 The third quality of presentation is associated with health and vitality. In early societies, leadership relied on physical efforts and, accordingly, good health. This was important, given that threats from disease were significant thousands of years ago.7 Thus, all three values are products of evolutionary pressures that encouraged the retention of characteristics to facilitate the formation of functioning, resilient relationships within larger communities. Although the physical dangers of early society are no longer around us, these qualities continue to influence social interactions today. On the basis of these three traits, people make initial judgments of others and distinguish between who they see as leaders or followers. There is mixed evidence regarding whether these judgments actually predict behavior.4 The emergence of psychological research on thin-slice judgment demonstrates the critical impact of first impressions. Split-second judgments concerning the people in an initial meeting can be determined within 100 milliseconds of the interaction. This phenomenon is known as “conscious awareness” and can have lasting effects. Associations between yearbook photographs and career success, and facial features of presidential candidates and electoral success demonstrate how these fleeting impressions can result in significant long-term outcomes.4 Although first impressions may not always determine success in careers or elections, they provide a clear starting point in our relationships.8 MAKING A GOOD FIRST IMPRESSION Though there is no “perfect” first impression, there are strategies that can be used to create a positive one. Impressions are affected by factors such as facial expressions, body language, and demeanor.9 This section applies these factors to the three major qualities of trustworthiness, dominance, and presentation to explain how to impart good first impressions. Trustworthiness Studies analyzing the relationship between trust evaluations and individual psychological state have shown that initial assessments of trustworthiness rely on the assessed person’s facial expressions and the assessor’s psychological state.10 Small details, such as direct eye contact, good posture, an open chest, and a neutral or happy face, can communicate trustworthiness. These studies also found that initial impressions of trustworthiness are lasting and affect the assessor’s perceptions in the long term. Any body language, facial expressions, tones of voice, or other details expressed during the initial impression will impact how an individual is perceived in future encounters. In addition to an individual’s perception of physical characteristics, intrinsic bias can cause first impressions to be impacted heavily by a person’s past experiences. For instance, familiarity with certain actions or body language can affect how an individual perceives another person, sometimes in ways that misinterpret that person’s intent. To create an impression of trust, an individual should be open-minded to the other person’s past experiences and maintain boundaries in conversation. This can be accomplished during initial conversations by simply exercising good manners, such as being patient for the other person to finish expressing his or her thoughts before responding. In other words, listen intensely and observe thoughtfully. To further achieve an equal dynamic, a person can aim to engage in friendly, yet respectful conversation. Finding similarities like common interests and hobbies can create a comfortable space and keep the conversation balanced. Furthermore, individuals who pay attention to how they speak and what they speak about can set comfortable boundaries for themselves and their conversation partner. This includes using a tone of voice equal to the other person, avoiding topics that may be invasive or uncomfortable for the other person to answer, and showing cultural understanding. Dominance A 2018 study on gender bias and impressions found that dominance was associated with confidence and superiority. This study also showed how traits like a lower vocal pitch and “power poses” specifically indicated dominance.11 “Power posing,” otherwise known as expansive body movements, are postures and/or body language that show high confidence and assertiveness. Power posing includes actions such as crossing arms across the chest, rolling shoulders back, reclining back while sitting, keeping an open chest and feet hip-width apart, and “the squinch”—squinting and pinching your eyes simultaneously.12 In a 2016 research article, a study on first impressions and nonverbal cues in politicians found an association between power posing and dominance. Researchers found that power posing among politicians indicated lower levels of trustworthiness and high levels of dominance, demonstrating how the main qualities can sometimes conflict with each other.13 A good first impression requires maintaining a careful balance between attributes. For example, too much dominance may be off-putting, whereas too demure of a posture may give the impression of low confidence. Dominance is a complicated quality with respect to first impressions, as different traits and cues communicate either positive or negative connotations to others. By carefully articulating individual actions, a person can use dominance to his or her advantage to leave a lasting, positive impression on others. Most effective leaders, for example, will engage in displays of dominance when facing threats, but then act more submissive, welcoming, and reassuring when the situation is noncompetitive.14 When making a good first impression, displays of dominance such as a firm handshake, consistent eye contact, and power posing create further depth. Presentation There is a common belief that a person’s physical appearance is the most crucial factor in a first impression. However, traits such as body language, facial cues, posture, and attire influence the “presentation” of an individual much more. In addition, it is important to acknowledge the variety of cultural standards across the world when deciding what will be considered an acceptable presentation.15 For instance, a gesture like a “thumbs up” is a negative sign in Greece and Sardinia, but a positive sign in the United States. Similarly, sitting cross-legged is common in Europe and North America; however, in Asia and the Middle East, it is disrespectful to face the sole of your shoe toward another person.16 Cultural competence is thus a valuable skill, as these differences in standards exist across all nuances of body language. Understanding such cultural differences is vital to avoid disrespecting others. Although one must be cautious with various types of body language, open body gestures are generally held in highest regard. Universally, open body gestures such as leaning forward, keeping shoulders back, chin up, and uncrossed arms and legs show interest, approachability, and confidence.12 Just as practicing good posture creates a more approachable figure, appropriate attire reflects how a person expresses confidence and presentation. Acknowledging the occasion and circumstances of a meeting through his or her choice of attire, a person can communicate credibility and competence. For example, a 2013 study found that dentists and lawyers who wear formal clothing (white coats for the dentists, dark suits for the lawyers) were perceived as more capable and well-suited to their professions. Appropriate dress that matches perceptions of professionalism will increase confidence in the outcomes of a working relationship.17 By combining trustworthiness, dominance, and presentation, we can learn how to articulate ourselves to others in an optimal way (Fig. 1). First impressions are meant to show one’s personality or demeanor in the best way possible. Authenticity goes a long way toward forming a strong foundation in our relationships.Fig. 1.: Making a good first impression.FIRST IMPRESSIONS IN PATIENT-PHYSICIAN RELATIONSHIPS A patient’s first impression of a physician often sets the foundation for their relationship. This section examines how the three qualities of trustworthiness, dominance, and presentation affect patient-physician relationships (Fig. 2). Findings from studies exploring these relationships may suggest potential avenues for improvement.Fig. 2.: The patient-physician relationship.One familiar obstacle to building patient trust is bias formed from past experiences. Patients who have had histories of bad experiences with medical care may approach new physicians with mistrust. Left unheeded, this mistrust may grow further, potentially leading to poor communication and worse health outcomes. Thus, building a positive connection with patients early on is crucial.18 Understanding how past encounters affect patient perceptions at the individual and group levels is a starting point. Studies such as the Tuskegee Syphilis Study have left a damaging legacy for physician-patient relationships among minorities today, inducing fear of participation in medical research and raising the specter of medical abuse among the African American community.19,20 Rebuilding trust begins with acknowledging the history of medical exploitation. At the interpersonal level, competent communication is vital to ensuring trust in the patient-physician dynamic. Asking patients for their explanations of illness, seeking information about culture, and adapting care to patient preferences give patients the sense that their culture is understood and respected.21 By apologizing for factors such as a busy schedule, physicians show empathy, care, and respect toward their patients.22 Therefore, trustworthiness relies not only on explicit communication methods but also more subtle, nonverbal cues such as those described in the previous sections. The quality of dominance is similar to competence in patient-physician relationships. A 2019 study on patient perceptions of surgeon competence and warmth, and postoperative pain found a potential association between high perceptions of physician competence and warmth, and lower patient experiences of postoperative stress and pain.23 The characteristics of “warmth” are akin to those of trustworthiness: eye contact, handshakes, and use of empathy in conversation. In contrast, physicians who are perceived as more competent speak in confident tones, dress in professional attire, and provide technical medical information. As discussed previously, dominance and trustworthiness have a complicated relationship, with leaders exhibiting either quality based on their circumstances. A patient’s desire for a competent surgeon in an operation can be compared with how followers prefer dominant leaders in situations of uncertainty. In prolonged care settings where uncertainty may not be as high, patients may prefer physician warmth. Physician competence relies partially on demeanor and is expressed through a confident vocal tone and display of technical knowledge. When physicians provide more information, opinion, and rationale to patients, they are perceived to be more competent. Patients are also more satisfied with their visits when physicians explain medical concepts and information through analogy, making the information more digestible.24 Furthermore, body language plays a significant factor in patient perceptions of physician competence. One qualitative study found that a physician’s nonverbal displays of stress and burnout may lead patients to be concerned about a physician’s wellness, in turn decreasing their confidence in the physician’s ability to treat them.25 Other behavioral signs, such as appearing disorganized or inattentive, may have further negative influences. In contrast, physicians who demonstrate control over medical situations through calm and confident poise may leave a positive impression on their patients. Physician presentation is amplified through physical appearance. A physician’s attire is known to impact his or her perceived intelligence, trust, charisma, and achievement.26 Although physician dress is dependent on geography, culture, and specialty, a study on patient preferences of physician attire found that, overall, formalwear such as dress shirts and pants were preferred. In surgical and emergency room settings, scrubs were preferred.27 Regardless of the context of care, patients considered white coats to be an essential part of physician attire.28 Throughout history, the white coat has played a dynamic role in the patient-physician relationship as a symbol of healing and authority to the patient in need.29 Although it is one of many factors that contribute to positive first impressions, wearing a white coat may provide a boost to physician image and instill confidence in care. Knowledge of first impressions may facilitate the start of meaningful relationships, whether between patient and physician or simply between two individuals meeting for the first time. This article examined the three major factors that influence first impressions and described the verbal and nonverbal actions associated with positive effect. With enhanced awareness of these cues, we may set the stage for better relationships with our patients and in our everyday lives. DISCLOSURE Dr. Chung receives funding from the National Institutes of Health, book royalties from Wolters Kluwer and Elsevier, and a research grant from Sonex to study carpal tunnel outcomes. The remaining authors have no financial interests to report. No funding was received for this work. ACKNOWLEDGMENT The authors appreciate the peer-review and edits from Mike Stokes, staff vice-president of communications at the American Society of Plastic Surgeons.