Why patients nod and smile--even when they're lost

By: C. Anthony Jones

The last thing anyone wants is to look dumb. Especially in a high-stakes setting like a medical visit.

When someone is on step five of a set of instructions and we’re stuck back on step two, most of us do something that transcends language and culture:

We smile and nod.

It signals that we’re tracking—even when we’re not. More than that, it signals that we’re smart enough to track. That we belong in the conversation.

Yep. I got it!
Before smartphones and GPS (yes, they weren’t always here), getting directions meant asking a stranger. If you’ve ever stopped at a gas station and asked for help, you know the moment: you’re following the explanation, turn by turn, until somewhere around “take the second left after the fork,” you lose the thread.

Did you ask them to repeat it?

Probably not. You smiled, nodded, and drove away.
Then promptly got lost.

It’s not defiance. It’s self-preservation.
Even when we’ll never see someone again, we still don’t want to look foolish. And when the stakes are higher—like in a clinic or hospital—it’s even harder to admit confusion.

Psychologists refer to this dynamic as social desirability bias: the tendency to present ourselves in a favorable light, especially to authority figures(1). In healthcare, that bias can override a patient’s need for clarity(2).

And clinicians rarely catch it—because nodding, smiling, and polite affirmation look like understanding.

What we heard from real patients
In our early trials with post-op patients, we interviewed users at the end of their surgical protocol. We could see from our logs how often they logged in, which instructions they viewed, how long they spent with each step.

And they consistently told us how much they appreciated being able to get their questions answered through the app rather than calling the surgeon’s office.

But not for the reason you might expect.

It wasn’t about convenience. It wasn’t about after-hours access.

It was about dignity. “I didn’t want my doctor to think I wasn’t smart enough to get it the first time.”

The hidden cost of silence
Clinicians often feel overwhelmed by repetitive patient questions. But those questions are just the tip of a much larger iceberg. Below the water line are all the patients who never ask—they Google it. Or they ask a friend. Not because they think that’s better—but because it feels safer.

In fact, health-related searches have consistently ranked among the top three most common online queries since the early days of the internet(3,4). That self-service instinct isn’t irrational—but it is risky.

Because without context, a search result might be close, but not quite right.

Maybe your surgeon modified the standard protocol for your case. Maybe you had a comorbidity they didn’t mention. Maybe what seemed like a minor detail changed everything.

That’s the problem with internet reassurance: You don’t know if it applies to your situation.

And that can lead to anxiety at best—or dangerous errors at worst.

The fix isn’t more information. It’s better support.
We’re not going to change human nature. Patients will continue to avoid looking uninformed. And clinicians—pressed for time—will continue to misread signals of politeness as understanding.

But we can close the communication gap.

Technology, especially when paired with AI, can help deliver clinician-approved instructions in ways that are easier to understand, better timed, and more personalized to how patients actually experience their care.

Unlike clinicians, technology has the luxury of near-infinite time and patience. It can explain, repeat, clarify—without judgment.

And if that helps more patients feel confident, capable, and informed?

That’s not just a better experience. That’s better medicine.

Sources:
1. Grimm, P. (2010). Social desirability bias. Wiley International Encyclopedia of Marketing.
2. Frosch DL, May SG, Rendle KA, Tietbohl C, Elwyn G. Authoritarian physicians and patients’ fear of being labeled ‘difficult’ as barriers to shared decision-making. Health Aff (Millwood). 2012;31(5):1030–1038.
3. Fox, S., & Duggan, M. (2013). Health Online 2013. Pew Research Center.
4. McCarthy DM, Waite KR, Curtis LM, et al. What did the doctor say? Health literacy and recall of medical instructions. Med Care. 2012;50(4):277–282.

Why the more clinicians know, the harder it becomes to communicate with patients

By C. Anthony Jones

In medicine, expertise saves lives. But it also creates a blind spot.
The deeper a clinician’s knowledge, the harder it becomes to imagine not knowing. That’s the paradox: the very mastery required to deliver excellent care can make it nearly impossible to communicate that care clearly to the people who need it most.

Expertise rewires how you think—and speak
One of my attending physicians said something I never forgot: “In medicine, you spend your career learning more and more about less and less.”

The deeper you go in a specialty, the more your thinking—and communication—gets shaped by that depth.

Years of training in an increasingly narrow field rewires how information is processed. Medicine stops being a language and becomes a reflex. Acronyms replace explanations. The difference between probability and possibility is deeply understood (if not always clearly communicated). Protocols become muscle memory. What once required careful thought becomes instinct.

But for patients, none of that exists.

They don’t think in differential diagnoses. They don’t distinguish side effects from adverse events. They hear, “You may experience some discomfort” and assume a dull ache—until the anesthesia wears off and they’re curled up in agony, wondering what went wrong.

You can’t “unknow” what you know
This isn’t about empathy. It’s about cognition.

Psychologists call it the “curse of knowledge”. Once you know something, it becomes incredibly difficult to imagine what it’s like not to know it. One study found that experts consistently overestimate how well others will understand their explanations—by a wide margin(1).

That’s a problem when you're talking to patients, many of whom are hearing these terms, instructions, and risks for the first time.

A systematic review in BMJ Quality & Safety found that 40% to 80% of medical information is forgotten immediately after it’s delivered—and nearly half of what’s remembered is wrong(2). It's not because patients aren't trying—it's because the system assumes understanding instead of ensuring it.

This isn’t a bedside manner problem
We’ve all encountered clinicians who could improve their bedside manner—or who simply lack the emotional intelligence to connect on a human level. But this goes far beyond listening skills.

This is a design problem. A systems problem. And it’s getting worse, not better.

When the entire care experience is built around expert workflows, expert language, and expert pacing, patients fall through the cracks—not because they’re “non-compliant,” but because they were never truly on the same page to begin with.

And the one thing that might help? Time.
Sadly, the system has stripped that away too.

If we want better outcomes, we need better translation
That starts by recognizing that patient understanding isn’t a given—it’s a goal.

It means rethinking how we deliver instructions, how we check for actual understanding vs. the ubiquitous head nod, and how we support patients in the days and weeks after they leave the clinic. Not by dumbing things down—but by structuring guidance the way patients actually process and act on information: clearly, incrementally, and in context.

Because no amount of clinical brilliance matters if the patient can’t follow the plan.

Sources:
1. Hinds, P. J. (1999). The curse of expertise: The effects of expertise and debiasing methods on prediction of novice performance. Journal of Experimental Psychology: Applied, 5(2), 205–221.

2. Kessels, R. P. C. (2003). Patients' memory for medical information. Journal of the Royal Society of Medicine, 96(5), 219–222.