Smiling Does Not Mean Understanding

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.