The Unspoken Presence

It took me a while to realise that I should never nod at a patient in the midst of an outburst. The gesture, so instinctive in everyday conversation, carries an unexpected weight in a clinical setting. A simple nod can be interpreted as agreement, encouragement, or even collusion, when in truth, it may be nothing more than a reflex of attentiveness. In moments of heightened emotion, every movement is observed — the faintest lift of an eyebrow, a barely perceptible shift in posture, a pause held a fraction too long.

Non-verbal communication speaks its own language, often more powerfully than words. A misplaced gesture can deepen distress, an ill-timed silence may be mistaken for judgement, an unconscious frown might introduce doubt where none previously existed. Even fatigue conspires against us. A yawn — however innocent or inevitable — may be misread as impatience or indifference, fracturing the fragile bridge of trust in an instant.

And then there is touch, that fleeting yet profoundly charged exchange. A handshake can be deafening. Cold hands may signal detachment; hands too warm, unease; damp palms, anxiety. The patient perceives not just the temperature but the meaning it seems to carry. A hesitant handshake can feel uncertain; a grip too firm, overbearing. Even in this briefest of interactions, there is a delicate balance to be struck.

It is curious how medical practices are among the few places where the thought of kissing someone on the cheek never even arises. Elsewhere, between friends or even acquaintances, social greetings are imbued with a certain physical warmth. But the consulting room enforces its own quiet formality. The handshake is, at most, the sole accepted touch — for greetings, at least, for touch itself is unavoidable in the physician’s work. A physical examination necessitates contact, but that is a different kind of touch, one governed by clinical duty rather than familiarity. The ritual of greeting, however, remains restrained, its boundaries instinctively understood. Before words are spoken, patient and doctor have already settled into the space between them.

I recall a patient — a reserved man, his words measured, his expression guarded. When I extended my hand in greeting, his grip was firm, yet his fingers were cool and damp. His shoulders, slumped beneath the weight of the day, told me more than his words ever could. There was a pause — fleeting, almost imperceptible — before he took my hand, as if gauging the nature of this exchange. The exhaustion, the tension, the quiet endurance — all laid bare in the way he carried himself. His anxiety had arrived before his voice. No verbal hesitation, no guarded remark could have told me what his posture and touch had already revealed. In that moment, I understood: silence is not an absence but a presence of its own.

In clinical practice, as in life, there are moments when stillness is the most powerful response. Not everything calls for immediate reaction. Holding space — neither reinforcing nor resisting — allows emotions to settle without interference. Over time, I have learnt to trust that quietude, to offer understanding through presence rather than impulse. A patient in crisis does not need a gesture that validates or contradicts their emotions; they need the steadiness of someone who can withstand them.

But empathy — oh, empathy — sometimes unravels all practice, all control. And when it does, restraint is no longer a discipline, but a struggle between instinct and duty.

And so, in those moments, I find myself tempted — just as I once was, in the early days, when I nodded without thinking. The impulse remains: to react, to fill the silence, to reach out beyond the measured distance of the profession. But I resist. Not always perfectly, not always without effort, but with the understanding that what a patient often needs is not an answer, nor an immediate response, but simply the presence of another who is willing to bear witness.

Communication, at its most refined, extends beyond words. It resides in the pauses, in the careful restraint of movement, in the recognition that what remains unsaid is often as significant as what is spoken. And in the end, the deepest connection may not lie in what we express, but in what we allow ourselves to perceive.