I have a seed of an idea to examine the kind of ‘face work’ that is part of everyday interaction and mapping it onto Patient Engagement practices on three levels:

• in healthcare professional – patient interactions

• in pharma industry to patient engagement

• how this applies across cultures: can a one-size-fits-all approach work?

Looking at patient engagement through the lens of ‘face work’ could provide insight into the deep-structure factors at play. This batch of articles (that nobody asked for) began as notes I wrote in an airport—pen on notebook—drawing on my knowledge, experiences, and hunches. Apart from the standard texts mentioned in the references section, I have done no literature scoping on this subject. I’m unsure if anyone has linked face work and patient engagement. Maybe my ideas won’t stand scrutiny, but that doesn’t matter. I wanted to write these notes up and get them out.

This article will focus on healthcare professional – patient interactions. The patient seems to be subconsciously doing a lot of the face work in a doctor-patient encounter where the outcome is not so much shared decision-making or empowerment but ensuring that the doctor’s authority remains intact. This puts into question the extent to which shared decision-making actually happens in provider-patient interactions.

What is face work and how does it relate to Patient Engagement?

Patient engagement is widely assumed to be a key component of high-quality healthcare. According to this assumption, patients participate actively in their care, make shared, informed decision with their health providers and hold an open, two-way channel of communication with their healthcare providers. In reality, all this can be compromised and complicated by social and cultural dynamics, particularly the concept of "face".

Face refers to an individual’s self-image, as seen by others. Sociologist Erving Goffman introduced the concept, later expanded by Brown and Levinson’s politeness theory, distinguishing between positive face (the desire for approval) and negative face (the desire for autonomy). These require intricate negotiation in most interactions, often unconsciously.

In healthcare, both patients and their care providers use face-negotiation strategies all the time that shape communication, decision-making, and health outcomes. Therefore, face work can be said to underlie provider-patient interactions.

Why do we do face work?

Face work is all about maintaining harmony and reducing conflict in social and institutional interactions. Social interactions can involve spontaneous developments that require constant changes in face negotiating gears. By contrast, institutional settings, such as a doctor-patient interaction, relies on a more formulaic choreography, but face work is nonetheless present at all times.

According to Brown and Levinson, face work can be part of positive politeness strategies that strengthen bonds through empathy and acknowledgment. In a clinical consultation, an example of this could be:

I really like how well you are managing your diabetes.

It can also be part of a negative politeness strategy, whose aim is to respect autonomy by not being imposing, such as…

Would you be open to this treatment option?

In provider-patient interactions, both must develop strategies to handle face-threatening acts (FTAs), such as diagnoses, corrections, or lifestyle advice. These could threaten a patient’s managing of a condition. Conversely, a patient questioning a doctor may be taken as a threat to their authority.

Cultural differences can also shape face management. Collectivist societies, e.g. in Latin America, prioritise harmony. This means that direct confrontation tends to be avoided, which would include questioning a doctor’s decisions. Meanwhile, individualist cultures like the UK encourage patient advocacy and control.

Face-Negotiation in a clinical setting

Patient engagement requires underlying mutual respect and trust between provider and patient. This is not static. It shifts and changes from one stage to another in a clinical consultation.

This has a direct impact on power dynamics. As part of the drive towards shared decision-making, doctors are encouraged to pursue collaboration with their patients with regard to therapy choices. They must balance their own concerns about maintaining authority with the need for the patient to feel validated. This usually comes in the form of the doctor suggesting a treatment and asking the patient their opinion about it. This is where shared decision-making becomes an illusion. The sleight of hand here is that the doctor has already selected a treatment. And they have an ally: they are in league with the decision-support system that would be interacting with the electronic patient record. The patient is always seated in a way that it is difficult to see the screen. This means that the doctor breaks off the interaction to consult with this ‘black box’, just as a traditional healer or shaman might read leaves or bones or burn incense: it is an activity that does not leave much of an active role for the patient and is bewildering.

Patients may withhold questions or symptoms to avoid seeming uninformed and not to seem confrontational to the doctor’s decision. This can lead to misunderstandings. In some cultures, avoiding disagreement with doctors is a sign of respect, potentially leading to non-adherence. This is face negotiation at its most acute. Consider who does most of the work in these consultations. It is the patient, and the primary concern is about maintaining the doctor’s authority – the doctor’s professional ‘face’.

How can healthcare providers enhance patient engagement while preserving face? They can use positive politeness by reframing advice as shared decision-making. Making recommendations feel less like commands and more like cooperative discussions. Active listening and empathy through non-verbal cues and reflective responses help build trust, ensuring patients feel heard and respected.

Patient engagement involves more than just simple medical advice. It requires attention to interpersonal dynamics and cultural sensitivities. By recognising face concerns, providers can improve communication, encourage patient participation, and ultimately enhance health outcomes. A patient-centred, respectful approach strengthens shared decision-making and encourages stronger provider-patient relationships.

Thank you for reading.

Mark Gibson

Boston, USA, November 2024

References for Patient Engagement articles:

Byrne PS, Long BE, Doctors Talking to Patients. A study of verbal behaviour of general practitioners consulting in their surgeries, The Royal College of General Practitioners, Exeter, 1984

Coulter A, Entwhistle V, Gilbert D, Informing Patients, An assessment of the quality of patient information materials, King’s Fund, London, 1998

Drew P, Heritage J (eds), Talk at work. Interaction in institutional settings, Cambridge University Press, 1992

Global Health Watch 6. In the Shadow of the Pandemic, Bloomsbury Academic, London, 2022

Heritage J, Maynard DW, Communication in Medical Care. Interaction between primary care physicians and patients, Cambridge University Press, 2006

Hum A, Koh M (eds), The Bedside Communication Handbook. Speaking with Patients and Families, World Scientific, Singapore, 2022

Keel S, Medical and Healthcare Interactions, Members’ Competence and Socialization, Routledge, London, 2024

Montalt-Resurrecció V, García-Izquierdo I, Muñoz-Miquel A, Patient-Centred Translation and Communication, Routledge, 2025

Moulton L, The Naked Consultation. A practical guide to primary care consultation skills, Radcliffe Publishing, Oxford, 2007

Neighbour R, The Inner Consultation. How to develop an effective and intuitive consulting style, Second Edition, Radcliffe Publishing, Oxford, 2013

Topol E, The Patient Will See You Now. The future of medicine is in your hands, Basic Books, New York, 2015

Whitaker P, What is a Doctor? A GP’s Prescription for the Future, Canongate, Edinburgh, 2023

Zarcadoolas C, Pleasant AF, Greer DS, Advancing Health Literacy. A Framework for Understanding and Action, Jossey-Bass, San Francisco, 2006