What can a violinist, a subway station, and 1,097 passersby teach us about patient engagement and experience? Let’s take a look…


On January 12, 2007, a violinist posted up in the L’Enfant Plaza Station in the Metro DC area. It was around 08:00 am, so rush hour. For 45 minutes, he played several classical pieces on his violin, as people shuffled to and fro, heading to their offices. Almost 1,100 people passed by him that morning. Seven (7) people stopped to listen for over a minute, and twenty seven (27) stopped to put some money in the open violin case, totaling $32 and some change. That means that the other 1,070 people simply walked on by, not seeming to notice the violinist.


Why does this matter? Because the violinist playing that morning was Joshua Bell, one of the most famous and accomplished musicians at the time (read the original story here). What’s even more surprising, is that only one person who walked by actually recognized him. Now, this is a performer who makes thousands of dollars a night, playing to sold-out concert halls. Yet, only 27 of the people —just 2.5%— who passed by him that day in the subway station noticed, cared, or paid attention.


Let that sink in for a moment.


One of the world’s most famous musicians stops in a public train station and plays some of the most famous classical pieces of music to a crowd of people, and no one really noticed. Why?


The answer lies in context and expectations.


Expectations Matter


Whether we realize it or not, our expectations shape our perceptions and experience of the world around us. In fact, some publish research even suggests that our expectations affect what we see (or, at least, what our brains tell us we see) [6]. To illustrate this example, take a look at the picture below:


To read more about this particular image, check out the MIT page here.


This visual illusion plays a “trick” on our brains. We see the original picture (on the left) and notice the shadow cast by the green cylinder. Given what we know about shadows and light, we expect there to be a difference between the colors of boxes A and B. However, when the gray lines are added (in the image to the right), we notice that they are both, in fact, the same color. What does this tell us? It tells us that our expectations impact how we perceive the world around us in a very real way.


Expectations, Perceptions & the Role of Context


Our expectations, also play a role in the placebo effect. Some researchers even refer to this as expectancy effects. These effects have been studied by clinical psychologists, neuroscientists, behavioral neuroscientists, and many more. And their research shows that expectancy effects can have lasting influence and impact on cognitive processing and behavioral actions [5]. Put plainly: we experience the world and make decisions based on those experiences. What we experience and how we experience it results from our perception of the world around us. Our perception is greatly influenced by our expectations. And what has a major influence over our expectations? That’s right, the context in which we find ourselves.


In other words, the environment or context affects our expectations. Our expectations influence our perception. And our perception affects what we experience, how we experience it, and the thoughts, choices, or actions that result from that experience.


Context to Experience


So, going back to that train station in 2007, is it any wonder most people simply walked on by one of the most famous violinists in the world as he played? In reality, the answer is no. The people traveling through the station that day didn’t expect to encounter a world-famous musician playing in the lobby that day. They didn’t expect that because they were traveling through a train station on a busy morning before work. Their context didn’t tell their brains to expect anything out of the ordinary, and therefore, they didn’t perceive anything out of the ordinary. How many times had they travelled through that station and seen or heard some amateur musician playing the same type of music, with their case open trying to make a few bucks? Probably countless times. So when they saw Joshua Bell playing in the same lobby, their brains told them not to expect anything spectacular, that he was probably just another amateur musician trying to pick up a few extra bucks.


This story should make you rethink the context or environment you create in your clinic, and how that may be affecting patient experience, engagement, and satisfaction. As the violinist in the subway station points out, people’s expectations impact their experience. You should try to create an environment —a context— that gives your patients the expectation that the services you provide are valuable and effective.



The Impact of Expectations on Patient Satisfaction


As discussed above, patient expectations can have a real impact on their experience in a clinic. In fact, clinical research has shown that an initial appointment/consultation can alter a patient’s expectations for treatment, resulting in higher (or lower) satisfaction scores [1]. This gives hope that, even if a patient may have low expectations going into an initial visit, they can leave that appointment with high expectations, increased engagement, and even a higher level of satisfaction.


But how many clinicians understand a patient’s expectations? Recent research shows that many clinicians and healthcare organizations don’t fully understand a patient’s expectations [2][4]. In fact, many organizations miss important patient expectations such as being given reassurance about treatment, receiving advice about their condition or diagnosis, information about benefits/limitations of certain treatment options, and opportunities to discuss their problems with their healthcare providers [2][3]. These expectations may seem like common sense, but many healthcare providers do not address them.


These expectations can also be influenced by the environment of the clinic as well. For example, if a patient goes to check-in for their first appointment and the front desk staff seems hurried, rushed, or dismissive, that patient may expect the same type of experience from the interaction with the clinician. Since expectations influence perception, you’ll have to work hard to overcome those low expectations.


Another interesting finding from this research, which ties into context and its effect, is that previous interactions with healthcare providers or experiences in other clinics have a strong influence on patient expectations [2].  How many times have you hears something like this from a patient: “Well, the last clinic I went to…”? Whether it was an amazing experience or a negative one, that experience influenced that patient’s expectation for what your clinic or clinicians can do for them. Understanding how your patient may feel about your clinic and treatment based off of their past experiences allows you to address and correct any potentially negative expectations upfront.


How Context Affects Patient Experience, Engagement, & Retention


We’ve got an understanding of how the context or environment can impact a person’s perceptions and experience. Now let’s discuss how you can take that understanding and apply it in your own practice, clinic or organization. The first thing to take a look at is how your clinic’s environment may be affecting patient expectations. From there, you can build, from the ground up, and intentional environment, culture, and context that molds a patients expectations toward the positive.


Context Affects Patient Expectations


As stated above, our environment or context influences our expectations. The same is true when your patients walk into your clinic. This fact means that you need to be aware of what expectations your clinic may be eliciting in your patients. Now when I say that the context or environment can influence expectations, it’s important to note everything that can be included in “context”. Obviously, this includes the physical space itself. The physical environment, layout, and organization of your clinic impacts not only your patient’s expectations, but also impacts the overall experience they have in your facility (read more about that here).


If your clinic is dirty, cluttered, or disorganized, your patients may come to expect the same about the services you provide or the skills and competence of your clinical and administrative staff. I’ve spoken with many patients over the years who have said something along the lines of, “Well, their office is always a mess. It’s no wonder they haven’t sent over those records.” At the very least, your clinic should be clean, well organized, and inviting to patients and prospective patients. Another reason to pay close attention to the physical environment is that expectations have been shown to influence and alter visual perception [6]. Put plainly: if your patient’s expect to see clutter, dirt, or grime, they’re actually more likely to see it in your clinic (even if it’s not really there!).


Context to ExpectationsAside from the physical environment of your clinic, what I would consider more important, is the context of interpersonal interactions. As I’ve written about here, interpersonal interactions between clinicians and patients play a large role in patient experience and engagement. And context influences whether an interaction between the clinician and the patient is positive or negative. Take something as simple as body language as an example. I’m sure you’ve heard of “point of service documentation” before. It’s supposed to be great for improving productivity, efficiency, and speeding up the documentation process. But what are the potential costs inserting point of care documentation within the context of a patient-clinician interaction?


When I worked at the VA, I was part of a team that helped roll out an initiative that was rooted in relationship-based care. The aim of the program was to improve both employee (clinician) and patient experience and engagement during the healthcare process. Part of the project included interviews and surveys from patients about things they felt were important for a high-quality healthcare experience. One of the most cited factors by patients we interviewed and surveyed revolved around what clinicians call point of service documentation. Patients said things like, “At XYZ clinic, you know they don’t care about you because they have their nose stuck in their computer the whole time they’re talking to you.” In many cases, inserting this type of documentation into the context of a normal patient-clinician interaction not only impacted that patient’s experience of that particular appointment, but it also had a lasting impact on what that patient expected from that clinic in the future.


Now, I’m not saying that point of service documentation is evil and you should never do it. But what I am saying is that you need to be conscious about when and how you use it during patient evaluations, assessments, and treatments. For example, it’s entirely appropriate to be taking ROM measurements of a patient’s hand or digits, and be inputing that into the computer as you’re taking measurements. I would argue that it’s entirely inappropriate to be typing up what a patient is saying during an initial interview. During that time, the patient expects you to hear, listen, and engage with them and their story. They want you to acknowledge and validate their feelings about their diagnosis, injury, or experience. In situations like that, put the computer away and be present to your patient.


Expectations Affect Patient Perception


The results from a recent survey that I completed on outpatient clinics showed that one of the main reasons clinic owners and managers cited for patients not completing their plan of care was “unrealistic expectations”. In fact, that’s a common excuse clinic owners, managers, and directors use to explain why patients stop showing up for therapy.


Now, usually a patient has unrealistic expectations for a couple of reasons. First, they may have been given unrealistic expectations from the provider that referred them. Other times, it results from a miscommunication or lack of communication between your clinic and the patient. Either way, you need to address expectations with patients at the first appointment. You do this by both educating the patient on their condition/diagnosis, the prognosis, and possible treatment options & by having a value discussion with the patient. You need to explain what the treatment options are, what their anticipated results are, and then how you (or your clinic) fit into that outcome. Addressing expectations early prevents any misunderstandings and also gives you a chance to demonstrate and explain your value.


Again, a patient’s expectations affect their perceptions about treatment and results. If they come to you with incorrect expectations, you need to address it early, so that they’re more likely to have an accurate and positive perception of the treatment you provide and the outcomes they experience.


Patient Perceptions Affects Patient Experience & Engagement


Now, what happens if a patient’s expectations are unrealistic? Let’s say they are overly optimistic about the timeline and magnitude of the outcomes they’ll experience after a few sessions of treatment in your clinic. They show up for appointment one thinking that you’ll “do something” to their sore shoulder and it will feel better.


What happens when you do provide some manual therapy to their shoulder and they still have pain afterwards (or it “works” for a bit, then the pain comes back)? Maybe the patient becomes discouraged. Maybe they begin to think that “it’s not working”. Or, they think “why am I even wasting my time/money coming here?”


If you don’t take the time, at the beginning to address these expectations and provide a realistic picture of what was going to happen & what to expect, you’ll find yourself with patients that become disengaged, unhappy, and unsatisfied. If you do address expectations early, you increase the odds of patients having a positive perception of both the treatment you provide and the experience of their outcomes. They become increasingly engaged and satisfied with the clinic, their clinician, and the services they receive. And that leads to them sticking around to complete their plan of care, and maybe even for another round of treatment.


The Ultimate Effect: Patient Retention


As I’ve written about here, patient retention relates to both patients completing their plan of care and returning to your clinic when another issue arises. In fact, both clinic retention and course of care retention hinge on patient engagement and experience. It goes without saying, that patients who are actively engaged in treatment are more likely to complete their course of care.


What is one of the best ways to actively engage patients in treatment? By delivering an amazing experience.


Since context, expectations, and perceptions influence a patient’s experience, you need to be intentional about every part of that chain. You need to ensure the environment and context inform a patient’s expectations. If necessary, you need to educate and provide guidance to your patient’s expectations. You need to also regularly gauge a patient’s perceptions during treatment and, if necessary, provide more information or education to guide their perceptions to ensure that they have a positive experience. When patients are having great experiences and are actively engaged, they’re more likely to complete their course of care. They’re also more likely to return to that clinic if they need those services in the future.




At the end of the day, it’s important to realize one thing: context plays a huge role in what your patients experience in your clinic. Context affects a patients expectations, which impacts their perceptions, and their perceptions impact their overall experience. Just like with the placebo affect, a patient’s expectations inform their brains of what they are (or are not) experiencing. What we experience and how we experience it results from our perception of the world around us.


Think of it like this:

  1. The environment or context affects our expectations.
  2. Our expectations influence our perception.
  3. Our perception affects what we experience, how we experience it, and the thoughts, choices, or actions that result from that experience.


Understanding this allows you to intentionally address each link in the experience chain to make sure that your patients have the best experience possible in your clinic. That will lead to higher levels of engagement and retention. And that leads to better outcomes for your patients, and increased revenue for your clinic or organization.


If you’d like to talk with me about your clinic, and how Rehab U can help you improve your clinic’s patient retention and engagement. Schedule a free 15-minute call with me.


Reach Out Now!


How have you taken context into account when designing a patient experience? Do you think about what patients expect when designing a patient experience?  Share any additional resources that you found helpful in the comments below!

For more informational reads, check out our Insights Page to see all the articles we’ve published to date. Click here to head over to our resources section and check out our variety of clinical and professional resources aimed at increasing your knowledge and skills. If you’d like to make some changes in your clinic or health center, and would like some help, check out our consulting and advisement services or contact us to see how we can help you break out of the norm and provide a truly impactful patient experience.



[1] Berhane, A., & Enquselassie, F. (2016). Patient expectations and their satisfaction in the context of public hospitals. Patient preference and adherence, 10, 1919–1928. doi:10.2147/PPA.S109982

[2] Bowling, A., Rowe, G., Lambert, N., Waddington, M., Mahtani, K., Kenten, C., … Francis, S. (2012). The measurement of patients’ expectations for health care: a review and psychometric testing of a measure of patients’ expectations. Health Technology Assessment, 16(30). doi: 10.3310/hta16300

[3] Patient Engagement: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. License: CC BY-NC-SA 3.0 IGO. Link

[4] Rao, J. K. (2000). Visit-Specific Expectations and Patient-Centered Outcomes: A Literature Review. Archives of Family Medicine, 9(10), 1148–1155. doi: 10.1001/archfami.9.10.1148

[5] Schwarz, K. A., Pfister, R., & Büchel, C. (2016). Rethinking Explicit Expectations: Connecting Placebos, Social Cognition, and Contextual Perception. Trends in Cognitive Sciences, 20(6), 469–480. doi: 10.1016/j.tics.2016.04.001

[6] Sterzer, P., Frith, C., & Petrovic, P. (2010). Believing is seeing: expectations alter visual awareness. Current Biology, 20(21), 1973. doi: 10.1016/j.cub.2010.10.036


Rafael E. Salazar II, MHS, OTR/L is the principal owner of Rehab U Practice Solutions. He has experience in a variety of rehab settings, working with patients recovering from a variety of injuries and surgeries. He worked as the lead clinician in an outpatient specialty clinic at his local VA Medical center, where he worked on a team to implement a relationship-based care model to increase employee and patient engagement. He also has experience as an assistant professor at Augusta University’s Occupational Therapy Program, as a Licensed Board Member on the GA State OT Board, has served on several committees for the national OT Board (NBCOT), and as a consultant working for the State of Georgia’s DBHDD. He is also on the Board of Directors for NBCOT. He works to help healthcare clinics and organizations increase revenue by delivering uniquely impactful patient experiences to increase patient engagement. Rehab U Practice Solutions: training & advisement services

Read his full bio Here. Read about Rehab U Here.

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