Please Take Your Seat

I brought my camp stool home from my office at the hospital yesterday. For the past several years and up until the time of the COVID-19 pandemic, I used it while interviewing hospitalized patients as part of my job as a consultation-liaison psychiatrist in the general hospital. I stopped only when I wondered whether carrying around an object which could be contaminated with the virus was a safe thing to do.

A colleague lent me the little chair when he and his colleagues on the Palliative Care Medicine consultation service started using them. I asked him whether he wanted it back and he graciously said I could take it with me now that I’m retiring—and use it as a camp stool (in a way, saying “Please take your seat”). For many years prior to getting the stool, I had been finding a chair or sending my trainees to find one for me. I felt more comfortable sitting eye to eye with patients and I got the impression that my patients appreciated that as well.

I got a lot of positive feedback from patients, family members, and other hospital staff about the little chair. I think it helped break the ice with patients and was a great opener, especially if they felt well enough to express a sense of humor— “Hey, doc; you don’t need nunchucks; I promise I’ll be good!”

There are a few papers in the medical literature supporting the usefulness of sitting with patients. Most authors assert that it helps build rapport and increases the patients’ perception of how interested their physicians or other health care clinicians are in their welfare (see the reference list below).

Once, when my original little chair broke beneath me during an evaluation for catatonia in one patient, the stool abruptly became a novel catatonia assessment tool.

The patient was mute but there was little evidence otherwise for catatonia, one of the chief features of which is the inability to react to any stimulus in the environment. I was seated on the chair explaining in detail the intravenous lorazepam challenge test for catatonia (which often interrupts the episode of muteness and immobility).

I was sitting in front of the patient but facing the family and the consult service trainees while expatiating on the topic. As I was droning on, I heard a sudden pop—and I fell flat on my fundament as the chair collapsed beneath me.

My audience exploded in loud laughter, and pointed at the patient. When I turned to look at him, he was convulsed with silent mirth.

I considered this a negative test for catatonia in this case, though impractical for regular use.

My colleague gave me a replacement camp stool, more securely built. However, he mentioned he might give up using his as a result of my accident which, incidentally, befell (rimshot) another doctor on his team. I’m not sure whether I’ll use the little chair. If I sit on it too long, my legs go numb. I think that’s about 10-15 minutes, about the length of time mentioned in one of the studies below. It didn’t seem to influence the positive perception of the visit—but it did make me walk funny.

I probably spend about the same time with patients now that I don’t use the little chair. But I don’t feel right about it. I’m always reminded of what Hackett said:

“As a matter of courtesy, I sit down when interviewing or visiting patients. Long accustomed to the ritual of making rounds, many physicians remain standing as a matter of course. Standing, physicians remind me of missiles about to be launched, poised to depart. Even if that is not necessarily true, they look the part. Patients sense this and it limits conversation. In addition, when standing, the physician necessarily looks down on the patient. This disparity in height is apt to encourage the attribution of arrogance. Looking down at a patient who is prone emphasizes the dependency of the position. Sitting at the bedside equalizes station. Sitting with a patient need not take longer than standing with him.”—Thomas Hackett, in MGH handbook of general hospital psychiatry, 1978.

References:

Johnson RL, Sadosty AT, Weaver AL, Goyal DG. To sit or not to sit?. Ann Emerg Med. 2008;51(2):188‐193.e1932. doi:10.1016/j.annemergmed.2007.04.024

Swayden KJ, Anderson KK, Connelly LM, Moran JS, McMahon JK, Arnold PM. Effect of sitting vs. standing on perception of provider time at bedside: a pilot study. Patient Educ Couns. 2012;86(2):166‐171. doi:10.1016/j.pec.2011.05.024

Strasser F, Palmer JL, Willey J, et al. Impact of physician sitting versus standing during inpatient oncology consultations: patients’ preference and perception of compassion and duration. A randomized controlled trial. J Pain Symptom Manage. 2005;29(5):489‐497. doi:10.1016/j.jpainsymman.2004.08.011

Orloski CJ, Tabakin ER, Shofer FS, Myers JS, Mills AM. Grab a Seat! Nudging Providers to Sit Improves the Patient Experience in the Emergency Department. J Patient Exp. 2019;6(2):110‐116. doi:10.1177/2374373518778862

Merel SE, McKinney CM, Ufkes P, Kwan AC, White AA. Sitting at patients’ bedsides may improve patients’ perceptions of physician communication skills. J Hosp Med. 2016;11(12):865‐868. doi:10.1002/jhm.2634

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