sitting with patients – Go Retire Psychiatrist

Thoughts on a Study of Sitting with Your Patients

I saw this interesting article on a study about the effect of chair placement on physicians’ behavior when in a patient’s room, specifically whether it altered the length of time a doctor spends with a patient or the level of satisfaction patients had with the interaction. In this study, it didn’t lengthen the time, but seemed to strengthen patient satisfaction with interaction with the physician. It’s a concept I recognize because I took this one level up—I carried my chair with me on hospital rounds in my role as a consultation-liaison psychiatrist.

I got a gift of a 3-legged camp stool from a colleague who ran the palliative care service at University of Iowa hospital. Other members of the palliative team had been using them as well.

Patients got a big kick out of a doctor who carried his chair around with him and actually sat down to talk with them. The way the camp stool folds up apparently made it look like nunchucks to some patients, so I got jokes about that occasionally. It really helped build rapport.

The only drawback with the camp stool was that my one of my legs would go numb the longer I sat on it, and could lead to a challenge getting up from it gracefully because it was partly a balancing act. Even so, I often spent much more than 10-15 minutes with patients.

Once, the stool actually broke and I dropped unceremoniously on my butt while evaluating a patient for catatonia—who proved not to be catatonic by the apparent facial expression of mirth as I fell on the floor. In that sense, the chair actually became a part of the evaluation—accidentally.

Thomas Hackett knew all about this. He was a famous consultation-liaison psychiatrist and a past president of the Academy of Consultation-Liaison Psychiatry (ACLP). One of his quotes from an early edition of the Massachusetts General Hospital Handbook of General Hospital Psychiatry fits perfectly in this context:

“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.”— Hackett, T. P., MD (1978). Beginnings: liaison psychiatry in a general hospital. Massachusetts General Hospital: Handbook of general hospital psychiatry. T. P. Hackett, MD and N. H. Cassem, MD. St. Louis, Missouri, The C.V. Mosby Company: 1-14.

Reference: Effect of chair placement on physicians’ behavior and patients’ satisfaction: randomized deception trial BMJ 2023; 383 doi: https://doi.org/10.1136/bmj-2023-076309 (Published 15 December 2023)

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

An Auspicious Chair

I took the picture of the little chair one of the residents brought to the psychiatry consult office yesterday. I got a big charge out of it, especially because I’ve been using a version made of wood and leather for a few years now. I think it’s possible that it could be an auspicious chair.

The resident actually used his, too. It was a busy day; I put in about 4 miles and 40 floors on my step counter—which meant the residents did too. The chair is obviously useful to rest our feet, but I think Thomas P. Hackett summed up the best ever rationale for sitting with patients:

I had a little fun with the chair in a YouTube video as well.

The chair I use now is a replacement for the first one I got as a sort of loaner from a colleague in Palliative Care Medicine. That one broke during a consultation visit with a patient and his family (circumstances disguised to protect confidentiality) in the emergency room in which we were asked to evaluate for catatonia. 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 sitting 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 unceremoniously on my rear end as the chair collapsed beneath me.

My audience exploded in loud laughter, of course, as you’d expect when a pompous ass falls on his ass. But they also pointed to the patient. When I turned to look at him, he was convulsed with apparent mirth although still unable to make a sound.

I considered this a novel test for catatonia, negative in this case. Of course, it would be impractical for regular use.

Where was I? Oh, the little chair the resident brought for consult rounds. I was honored by it. It seemed to show that I was leaving a legacy as I head for retirement in June.

Another sign of leaving a legacy was a New Year’s email message I got from a former resident, Dr. Paul Thisayakorn, MD, who has been making an auspicious beginning in the field of consultation-liaison psychiatry in Thailand. He’s working very hard and is an outstanding clinician, researcher, and teacher. He has a lovely family. He and I respect each other a great deal.

Speaking of auspicious, when Paul graduated from our psychiatry residency and before leaving for his Consultation-Liaison fellowship program, he gave me a necktie with white elephants printed on it. I still have it. I may not have the symbolic meaning of the white elephant exactly right, but I think the white elephant in Thai culture is called “chang samkhan,” or maybe “chang phueak” which means “auspicious elephant.” In general, I think the idea is they symbolize success or at least the promise of success. Paul’s gift showed his gratitude and respect for me because I was one of his teachers. I am still honored to have been a part of his education and his life. I will always treasure his gift of gratitude.

Paul is very hard-working and very successful. And if the residents now start to use the little camp stools to sit with their patients, I would treasure that legacy as well.