Consultations in primary care should be held standing up
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1558 (Published 18 February 2014) Cite this as: BMJ 2014;348:g1558
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I read with interest this article and its responses, particularly that by Dr Martin Wilkinson regarding Type 1 and Type 2 thinking, and the greater propensity for error and shortcuts whilst 'exercising'.
Most inpatient consultations and those with patients presenting to acute services and Emergency Departments are conducted with the doctor standing, or perhaps in an awkward crouch as an attempt to be at eye level with the patient who is likely to be sitting or lying down. Perhaps such environments should be redesigned to allow doctors to sit and engage with the patient, both to improve the quality of clinical decision-making and also to encourage a better doctor-patient relationship, rather than the doctor either looming above the patient, or developing cramp in a rather undignified squat.
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At our practice we use the Patient Access model and call back our patients the same day. Thus we undertake blocks of telephone consultations interspersed with face to face consultations for those who need them. Whilse doing my phone consultations I use my varidesk in the standing position, with a telephone headset for keeping hands free. I usually move it into sitting position when seeing patients. This takes about five seconds.
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I am obviously writing this letter in the vertical position, whilst still lying down. I commend the tilt table, especially for those of you who have back problems.
Of course, primary care is not just about GPs and there are plenty of primary care practitioners who clock up miles every day, although many more could cycle if their premises were provided with the facilities to refresh.
Years ago I read of a study where people seeing a GP spent less time in the consultation when wedges were discretely fitted to the rear legs of the chair in which they sat - an average of 8-12 secs I recall - all worth having in a QoF age?
Of course, posture matters, not just standing up. And more important is 'presence' - being there for the patient and being able personally and emotionally to 'hold' them. So, I would also recommend that every consultation is followed by a minute of mindful reflection in whatever posture springs to mind and is found to be personally most beneficial by the practitioner.
In my day, you could actually consult lying on the floor in a non-threatening position for people who had been traumatised - very unthreatening. In some cases, I also used to walk round the health centre with the person and then they would have a cuppa.
Whole person practice - the mantra on so many a lip. Bring it back I say!
Look after yourselves and each other!
Yours etc,
Dr Chris Manning MRCGP
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Standing during consultations is quite common in the UK usually to greet a patient and to examine them. Change of posture to standing and greeting the patient in the waiting room is also common not only for better communication, but for improved assessment of the patient and the health reasons for the doctor.
Use of desks that can be used in the standing position whilst the doctor undertake physical activity such as use of a treadmill might well be limiting for a doctor undertaking higher order mental tasks. Type 1 thinking is the norm when undertaking exercise. This is the simple quick thinking mode often associated with medical error. When one is needing to think deeper, undertake calculations and other higher order functions type 2 thinking takes over. Type 2 thinking is especially difficult exercising, and is sitting, relaxing and focussing energy on mental function. Try subtracting 7 from 100 when walking, you are likely to come to a halt.
Consultations whilst standing is common in primary care systems with extremely short consultation times such as China. Type 1 thinking is encouraged, and pressures of short appointments leads the doctor to make short cuts, and potential error. We know that longer consultations are associated with better quality of care and psychosocial and prevention issues more likely to be covered (1)
I think it would be a very sad day if we started to provide 2-3 minute standing appointments with doctors or nurses. There would be little to be gained by patients and potential harm. Sitting is is part of communication with a patient that we have time, and we are listening.
(1) Freeman et al. A.Evolving general practice consultation in Britain: issues of length and context. BMJ. Apr 13, 2002; 324(7342): 880–882
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Twenty five years ago my husband went for a general practice interview for a partnership; wife and baby had to be seen as well.
“I see fifty four patients in a surgery” said one partner. My jaw dropped but giving him the benefit of the doubt I asked how long was a surgery? “Two hours” he responded, “I do not let them sit down”. Was he already challenging the seated consultation?
This, and other factors, meant this interview was not pursued.
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The suggestion to stand during consultations is an interesting idea, but I suspect for most GPs rather impractical.
I would suggest however that there are a few opportunities to improve activity levels during the consultation.
As others have suggested going to the waiting room to call your patient through, however if like myself the time waiting for a patient to arrive is put to good use through reviewing last consultation, recent investigations etc. then at least stand up to welcome the patient, whether that be to shake hands or hold the door open for a mother with pram and entourage of children. During the consultation itself examining the patient can be an excuse for getting to your feet. Finally at the end of your consultation get to your feet as a polite departing gesture and also if not already done so to walk to the sink to wash your hands!
Moving from sitting to standing position 150 times a day will soon increase the activity levels.
Also why not try parking the car a couple of hundred meters further away from each home visit, weather permitting of course.
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Our practice gave up using the tannoy system when it became unavailable during a building refurbishment 10 years ago. Once we were in our new building we didn't go back to using it. We all noticed the benefits of getting out of the consulting room to take a stroll down the corridor to collect our patients from the waiting room. The clinical assessment starts as soon as we see the patient in the waiting room. We get to see who else is waiting who we may have lost from our radar. Since we introduced a computer to check the patient in it's nice for them to have a friendly human face providing a welcome. It all seems a lot friendlier and more practical than standing during the consultation, although the carpet in the corridor is getting a bit worn......
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Consulting standing up is an interesting idea, but I fear that any cardiovascular gain would be offset by an increase in low back pain related to standing still. This new occupational syndrome would have the same aetiology as cocktail party back, but could be much more common as GPs would be spending much more time standing than even the most ardent socialite.
Many GPs now call their patients by pressing a button and waiting, seated, till the patient has responded to flashing LED and found their way to the right door. This impersonal system is unpopular with patients and is creating a generation of chair-shaped GPs.
I propose a compromise strategy: that GPs fetch their patients from the waiting room. They would gain a little exercise and a brief change of scene, they could evaluate the level of stress in the waiting room and behind the desk, and as they accompany their patients down the corridor they can asses their mood and their mobility. A win-win outcome.
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Dear editor,
The plead to stand up during consultations is another clear thread for the patient-physician communication, which already is under great pressure. The rapid implementation of the electronic patient records seduces us to kreep behind our screen right from the start of our consultation, and type, while look at our keyboard and screen, instead of having eye contact.
Smart phones that often call us or bleep for the last e-mail or whatsapp, form another distracting barrier to pass in order to mentally stay with our patients.
Looking back in recent history, professional communication skills improve much slower than, medical technology advances. In 1984 Beckman and Frankel showed in their landmark study that physicians only succeeded in waiting for 18 seconds before interrupting their patients (1). It took about 15 years to improve this figure with 5 seconds (2)! In the mean time our patients grow older, have more complex combinations of diseases, and from the start are in great need of excellent and active listening and priority setting, to safeguard added value of our diagnostic and therapeutic procedures, or referrals (3).
Standing during consultation is a step backward in the basic communication skills, which require eye-contact, full attention, and being at the same level. These skills still needs to be improved substantially to meet the challenges of current medicine and reach our aims of patient centered care and shared decision making. However, we seem to be proceeding to these goals only similar to a proceesion in Echternach, during which pilgrims take 3 steps forward and 2 steps backwards, thus taking five steps in order to advance one. This may be healthy and improve our cardiovascular risk profile, but is far from being patient friendly and efficient during working hours. There are enough alternative ways to walk and stand for all physicians if we are creative, for example while getting the patient, bringing him or her back, and by testing the exercise limits together. All great advances in medicine are of limited significance if not provided within the context of an ongoing trusting relationship with a professional, such as a GP, medical specialist or practice nurse, who genuinely care for them (3). Let's sit down for this.
1. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med 1984;101:692-6.
2. Marvel MK, Epstein RM, Flowers K, Beckman HB Soliciting the patient's agenda: have we improved?JAMA 1999;281:283-7.
3.Robben S, van Kempen J, Heinen M, Zuidema S, Olde Rikkert M, Schers H, Melis R. Preferences for receiving information among frail older adults and their informal caregivers: a qualitative study. Fam Pract 2012;29:742-7.
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The world’s first standing computer desk was invented in 1998
I invented a standing computer desk in 1998, and a summary of my 23 years of research which led to its development was published in the rapid responses of the BMJ on 30-3-2014.
Essentially I concluded that leaning toward a desk was compressing the chest and abdomen to cause various symptoms, and ultimately found that standing at a computer prevented them.
However I also considered that if pressure from sitting was causing symptoms, that changing to standing may redirect the postural pressure to other locations and produce different symptoms, so I decided to vary my activities throughout the day from sitting to walking to standing etc. and to monitor the results to detect any adverse affects as soon as possible and minimise them.
Some individuals have said that there is nothing new about standing desks, and they give examples of them being used by famous people of the past such as Sir Winston Churchill and the genius Leonardo Da Vinci.
Nevertheless some thought needs to given to the fact that Churchill and Da Vince didn’t use computers.
I can also say that at the time I invented the desk it was viewed with skepticism or completely ignored, and was extremely rare, but since then it’s value has been tested and verified and they have been manufactured in their millions, if not tens of millions.
Furthermore, they are not sold on the basis of being just a desk, but are promoted as a status symbol of prestige in creativity, innovation, and design, for health reasons, in the “workwise environment”, and they are now being used by the Prime Minister of Australia, Malcolm Turnbull, and in the White House of U.S. President Barack Obama, and in the headquarters of the Apple Computer Company in Silicon Valley, and in the head offices of Google, and Facebook.
References
Banfield M.A. 2014 (March 30th), The Posture Theory as an explanation for many previously unexplainable symptoms, BMJ 2008;336:1124, (Online Rapid Responses), Actual page of response for 30-3-14 is http://www.bmj.com/content/336/7653/1124/rr/692354
Ireland, Judith, 2015 (October 27th), Standing desks, tea cups and exclusive art: inside Malcolm Turnbull’s new office, The Sydney Morning Herald http://www.smh.com.au/federal-politics/political-news/standing-desks-tea...
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