Consultations in primary care should be held standing upBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1558 (Published 18 February 2014) Cite this as: BMJ 2014;348:g1558
- Mohammed Ahmed Rashid, academic clinical fellow, Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Cambridge CB1 8RN, UK
In the 1950s, epidemiologists discovered that heart disease was more common among bus drivers than bus conductors, and among clerical workers than postmen, leading to the hypothesis that “men in physically active jobs have a lower incidence of coronary heart disease in middle-age than men in physically inactive jobs.”1 In the following decades, the associations between occupational activity and cardiovascular disease were confirmed, as were its relations with physical activity generally.2
However, an additional nuance has recently emerged. Overall time spent sitting has been shown to be associated with several cardiovascular and metabolic diseases, as well as total mortality.3 This relation exists independently of exercise levels. In other words, regardless of time spent in formal exercise, spending prolonged periods sitting can contribute to premature morbidity and mortality.
Although researchers are attempting to further understand and define this relation, the evidence so far has been sufficiently persuasive to prompt policy makers to begin to explore avenues for intervention. One target is to reduce time spent sitting at work. Interventions developed have included personally tailored activity, counselling for employees, sending motivational email messages, encouraging use of pedometers, and suggesting local walking routes. A recent systematic review, however, concluded that the evidence base for these interventions remains small and more research is needed.4
As clinicians, our first thoughts naturally turn to our patients and how this new knowledge should inform the lifestyle advice we give. However, we should also consider the health needs of the medical profession. Doctors vary widely in their sitting time, and this is closely related to specialty. Surgeons are likely to spend much time standing in the operating theatre; physicians may find themselves carrying out long post-take ward rounds; and emergency doctors are unlikely to find much time to sit in a busy department.
What, though, of general practitioners? Aside from home visits, the working week is unlikely to include any time away from the consultation room and, importantly, the comfort of the office chair. Sitting during consultations, for both doctor and patient, is historically and clinically established. We learn early on that sitting facilitates the building of rapport.5 “Please come in and take a seat,” we might say on greeting the patient. Sitting creates a safe space for difficult conversations to take place. This all means that there is likely to be a temptation to ignore the occupational hazard to doctors that this behaviour engenders. We know doctors underuse health services and neglect their health,6 and this makes it even more important that we invest efforts in optimising the wellbeing of this hard to reach group.
A review of the literature found little to merit sitting. The evidence available is drawn from studies in secondary care. A study in which patients watched video recordings of simulated oncology consultations found that the patients preferred seated consultations.7 In the emergency department, a recent study showed that although patients perceived consultations to be longer when physicians were sitting, their perceptions of bedside manner, sense of caring, and understanding of their problems were not influenced by the doctor’s posture.8 Meanwhile, a study of ward rounds after surgery found that patients experienced standing consultations as shorter and that sitting consultations were associated with higher rates of positive comments. However, all consultations in this study, both sitting and standing, were conducted with the same doctor, and the comments were drawn from only 38 consultations.9
So dare we challenge the seated consultation and ask general practitioners to stand up?
A solution might lie in considering the present struggle to balance access with continuity, two components of quality of care that are dear to patients yet have proved persistently challenging to provide in parallel. The current focus has primarily been on access, with the requirement to supply same day appointments leading to an increased role of “duty doctor” or “on-call” arrangements at many practices. However, reforms to appointment systems have led to complaints about compromised continuity.10
A two tier appointment model using two types of consultation might respond to the need for access and continuity. Shorter standing appointments could be made available on the day for single acute problems and tackle paucity of access. Meanwhile, non-urgent, longer, sitting appointments could be offered to give time to tackle the complexity of chronic disease management, multimorbidity, and psychosocial illness, and thus protect continuity for patient groups who most need and want it.11 Standing for acute consultations would decrease sitting time and gently signal to both doctor and patient that time is limited.
A similar two tier appointment system exists in high street banks. Many quick queries can be dealt with on a walk-in basis by standing advisers at high desks with computers. Meanwhile, more complex encounters, such as discussing mortgages, are arranged by appointment, take place seated, and last longer. In healthcare attention must be paid to privacy and access to seating should patients be unable to stand.
Although standing consultations may be considered radical and prove unpopular for some, there is always a need to consider and debate innovations that may benefit patients, clinicians, or both. Behavioural change remains a struggle to implement, and the most successful strategies are increasingly thought to be those cued to environmental stimuli, implicitly modifying daily activities without the need for conscious decision making.12 Modifying our occupational environment is a clear example of this. Introducing this change to our practice also serves to promote a culture of attending to our own wellbeing.
The prevailing convention in UK general practice is a “one size fits all” appointment model for consultations, and clinicians are stranded in their chairs throughout the working week. The UK has a shortage of general practitioners, and as well as tackling recruitment, the challenge is also to ensure that clinicians remain healthy and able to work. As such, the negative health effect of prolonged sitting at work may be an important element to consider when designing future models for general practice.
Cite this as: BMJ 2014;348:g1558
I thank Nadia Llanwarne for further substantiating my arguments, revising the original draft, and for supplying valuable references.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; not externally peer reviewed.