Physician posture affects patient experience and outcomes

Doctors and other health care workers caring for hospitalized patients may want to sit down to hear this news.

New research suggests that speaking to a patient at eye level can really make a difference. Sitting or squatting at a patient’s bedside is associated with greater trust, satisfaction and even better clinical outcomes than standing, according to a new review of the evidence.

The study's authors, from the University of Michigan and the VA Ann Arbor Healthcare System, note that most studies on the topic varied in their interventions and outcomes and had a high risk of bias. Their findings are published in a systematic review in the Journal of General Internal Medicine.

So the researchers decided to explore this question as part of their larger study on the influence of various nonverbal factors on care, perception, and outcomes.

Until their new study is completed, they believe their systematic review should encourage clinicians and hospital administrators to encourage more bedside sitting.

Something as simple as providing folding chairs and stools in or near patient rooms can help - and, in fact, the Ann Arbor VA has installed folding chairs in many hospital rooms at Lt. Col. Charles S. Kettles Medical Center.

Nathan Houchens, MD, a U-M medical school faculty member and VA physician who worked with U-M medical students to review the evidence on the topic, says they focused on physician posture because of the power dynamics and hierarchy in hospital care.

A supervising physician or resident can change that relationship with a patient by getting down to his or her eye level rather than standing over him or her, he notes.

He credits the idea for the study to two former medical students who have now completed and are continuing their medical training elsewhere: Rita Palanjian, MD, and Mariam Nasrallah, MD.

"It turned out that only 14 studies met the criteria for evaluation in our systematic review of the effects of eye level shifting, and only two of these were rigorous experiments," Houchens said.

The studies also measured a variety of things, from the length of patient contact and patient impressions of empathy and compassion to patients' overall assessments of hospitals, measured by standardized surveys such as the federal HCAHPS survey.

Overall, he said, the data showed that patients preferred doctors who were seated or at eye level, though that wasn't always the case. And many studies acknowledged that even when doctors were instructed to sit with patients, they didn't always do so — especially if there were no designated seating areas.

Houchens knows from his experience supervising medical students and residents at the VA that doctors may worry that sitting will prolong interactions when they have other patients and responsibilities. But the data the team reviewed suggests that’s not the case.

He notes that other factors, such as concerns about infection transmission, can also make it difficult to stay at eye level all the time.

"We hope our work will bring more attention to the importance of sitting and the general finding that patients value it," Houchens says. Providing seating, encouraging physicians to be at eye level, and senior physicians modeling this for their students and residents can also help.

A recently launched VA/UM study, funded by the Agency for Healthcare Research and Quality and called the M-Wellness Laboratory study, includes physician posture as part of a suite of interventions aimed at creating hospital environments that promote healing and patient-physician bonding.

In addition to encouraging physicians to sit at patients' bedsides, the intervention also includes encouraging warm greetings upon entering patients' rooms and asking patients questions about their priorities and backgrounds during conversations.

Researchers will look for differences in length of hospital stay, readmissions, patient satisfaction scores and other measures between units where the intervention package is being implemented and those where it has not yet been implemented.