Linus Geisler - Doctor and patient [3]: The correct distance. Correct seating. (2024)

The phenomenon is based uponthe fact that there are distances between people in the differenttypes of communicative situations, which are felt unconsciously, by tacitunderstanding, to be appropriate. These distances depend on cultural group,nationality and race, social level, sex, and age as well as psychologicalmakeup. Everybody has his "personal space", which is nevertheless verysimilar over a hom*ogeneous group of people. If this distance is changed,either encroached upon or elongated, major disorders of communicationcan result. There is always a symbolic meaning to the distance betweenpeople, and this counts as one of the non-verbal means of expression. Themost successful discussions between doctor and patient depend on doctorand patient finding each other at a distance that both unconsciously perceiveas correct.

What Fast is describing isthe classical reaction to a threat to one's territory or movementinto the personal space of the individual. Studies of the specific spacerequirements of people, and the optimal distance in certain particularcommunicative circ*mstances, have become a new science, called proximately.E.T. Hall, an anthropologist, has described the most important facts aboutthepersonal space between people. Hall differentiates between 4distancezones, within which most people communicate.

1. The intimate distance
2. The personal distance
3. The social/business distance
4. The public speaking distance

Description of the existenceof these 4 distance zones has been a helpful explanation for the reasonswhy people find certain distances between each other or a group eithercorrect or disturbing (table).

Intimate distance

The close intimate distanceis the accepted physical distance between two dose friends, lovers, childrenand their parents, as well as between married couples. In Western societies,the dose intimate distance between women is accepted in society, whereasit is not between men. The dose intimate distance is normal for Arab menand for people in some south European countries.

Proximetry zones forthose who do not know each other well (acc. to R.H. RUHLEDER)

If it happens that peoplewho do not know each other find that they have been forced into the doseintimate distance (lift, crowded public transport, crowded public places)restlessness and aggression can be observed. Fighting in football stadiumsis probably due to the crowding that forces people into dose proximity.

The personal distance

People still can shake handsin the closer personal distance. It is the typical distance seenat co*cktail parties or between married couples in public.

The wider personal distanceis the limit of the personal area of domination. This is the distance thatpeople usually take up when they meet unexpectedly (i.e. in the street)and attempt conversation about things that are not particularly private.The message that this distancing gives is one of being preparedfor open and neutral conversation. This is the distance (90 to 150cm) which doctors and patients should use in discussion with one another.This is also the distance which has been shown to be most convenient fordiscussions whilst sitting. This also applies to the situation in whichthe doctor is in discussion with patients who are in bed. When ward roundstake place at the foot of the bed, the doctor is already out of the personaldistance and has entered the so-called "business" distance, which is nolonger appropriate for confidential discussion. Most of the technical,non-invasive and invasive investigations (ultrasound, endoscopy, catheterization)are carried out in the personal distance. A patient who is expected tosit 3 m away from his doctor, discovers that he has major problems in communicating,similar to those experienced by a patient encased in a computer tomographwho cannot see a doctor close at hand.

The social/businessdistance

This more distant portionof the business distance is used for official social or business functions.It is protective to a certain extent. Continual eye-contact is expectedat this distance.

The person who is speakinginterprets fleeting eye contact from the person to whom he is speakingas inattention. When a person in authority wants to be critical, he mayuse the social/business distance instead of the personal distance. Thewider social distance also gives the possibility of politely indicatingthat one does not wish to communicate; for instance it allows the receptionistto turn from visitors who are waiting, and to continue typing.

The public speakingdistance (lecturing distance)

The teacher is most likelyto be at a close public speaking distance (4 to 8 m) from pupils, as isthe manager who is lecturing his workers, or speaking to a group that hewishes to keep within view. This is the necessary distance for a speakerwho needs to keep all of his audience in his visual field.

Interestingly, certain sortsof animals keep to the dose public distance, and will only come as doseor as near as this. If the person approaches them, they will either retreat,flee or attack. This characteristic is used by the lion-trainer; he movesdirectly towards the lion and as soon as he is between 4 and 6 m away,the lion backs until it reaches the railings of the cage. If the tamerwere to go nearer, the lion would attack him. The trainer takes advantageof the situation and places a stool for the lion between him and it. Theshortest way for the lion to get at the trainer is to climb onto the stool.As he is doing this, the trainer is able to escape from the public distanceand has the lion where he wanted him.

The need for space andits interpretation are to a certain extent completely different invarious cultures. For example Japanese tend to huddle together into thesmallest space possible, a characteristic which can be studied in a groupof tourists. It is interesting that there is no Japanese equivalent forthe term "personal space". Arabs also love to get dose together, and theyfind it very strange that Europeans, especially Germans, have such relativelylarge private spheres. Arabs prefer considerable closeness, crush and physicalproximity; this specific proximity contributes to a considerable extentto the flair of the oriental bazaar. The "unfriendly behaviour" of theNew Yorkers in their completely overpopulated city, probably has not todo so much with unfriendliness as with a need to maintain their privatesphere so that they ignore others in the subways and the streets.

Maintaining a certain distanceto others has the character of a non-verbal message. Its preconditionis that the other person has the same need for space. If this is not thecase, misunderstandings are very likely to arise rapidly. The appropriatedistance between strangers in Mediterranean and South American countriesis much less than in West Europe, or North America. The Greek or Turk,who wants to speak to a French person or a German, will take up a positionwhich is nearer to the other than when 2 Germans or Frenchmen speak toone another. A German who in spoken to by a Turk, can soon get a strongfeeling of intrusion, and unconsciously move backwards in order to takeup the correct distance. This backward step could then be taken as a disparagingor evasive non-verbal signal.

If the discussion takes placeover a table, this should not be wider than 80-100 cm. There are however2 seating positions which can be used for doctor-patient discussions:vis à vis and sitting to the side (see illustration).

Seated face to face

Seated over the cornerof a desk

"Sitting over a corner"(at an angle between 90 and 150 degrees) has some advantages. It avoidsthe occasionally unavoidable "frontal attack" character of sitting faceto face. The variability of the angle gives both partners room to moveand a certain flexibility. This sort of "oblique desk" situation (overthe left corner of the desk) allows the person leading the discussion tomake notes and to look at records without having to hold them up or laythem down between himself and the patient. It is also easier to introducepauses in the discussion. Changes in position of either partner are notexperienced as intensely by the other as they would be face to face. Finallythe distance between the two can be varied more easily, although this shouldnot be out of the 90-150 cm range. Larger distances would be interpretedas "keeping one's distance", and lack of concern; but a shorter distancecan be interpreted as an intrusion into the personal space, and releaserestlessness or aggression.

There are doctors who liketo sit at the same side of the desk as their patients. This seating arrangementexpresses the desire that there is no asymmetry between doctor and patient.Many patients may appreciate this, but the disadvantage is that the doctorcan hardly make any notes, and that some patients find that sitting nextto the doctor is an encroachment on their intimate space.