THE PRACTICE OF EMERGENCY MEDICINE/EDITORIAL

To Sit or Not to Sit: A Question of Cultural Performance

Alexandra Murphy, PhD From the College of Communication, DePaul University, Chicago, IL.

0196-0644/$-see front matterCopyright © 2008 by the American College of Emergency Physicians.doi:10.1016/j.annemergmed.2007.06.477

SEE RELATED ARTICLE, P. 188.

[Ann Emerg Med. 2008;51:194-196.]

As a scholar and teacher of communication studies, I wasvery interested and excited to see the study “To Sit or Not toSit.”1 In its efforts to explore the relationships among 2nonverbal cues (physician posture and time) to patientsatisfaction, it provides a much-needed example of theapplication and important implications of nonverbal cues in thehealth communication process. The study finds that patients’perception of time was influenced by the physician position ofsitting or standing. Patients overestimated the time spent withthem when a physician was sitting and underestimated the timespent with them when the physician was standing. The authorswere surprised, however, that despite past studies in other healthcare settings that have shown that time spent with a provider isa determinant of patient satisfaction, the difference in timeperception in the emergency department (ED) did not translateinto a significant finding in patient satisfaction.

A quick explanation for this might be that if you spend yourtime well (whether sitting or standing), then patients do notneed a lot of it. This, of course, could be seen as a relief foremergency providers because they do not have a lot of time.And, as the authors indicate at the end of the study, it seemsmuch more important to understand how physicians canexpress empathy and build rapport within the tight timeconstraints of the ED. In other words, at the heart of the study(whether sitting or standing) may be the physician’s heart. Hereis where I would love to be able to pick up where the study leftoff and explore the numerous other nonverbal cues that couldinfluence patient perception of empathy and rapport. But thislist could go on forever (much longer than the page allotmentfor this editorial), with no real guarantee of working. Instead,I would like to take this time to explore the problems andpossibilities associated with patient-physician communicationby considering organizational cultural performances.2 From thisperspective, patient-physician interaction is much more than theverbal and nonverbal transfer of information from one person toanother.

First, the physician-patient interaction is a ritual performance;it is a standard occurrence, with an identifiable beginning andend each time a physician meets his or her patient. As a ritual, itserves to orient members to one another, to synchronize their

focus and their experience, and introduce a sense of regularity.3

194 Annals of Emergency Medicine

The physician-patient interaction is also a performance in thesense that it requires each party to “present” a sense of himselfor herself to the other. As the “Sit or Stand” study reminds us, apresentation of physician concern and empathy is consideredcritical for establishing patient rapport and satisfaction.

Although the patient and even the hospital may benefit fromsuch emotional displays, the benefit for the physician is lesscertain. For physicians, some emotional detachment may benecessary to maintain their personal well-being.4 Much researchattention has focused on identifying strategies for protecting thehealth worker from stress and burnout resulting from too muchemotional involvement. A distinction, for example, can be madebetween “emotional contagion” and “empathic concern.”5

Health care workers express empathic concern for a patientwhen showing feelings for the other person, but they maintainmore distance between their own feelings and the feelings of thepatient. If health care workers experience emotional contagion,then they are more caught up in the feelings and experiences ofthe patient. They experience the patient’s own emotionalturmoil. This emotional contagion is a dangerous path to morestress and burnout for the caregivers. Therefore, it isrecommended that caregivers foster a position in which they candemonstrate concern for another without being emotionallyinvolved.5

Second, organizational cultural performances are notmonologues but are dialogues.2 Seen this way, physicians cannotsimply “perform” empathy for their patients. Physicians andpatients jointly participate in creating both the meaning andhow meaningful their exchange will be. Although it may appearthat a physician asks predetermined questions and the patientresponds, they are interlocked because each communicative actenables and constrains the next. For this reason, it may not beeffective to tightly script what a physician says or how aphysician approaches a patient. If it is too scripted, no matterwhether the physician is sitting, giving appropriate eye contactand head movements, leaning in, or even touching the patient’sshoulder, it will appear rote and the patient will respond inkind. Most of us are familiar with these kinds of customerservice situations. The most extreme example has to be therecent use of automated telephone services that use a voice withinterpersonal inflections. Emergency physicians interact morewith the patients: listen to their stories, as people and not as

objects. Patients, too, are involved in the dialogue even if the

Volume , . : February

Murphy To Sit or Not to Sit

extent of their involvement means they actively listen to andfollow the physician’s orders.

Third, organizational cultural performances are contextual inthat they are embedded in past interactions and perceptions ofthese interactions and yet are situationally relative and variable.2

Historical meanings serve as a resource as individuals confrontnew situations and draw on experiences to know how to act.When physicians and patients enter into their exchange, theycarry with them certain expectations about what will happen,according to their own experiences, cultural stories, hospitalfolklore, or myths. When the performance is interrupted, (ie,does not go as either party believes is dictated by the historicalscript), it provides a reminder of the rules that hold together“normal” social relations. This may partially explain why thepatients in this study overestimated the time the physiciansspent with them when the physicians were sitting. This is aperformative violation, given the historical norms of physician-patient interactions (eg, emergency physicians are always in arush).

Organizational cultural performances are also situationallyrelative and variable.2 The actors draw not only on theirexperiences but also on the specific context of the interaction. Inshort, individuals act differently with different people and indifferent situations. For example, coworkers meeting each otherat a bar after work will interact differently than they do at theoffice. Emergency physicians are faced with different audienceswith competing needs for their professionalism: peers andpatients. For example, a major performative characteristic of aphysician is the ability to efficiently recite a list of patientdemographics, chief complaints, and diagnosis to other medicalstaff. They must transform the patient into an efficient list ofsymptoms and diagnoses.6 They begin with patient name or bednumber, sex and age, chief complaint, diagnosis, and testsordered, completed, and pending. The patient is efficientlyobjectified in this context. However, as noted above, thephysician is expected to interact with the patient as a person andnot an object. The definition and redefinition of patient fromperson to object and back is a difficult process for any physician.And, unlike other hospital physicians, emergency physicians donot create long-term relationships with their patients. The EDis, by definition, a liminal space, a threshold patients cross overto enter the hospital, be discharged, or, in unfortunate cases,die. In all situations, the relationship between patient andphysician will end. The personalization, therefore, must happenin brief moment-to-moment encounters. One emergencyphysician told me, “You have to listen to [the patients]. Theproblem is that you only have a few minutes to do this. If youask them what brought them into the ER today, they will startwith telling you about how they were making a peanut butterand jelly sandwich and finally get to the part that you careabout.”6

The liminal characteristic of the ED is another possibleexplanation for why the patients in the “Sit or Stand” study who

perceived that their physicians were spending more time with

Volume , . : February

them were not more satisfied with their encounter. Patients maynot want the physician to spend a lot of time with them becausethey do not want to spend much time in the ED. Just as wordshave meaning only in some context, actions (such as sitting orstanding) also only have meaning in a particular context, andtime only has meaning in a particular context.

Finally, organizational cultural performances are political. Aswe explore the ritualistic, dialogic, and contextual characteristicsof ED physician-patient communication, we must also considerhow organizational cultural performances are always relationalbecause the communicative process exists, historically, betweensubjects in relations of power.7 Physicians are technicalauthorities in medicine and patients are experiential authoritiesof their bodies. Often physicians and patients vie to control themeaning of their interactions by privileging their expertise overthe other. As the “Sit and Stand” study implies, there is anincreased emphasis on building rapport between physicians andpatients, placing even more power in the hands of the patient asthe physician is encouraged to “listen” and to “empathize.”Overall, this can lead to more effective health care becausepatients may be more willing to open up and discuss theirsymptoms and to follow the prescribed treatment. In extremecases, however, physicians must also guard against patients whomight exaggerate or even manufacture symptoms to receive drugtreatments.

In the end, whether sitting or standing, emergencyphysicians are charged with a difficult performance: they mustcare equally for all patients, express empathy, listen to thepatient story with a “compassionate” ear, yet maintain their ownclinical expertise. And while doing this, it is important that theycommunicate with rather than to their patients.

Supervising editor: J. Stephan Stapczynski, MD

Funding and support: By Annals policy, all authors are requiredto disclose any and all commercial, financial, and otherrelationships in any way related to the subject of this article,that might create any potential conflict of interest. The authorhas stated that no such relationships exist. See theManuscript Submission Agreement in this issue for examplesof specific conflicts covered by this statement.

Publication date: Available online August 24, 2007.

Reprints not available from the author.

Address for correspondence: Alexandra Murphy, PhD, Collegeof Communication, DePaul University, 2320 N Kenmore Ave,Chicago, IL 60614; E-mail amurphy1@depaul.edu.

REFERENCES1. Johnson RL, Sadosty AT, Weaver AL, et al. To sit or not to sit? Ann

Emerg Med.. 2008;51:188-193.2. Pacanowsky M, O’Donnell-Trujillo N. Organizational

communication as cultural performance. Commun Monogr.1983;50:126-147.

3. Putnam L, Phillips L, Chapman P. Metaphors of communicationand organization. In: Handbook of Organization Studies. Thousand

Oaks, CA: Sage Publications; 1997:375-408.

Annals of Emergency Medicine 195

To Sit or Not to Sit Murphy

4. Rafaeli A, Sutton RI. Emotional contrast strategies as a means ofsocial influence: lessons from criminal interrogators and billcollectors. Acad Manage J. 1991;34:749-775.

5. Miller KI, Stiff JB, Ellis BH. Communication and empathy asprecursors to burnout among human service workers. Commun

Monogr. 1988;55:250-265.

196 Annals of Emergency Medicine

6. Eisenberg E, Murphy A, Sutcliffe K, et al. Communication inemergency medicine: implications for patient safety. CommunMonogr. 2005;72:390-413.

7. Clifford J. Introduction: partial truths. In: Writing Culture: ThePoetics and Politics of Ethnography. Berkeley, CA: University of

California Press; 1986.

Did you know?

You can personalize the new Annals of Emergency Medicine Web site to meet your individual needs.

Visit www.annemergmed.com today to see what else is new online!

Volume , . : February