The correct distance
The physical distance
between the doctor and patient should be correct when a doctor and patient
talk. If this is not the case, a feeling of uneasiness can arise, which
can lead to a serious disturbance of the discussion.
The phenomenon is based upon
the fact that there are distances between people in the different
types of communicative situations, which are felt unconsciously, by tacit
understanding, to be appropriate. These distances depend on cultural group,
nationality and race, social level, sex, and age as well as psychological
makeup. Everybody has his "personal space", which is nevertheless very
similar over a homogeneous group of people. If this distance is changed,
either encroached upon or elongated, major disorders of communication
can result. There is always a symbolic meaning to the distance between
people, and this counts as one of the non-verbal means of expression. The
most successful discussions between doctor and patient depend on doctor
and patient finding each other at a distance that both unconsciously perceive
How much room does
a person need?
Julius Fast, one of the major
authorities on body language, described an event which turned out to be
a major lesson in body language. Fast was sitting at a table with a psychiatrist
who was a friend of his. They were eating lunch in a restaurant opposite
each other at a table for two. His friend took a packet of cigarettes from
his pocket, lit one and laid the packet just in front of Fast's place setting
while continuing to talk. Fast found that he was uncomfortable, but was
unable to define this in more detail. This uneasiness increased as the
friend pushed his place setting toward the packet of cigarettes. When the
friend then leant over the table directly towards Fast, the latter felt
so irritated, that he had to interrupt the conversation. Then his partner
leant back and said smiling: "I have demonstrated to you a basic fact of
body language. Initially I pushed my cigarette packet towards you. We had
already divided the table into two, on the basis of established convention;
one half for me and the other for you. In imagination, we had marked our
respective territories. Normally we should have politely divided the table
into two and respected the other's half. I put my cigarettes deliberately
into your half, and thereby broke the agreement. Although you did not know
what I was doing, you felt uneasy. When I made another move into your territory,
pushing my plate and cutlery forward, and then leant forwards myself, you
were feeling more and more uncomfortable and threatened, but you still
did not know why".
What Fast is describing is
the classical reaction to a threat to one's territory or movement
into the personal space of the individual. Studies of the specific space
requirements of people, and the optimal distance in certain particular
communicative circumstances, have become a new science, called proximately.
E.T. Hall, an anthropologist, has described the most important facts about
personal space between people. Hall differentiates between 4
zones, 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 existence
of these 4 distance zones has been a helpful explanation for the reasons
why people find certain distances between each other or a group either
correct or disturbing (table).
Distances in the 4 proximetry
zones (according to R.H. RUHLEDER)
As can be seen, the distance
zones are greater, the less one trusts the other person. The existence
of these sorts of distance zones explains why we have the urgent desire
to get out of a full lift, and why both teachers and students find a distance
of 4 m between them as right, as well as why it is normal that 2 men in
Arabic countries walk one with his arm around the other, which would immediately
arouse surprise if seen in Hamburg. This also explains why Charlemagne
erected his throne in the Cathedral of Aix-la-Chapelle as high as he did
(in order that nobody from Rome could sit higher than him). The following
correct distances apply to West Europeans.
The close intimate distance
is the accepted physical distance between two dose friends, lovers, children
and their parents, as well as between married couples. In Western societies,
the dose intimate distance between women is accepted in society, whereas
it is not between men. The dose intimate distance is normal for Arab men
and for people in some south European countries.
Proximetry zones for
those who do not know each other well (acc. to R.H. RUHLEDER)
Men who do not know each
other well experience the wider intimate proximity zone as painful
and react with uncertainty and restlessness. When they are in the intimate
distance zone, it is only possible for them to exchange a brief, neutral
eye contact. Any eye contact which lasts more than 3 seconds is perceived
as intrusion or pressurization; it creates the impression of being stared
at, and can lead to aggressive reactions.
If it happens that people
who do not know each other find that they have been forced into the dose
intimate distance (lift, crowded public transport, crowded public places)
restlessness and aggression can be observed. Fighting in football stadiums
is probably due to the crowding that forces people into dose proximity.
The personal distance
People still can shake hands
in the closer personal distance. It is the typical distance seen
at cocktail parties or between married couples in public.
The wider personal distance
is the limit of the personal area of domination. This is the distance that
people 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 prepared
for open and neutral conversation. This is the distance (90 to 150
cm) which doctors and patients should use in discussion with one another.
This is also the distance which has been shown to be most convenient for
discussions whilst sitting. This also applies to the situation in which
the doctor is in discussion with patients who are in bed. When ward rounds
take place at the foot of the bed, the doctor is already out of the personal
distance and has entered the so-called "business" distance, which is no
longer 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 to
sit 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 tomograph
who cannot see a doctor close at hand.
This more distant portion
of the business distance is used for official social or business functions.
It is protective to a certain extent. Continual eye-contact is expected
at this distance.
The person who is speaking
interprets fleeting eye contact from the person to whom he is speaking
as inattention. When a person in authority wants to be critical, he may
use the social/business distance instead of the personal distance. The
wider social distance also gives the possibility of politely indicating
that one does not wish to communicate; for instance it allows the receptionist
to turn from visitors who are waiting, and to continue typing.
The public speaking
distance (lecturing distance)
The teacher is most likely
to be at a close public speaking distance (4 to 8 m) from pupils, as is
the manager who is lecturing his workers, or speaking to a group that he
wishes to keep within view. This is the necessary distance for a speaker
who needs to keep all of his audience in his visual field.
Interestingly, certain sorts
of animals keep to the dose public distance, and will only come as dose
or 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 moves
directly 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 tamer
were to go nearer, the lion would attack him. The trainer takes advantage
of the situation and places a stool for the lion between him and it. The
shortest 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 distance
and has the lion where he wanted him.
The need for space and
its interpretation are to a certain extent completely different in
various cultures. For example Japanese tend to huddle together into the
smallest space possible, a characteristic which can be studied in a group
of tourists. It is interesting that there is no Japanese equivalent for
the term "personal space". Arabs also love to get dose together, and they
find it very strange that Europeans, especially Germans, have such relatively
large private spheres. Arabs prefer considerable closeness, crush and physical
proximity; this specific proximity contributes to a considerable extent
to the flair of the oriental bazaar. The "unfriendly behaviour" of the
New Yorkers in their completely overpopulated city, probably has not to
do so much with unfriendliness as with a need to maintain their private
sphere so that they ignore others in the subways and the streets.
Maintaining a certain distance
to others has the character of a non-verbal message. Its precondition
is that the other person has the same need for space. If this is not the
case, misunderstandings are very likely to arise rapidly. The appropriate
distance between strangers in Mediterranean and South American countries
is 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 position
which is nearer to the other than when 2 Germans or Frenchmen speak to
one another. A German who in spoken to by a Turk, can soon get a strong
feeling of intrusion, and unconsciously move backwards in order to take
up the correct distance. This backward step could then be taken as a disparaging
or evasive non-verbal signal.
Most discussions between doctors
and patients are carried out while both are seated. Discussions
carried out while standing, on the corridor or by the open door should
be avoided whenever possible. Usually doctors stand within the so-called
distant "personal space" of the bed. In order to achieve a more favourable
discussion, it is better to sit at the bedside (this is also less tiring
for the doctor). It also eliminates the unfavourable height differences
between the person who is standing and the other who is sitting or lying,
and lessens this external symbol of asymmetry. Both partners find themselves
in the business zone if discussions are initiated from the foot of the
bed. Sitting is very conducive to the climate of discussion. Samy Molcho,
the pantomimes, describes sitting as "an ideal position for communicative
exchange". According to him: "Sitting is a physical stance which leads
to relaxation and unburdening of the organism... the body is in a condition
where it can carry out a wide range of activities including gesticulation
and gestures without a continuous tension in all of the muscles. This includes
giving most of the signals which are used in the code of social understanding."
When seated, both partners have taken up a fixed position in space which
has significance for their relationship during the discussion. The spatial
distance between the two is also an expression of their personal distance.
This also has an effect on the loudness of speech, the possibility of watching
one another, and the sorts of eye contact. The "seating code" that is selected
has a symbolic character, as it is usually chosen mutually. The height
of the seats should be the same. A feeling of inferiority can arise
in a person who is invited to sit in a deep armchair by someone sitting
at a table. The optimal conversation distance is between 90 and
150 cm. This is the distance that can be bridged by a hand-shake. It is
also suitable for discussion about difficult or awkward subjects without
the danger of having to speak so loudly that the conversation can be overheard
by somebody nearby. This does not apply to discussions involving several
people (i.e. relatives) in which case the business distance (2-3 m)
If the discussion takes place
over a table, this should not be wider than 80-100 cm. There are however
2 seating positions which can be used for doctor-patient discussions:
vis à vis and sitting to the side (see illustration).
Seated face to face
Sitting face to face demonstrates
that one is fully devoted to the other person and completely concentrating
on him alone. However, this is not always pleasant for some people, who
instead experience feelings of direct confrontation with the other. This
is the reason why this position is used by civil servants to "get the public
under". Barriers can be created by papers, files, pens or x-ray films.
Sitting opposite is the typical form of seating for "legal discussions".
Seated over the corner
of a desk
"Sitting over a corner"
(at an angle between 90 and 150 degrees) has some advantages. It avoids
the occasionally unavoidable "frontal attack" character of sitting face
to face. The variability of the angle gives both partners room to move
and a certain flexibility. This sort of "oblique desk" situation (over
the left corner of the desk) allows the person leading the discussion to
make notes and to look at records without having to hold them up or lay
them down between himself and the patient. It is also easier to introduce
pauses in the discussion. Changes in position of either partner are not
experienced as intensely by the other as they would be face to face. Finally
the distance between the two can be varied more easily, although this should
not be out of the 90-150 cm range. Larger distances would be interpreted
as "keeping one's distance", and lack of concern; but a shorter distance
can be interpreted as an intrusion into the personal space, and release
restlessness or aggression.
There are doctors who like
to sit at the same side of the desk as their patients. This seating arrangement
expresses the desire that there is no asymmetry between doctor and patient.
Many patients may appreciate this, but the disadvantage is that the doctor
can hardly make any notes, and that some patients find that sitting next
to the doctor is an encroachment on their intimate space.
Posture whilst sitting
Posture is part of body language
and thereby also a part of the discussion. The way in which a person sits
allows interpretation of his immediate mood, his internal disposition,
his nature and his attitude towards the other. S. Molcho analyzed the meaning
of the expression of posture as follows:
However when interpreting
body language, it must be remembered that although these rules may
apply to some, they cannot be applied to everybody. All rigid "that means
that" rules can lead to incorrect interpretations. There must be a synchronous
appreciation and analysis of verbal and non-verbal forms of communication
before it can really be understood what messages the conversation partner
is actually giving (see chapter on Body Language ).
of the trunk: Erect, alert posture signals dynamism and vitality as
opposed to slumping with its connotations of lack of drive and possible
depressive mood. Leaning of the upper part of the body towards the other
reflects interest in the other and invites dialogue; leaning back implies
skepticism, withdrawal or avoidance. This means that body language
and words can contradict each other. Someone who agrees verbally
but leans backwards is distancing himself from his words. In case of doubt,
apply the rule that the body does not lie.
||Careful positioning on
the edge of the chair signals time pressure or jumpiness. It can also
be a sign of inferiority or uncertainty, as well as a desire to end the
conversation. Exaggerated leaning backwards, even to the point of
balancing on the hind-legs of the chair, reveals a retreat to the role
of observer, who is watching and waiting. Getting up briefly or shifting
in the seat is an indication of unease and a non-verbal signal that he
would like to leave.
||The position of the legs
whilst sitting can also be an important signal. If the feet are locked
together at the ankle, this can imply reserve, internal tension and danger.
If the feet wind themselves round the chair-legs, the position that has
been taken up is rigid and not easy to change, whereas loosely crossed
legs speak for openness with some degree of reserve. An open relaxed position
with outstretched legs demonstrates trust, but also territorial claims,
but a wide seat with shins set obliquely indicates a protective barrier.
If two people sit cross-legged next to each other with toes pointing towards
each other, contact is being sought between them. However differences and
distancing are indicated by toes of the two people pointed away from each
||The upright position with
closed knees and feet, perhaps with a bag tightly clenched in the lap,
is more often seen in women, where this stance is a sign of being "brought
up correctly" although inhibition, uncertainty and anxieties lie behind
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
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