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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
The correct distance
How much room does a person need?
Correct seating
Posture whilst sitting
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 as correct.
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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 the personal space between people. Hall differentiates between 4 distance 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)

more introverted person
more extroverted person
Intimate distance
0,40 m - 1,50 m
0,30 m - 0,50 m
up to 0,50 m
Personal distance
1,50 m - 2,00 m
0,40 m - 1,50 m
0,50 m - 1,50 m
Social/business distance
2,00 m - 4,00 m
1,50 m - 3,00 m
1,50 m - 3,00 m
Public speaking distance
from 4,00 m
from 3,00 m
from 3,00 m
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 rules for correct distances apply to West Europeans.

Intimate distance

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
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.

The social/business distance

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.
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Correct seating
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) is preferable.

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
Seated face to face

Seated over the corner of a desk
Seated over the corner of a desk

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".

"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.
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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:
  Posture 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 other.
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 it.
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 link). 
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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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