Note to self: “Sit down and shut up” 

As a pediatrician (and the father of three children) who wants to encourage independent thinking and creativity, “Sit down and shut up” has as always rubbed me the wrong way. It’s something that I think we should never say to a child. But when I think about what I need to do to be the best clinician I can be, sitting down and shutting up is exactly what I need to do. It’s also what I try to teach all of my trainees.  So, let’s parse that expression and see why. 

“Sit down” 

Why do we need to sit down?  Many studies have shown that when you sit down it has a huge impact on the interaction between patient and clinician and improves care. Sitting down shows a commitment to spending time, instead of the perception by standing that the healthcare professional already has one foot back out the door. By bringing your head to the level of the patient it establishes a feeling of an equal partnership in care, rather than looming over the patient.  

One the first studies to look at this summarized “Patients perceived the provider as present at their bedside longer when he sat, even though the actual time the physician spent at the bedside did not change significantly whether he [or she] sat or stood. Patients with whom the physician sat reported a more positive interaction and a better understanding of their condition. . . . Simply sitting instead of standing at a patient’s bedside can have a significant impact on patient satisfaction, patient compliance, and provider-patient rapport, all of which are known factors in decreased litigation, decreased lengths of stay, decreased costs, and improved clinical outcomes.”  

There have been multiple follow-up studies to validate the need for providers to sit down, even in locations such as the emergency department where the assumption is for “faster” care. “Regardless of hospital site, provider sitting at any point during an ED encounter as opposed to standing improved responses to satisfaction questions (polite [67% vs 59%], cared [64% vs 54%], listened [60% vs 52%], informed [57% vs 47%], time [56% vs 45%]; P < .0001 for all measures.” There’s just so much evidence that the simple act of sitting down makes a significant improvement in clinical care, rapport, and patient satisfaction. Personally, I know that when I sit down, I do a better job of focusing on the family in front of me    

“Shut up” 

I believe that the “shut up” part is even more important than sitting down. We learn very early in our healthcare training that the most important part of getting an accurate diagnosis is getting an accurate history. I like to focus on the important word “history” and break it down to his-story because that’s exactly what the patient/family should be telling us. It’s his, her, or their story. Sadly, studies have shown that most physicians will only wait about 11 to 18 seconds before interrupting a patient and asking questions. Sometimes as quickly as three seconds.  

This information is so prevalent that it’s even been summarized in a scathing article in “Forbes” magazine, that starts with “Apparently it takes mammals on average 21 seconds to pee regardless of their size, based on Georgia Tech researchers watching different animals urinate. Therefore, you may have much more uninterrupted time to empty your bladder than you do to tell your doctor why you are seeing him or her on a visit.” 

This article sites a study from the Mayo Clinic that focused on eliciting the patient’s agenda (the reason for the visit) and summarizes the results in layman terms as “The majority of the time the doctor did not even ask the patient the purpose of the visit: 64% of primary care visits and 80% of specialist visits. Even when doctors gave patients the opportunity to explain the purpose of the visit, most of the time doctors interrupted the patient: 19 (63%) of the 30 primary care encounters and 8 (80%) of the 10 specialty care encounters These interruptions came pretty quickly: a median of 11 seconds with a range of 3 seconds to 234 seconds. (3 seconds?!?) And most of the time (59%), the interruption wasn’t something like “I see, tell me more” or “That must be hard for you” or “I really have to go pee” but instead it’s more often a closed-ended question, that is, a question just seeking a “yes” or “no” response. 

This willingness to interrupt patients is likely worse in the U.S. than in other countries. Avril Danczak in the BMJ wrote “The average time to interruption in Slovenia and Croatia was 28 seconds. In Israel the average was 26 seconds, although the median was only 15 seconds. In Britian for GPs the average time was 47 seconds, and the audit found a strong training effect. Doctors in their first two years of specialty training spoke sooner, after a mean of 36 seconds (median 37), compared with a mean of 51 seconds (median 48) among third year or experienced doctors.” 

As a specialist and a U.S. trained and practicing physician this is discouraging, and I realize I need to be even more aware of giving patients, or the parents of younger children, enough time. Just as with sitting down, being quiet at the beginning of the interaction will lead to a more accurate diagnosis and a significant improvement in clinical care, rapport, and patient satisfaction.  

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.