Effects Upon Patient Satisfaction of Sitting Versus Standing During Inpatient Rounding Lee Radosh, MD Associate Director, Family Medicine Residency Program The Reading Hospital and Medical Center, Reading, PA Brett Keller Philadelphia College of Osteopathic Medicine, Philadelphia, PA Jamie Spicer Drexel University School of Medicine, Philadelphia, PA

Introduction: Why Care About Patient Satisfaction? Patient satisfaction associated with improved health outcomes [1,6] –Increased compliance with instructions –more likely to follow-up Improved HA1C in Type 2 Diabetes [1] Fewer lawsuits [5] Time influences satisfaction with care [2]

Introduction: Why Care About This? We’re all busy Time is limited What can we do to maximize efficiency (time), yet not impact patient satisfaction? Dr. Cain’s story!

Selected Background Literature Patients shown 2 videos of physician encounters –Doctor sat in one and stood in the other –No significant difference in time perceived or patient satisfaction between sitting and standing [3] ER setting –Providers randomly assigned to sit or stand –Perceived time spent was greater in the sitting group however there was no difference in patient satisfaction [4]

Research Question Does sitting versus standing during inpatient rounding affect patients’ perception of time spent by the physician, and/or satisfaction with care?

Study Background Randomized, controlled trial IRB review (exempt)

Setting The Reading Hospital and Medical Center –Reading, PA –Main hospital for Berks County (population 400,000) –700 beds, 300+ ER visits/day Busy Hospitalist service Piloted summer 2008 –Feasability –Family Medicine Inpatient service

Methods Set weeks, summer Hospitalists included Each chosen because: –Available during study time period –Assigned by director of the Hospitalists –Agreed to have medical student shadow them for the study

Methods (con’t) Observer shadowed Hospitalist for the day/half-day Each patient encounter potential case/subject Encounter directly observed by 1 of 2 (trained) research assistants

Methods (con’t) Observer tasks: –Let physician know to sit or stand (every other randomization) –Set-up chair if one not in the room –Observe encounter (silently) –Discretely record time with stopwatch –Following the encounter, usually when Hospitalist left to write note: Administer brief survey to the patient –Record pertinent data (demographic, etc.) All data de-identified

Survey Instrument Day of hospitalization Demographic data Satisfaction with care received Satisfaction with time spent Perceived time spent Degree of pain or discomfort

Patient Exclusion Criteria Isolation Dementia/communication problem –At physician discretion Non-English speaking Younger than 18 yrs Patient had been given survey before Patient refused Physician was to break bad news/family meeting

Disclaimer.. New patient data found Different results than in abstract Sorry for any inconvenience..

Patients Excluded 75 patients given survey 40 included 35 excluded –Isolation – 10 patients –Dementia – 11 patients –ICU – 2 patients –Physician did not sit/stand (indeterminate!) – 5 patients –Patient rec. survey before – 5 patients –Patient in distress – 1 patient –Physician broke bad news – 1 patient

Patients Included Sitting (n=22) Standing (n=18) Median Age: 72 years Median Age: 72 years All white All white 9 females 9 females 13 males 13 males Median Age: 70.5 years Median Age: 70.5 years All white All white 10 females 10 females 8 males 8 males Note: some exclusions occurred after randomization, hence unequal numbers

Actual Time of Encounter Sitting (n=22) Range –2.3 – minutes Mean –7.05 minutes Standard deviation –4.07 Standing (n=18) Range –2.58 – 22.72Mean –7.89 minutes Standard deviation –5.08 The two-tailed P value equals – NO difference (unpaired t test)

Perceived Time of Encounter Sitting (n=22) Range – minutes Mean –9.36 minutes Standard deviation –6.09 Standing (n=18) Range –3 - 30Mean –9.8 minutes Standard deviation –6.75 The two-tailed P value equals – NO difference (unpaired t test)

Results Sitting Perceived time spent –2.31 minutes greater than actual time Satisfaction with care –9.24 Satisfaction with time –9.43 Satisfaction was measured on a scale from 1-10 Standing Perceived time spent –1.91 minutes greater than actual time Satisfaction with care –9.57 Satisfaction with time –9.54

Limitations of Study Many patients (50%) excluded Small sample size Small number of Hospitalists Other verbal/nonverbal confounders Biases Hospitalist schedules –ER,ICU,discharge patients, phone/pages

Future Studies Further statistical analysesFurther statistical analyses Time correlation with satisfaction? With other variables? Time correlation with satisfaction? With other variables? Satisfaction correlation with other variables? Satisfaction correlation with other variables? Larger sample size neededLarger sample size needed Look for confounders, other factors Look for confounders, other factors Larger number of Hospitalists/physicians neededLarger number of Hospitalists/physicians needed Limit bias by standing outside the room, then coming in at end to administer surveyLimit bias by standing outside the room, then coming in at end to administer survey Tighter randomizationTighter randomization Modify questions to fit population (this was only a pilot study)Modify questions to fit population (this was only a pilot study) Change scale from numbers to words Change scale from numbers to words Add additional question Add additional question Effects of MRSA, stricter infection control policies?Effects of MRSA, stricter infection control policies? Ex: no charts in the room Ex: no charts in the room

Acknowledgements to The Reading Hospital and Medical Center Janelle Mensinger, PhD –Former Research Director Academic Office Hospitalists who agreed to be shadowed

Conclusion High satisfaction scores regardless of whether the physician sat or stood Despite small numbers, very consistent actual and perceived times (means) The perceived time spent in both groups was greater than the actual time spent

References [1] M. H. Alazri and R. D. Neal (2003). "The association between satisfaction with services provided in primary care and outcomes in Type 2 diabetes mellitus." Diabetic Medicine 20(6): [2] Lin, C.-T., G. A. Albertson, et al. (2001). "Is Patients' Perception of Time Spent With the Physician a Determinant of Ambulatory Patient Satisfaction?" Arch Intern Med 161(11): [3] Florian, S., J. L. Palmer, et al. (2005). "Impact of Physician Sitting Versus Standing During Inpatient Oncology Consultations: Patients' Preference and Perception of Compassion and Duration. A Randomized Controlled Trial." Journal of pain and symptom management 29(5): [4] Rebecca, L. J., T. S. Annie, et al. (2008). "To Sit or Not to Sit?" Annals of emergency medicine 51(2): e2. [5] Henry Thomas, S., K. G. Tejal, et al. (2005). "The relation of patient satisfaction with complaints against physicians and malpractice lawsuits." The American journal of medicine 118(10): [6] Williams, B. (1994). “Patient Satisfaction: A Valid Concept!" Soc. Sci. Med 38(4):