Power of the layout

A few days ago, I was sitting in an office of a psychologist/psychotherapist and commented on the fact that I barely saw her. It was sunny outside, the psychotherapist’s was sitting close to the window with her back towards it and as the glare dazzled me. I am sitting in the shade, she responded. I thought it was a very interesting response, but what struck me again, was the layout of the office/surgery. The blog on surgeries’ layout has been long coming.

When I arrived in the UK, all those years ago, I noticed a significant difference in the layout of doctors’ surgeries. In Poland, when you saw a doctor, you faced them sitting on the other side of the desk they would sit at. The layout was something like this:

The circles stand for the clinician (C) and the patient (P), while the arrows indicate the direction of the body and eyesight as the person takes a default position on the chair. The rectangle in the middle is the desk. By default, the patient and the clinician look at each other. In the UK, the layout of the office was different. It was (and continues to be) something like this:

The clinician also sat behind their desk, but the patient sat at its side.

I commented on it a few times and every time I was told that the change in the layout resulted from medics’ wish not to be behind the physical barrier of a desk. The patient was closer to the doctor, as the asymmetry of power created by the desk was remedied by the patient sitting at the side. I was sceptical of the reasoning, and over the years, I reassured myself in the view that the explanation was nonsense. And if it achieved anything, it was helping doctors to feel better about themselves, as they shove the patient around to their hearts’ delight.

When I moved to Poland two years ago now, I was surprised to see seeing that the new layout was also taking off here. Quite a few times now, I was asked to sit at the side of the clinician’s desk. And so, we come to the main point of this blogpost. I want to explain why I don’t like it.

Let’s go back to Figure 2. Look at the arrows first. The default position is that if you and the medic sit down on your chairs and do nothing with your body or head, you will not look at each other. It means that the patient (let’s say: me) and/or the doctor must turn their head sharply in order to face each other. There are two scenarios for the patient.

In figure 3, your body remains straight and ‘unengaged’, while your head turns. This is what it might look like:

In figure 4, you twist your entire body perching on the edge of the chair.

Fig. 4

Myself, I always twisted my body, as keeping the head turned for a prolonged amount of time is more uncomfortable than sitting sideways on the chair.

But what about the doctor, you will ask. Well, that’s a bit complicated. If the doctor turns, they tend to be on a swivel chair, so they avoid any discomfort. My GP kept spinning on his leather armchair, sometimes stretching on it comfortably. Incidentally, a few years ago, I saw a Romanian specialist doctor with whom I chatted briefly about our immigrant experience every time I saw him. Astonishingly, every time I sat down, he moved his chair from the centre of the desk towards me, positioning himself also at the end of the desk. Remember this story, I will co me back to it.

Now, even if the clinician turns on the swivel chair, it tends to be for a brief moment, as there is one element of the surgery layout which is missing in my little drawings. It’s also one which often prevents the medic from turning at all. What the default situation looks like, in fact, is this:

And here we come to the first interesting fact about the common side-desk layout. The default position of the doctor makes them look at the computer screen. And, indeed, my and others’ experience suggests that the clinician’s main interaction is with the computer. Time and again, I spoke to the doctor’s side, as they typed something on their keyboard.

(There is much more to be written about the clinician’s interaction with the computer and the information they get, and its status. My GP was firmly of the opinion that the real evidence is only in the computer not in what I say. But that’s not the point here.)

There is of course some variation in how the computer screen is positioned, but over the years, I observed the movement of the computer from the side of my GP’s desk, and the screen being positioned diagonally with respect to the desk. In the last few years, the screen took its rightful (I’m sure) position at the very centre of the medic’s desk.

And so, as I was perched on the edge of the chair, speaking to the side of the GP whose primary interest was in the computer screen, the whole layout suggested to me that I was a bystander. I was on the sideline. To make matters worse, I was making an effort to engage with the GP, twisting body uncomfortably, but the GP was offering me his cold shoulder as he continued to ‘talk’ to the computer. And that’s the main reason why I think that the side-desk layout is unhelpful. As clinicians repeat the mantra about the physical barrier and their bid to remove it, the new layout is, I think, even more about their power.

You see, when I sit in front of the desk, spatially, my position is on a par with the doctor’s. The computer must be on the side (otherwise the medic would not be able to see me) and the doctor’s attention is on me. Put differently, the doctor must engage in some action in order to turn their attention away from me – the layout of the surgery forces them to interact with me. Yes, it is the doctor’s office and desk but that never changes. Even if we’re both on a lamp and I lie down flapping my ears, the lamp is still the doctor’s and it was their decision that put us on it.  The crucial point here is that sitting behind the doctor’s desk, I sit in the same way as the medic and the position of the furniture suggests that our encounter is about our contact, as our positions, by default, make us look at each other.

It all changes when I sit at the side. Not only am I uncomfortable, but I am also sidelined. We are no longer positioned as the two important parties in the encounter. And this is precisely what happened when the Romanian doctor moved his chair in the story above. He must have understood it well (in contrast to the person who first put the patient at the side of the desk), so he shifted his position not only to talk only to me (and not the computer), but also to even out our positions. We both were at the side of the desk, looking at each other across its corner. What he did was an attempt to suspend his position of advantage. As much as I appreciated it, I also understood that unwittingly, he was also confirming what the side-desk layout does.

Now, do I think, doctors should now rush to change the layout of the surgeries*)? I think the question is moot, actually, as nobody will anyway. I also think there is considerably more to a good relationship with a doctor than a chair at the side of their desk. I just wish medics would stop the nonsense that moving me from behind the desk to its side was really a favour they did for me. It wasn’t at all. I also wish medics would occasionally reflect on what they do.

*) But yes, if it were up to me, I would ask medics to change the desk and the chairs around. And next time a patient comes in, I’d have them say: now, we’ll be able to look at each other more easily.

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