While working on my PhD dissertation a few years ago I became intrigued by the idea of liminality. In cultural anthropology, liminality (from the Latin līmen, meaning “a threshold”) is the ambiguity or disorientation that occurs in the in-between or transitional phase of social rituals.
Healthcare researchers have begun to use the concept to explore the experience of living with illness and chronic disease. For my research, I explored the spaces I move through at the hospital through the lens of liminality to help me make sense of interactions between practitioners and patients.
Recently I had an experience as a patient that made me think again about liminality in healthcare settings. I arrived for an appointment to get the results of an ultrasound. As I sat in the waiting room, I became aware, once again, that worry and anxiety are constant companions in hospital waiting rooms. I watched the other patients and tried to imagine their stories.
In time, a woman called my name and asked me to follow her to the exam room to meet the doctor. She had no uniform to indicate her role. She did not introduce herself by name or position, and the small ID badge around her neck was impossible to read as we walked. As we proceeded down the hall, she asked me how I was. I responded with a courteous but brief “fine,” assuming this was polite banter to fill the time as we made our way to the exam room.
She glanced at my chart and asked whether I was there to get test results. I said yes, and then she asked again: “How are you?” Our interaction suddenly seemed unclear and I was confused about how to respond. Was this more than social chit-chat? Why was she asking again? Did she expect me to say more about how I was feeling? I mumbled something once more about being fine; at this point we reached the exam room and she left me to wait for the doctor.
Our brief interaction left me unsettled. I wondered who she was — a nurse, a medical resident, or perhaps, a secretary? If she was the clinic nurse I wondered why a skilled professional was spending her valuable time escorting patients to exam rooms. If her role was to identify patient concerns before they see the doctor, this was never explained.
It got me thinking about the impact a seemingly innocent question such as “how are you?” might have in the context of a health care visit. While we use this question in daily life as a greeting ritual, social lubricant, or invitation for further conversation, it takes on a more complex meaning during a clinical encounter. In these moments patients are vulnerable and focused on their health status — hoping that things truly are fine. In an oncology waiting room, for example, patients and their families might be trying to hold back a flood of worries and anxieties that accompany a frightening diagnosis or the prospect of invasive treatments.
I think a few things would be helpful in those ambiguous moments. The first is for health care professionals to introduce themselves and tell patients what their role is. The woman who escorted me could have said, “Hi, my name is Maureen and I’m the nurse who works with Dr. G. I check in with patients before he arrives to ask if they have any concerns.” That would provide context on who she is and what she is there to do. It seemed to me that the offer of extra support is something patients and families visiting the clinic that day might really need.
This got me thinking about the #hellomynameis campaign in the UK, started by doctor and cancer patient Kate Granger. The campaign emphasizes the role of simple introductions when providing care. Following her own experiences in the hospital Granger writes,
It felt incredibly wrong that such a basic step in communication was missing. I firmly believe it is not just about common courtesy, but it runs much deeper. Introductions are about making a human connection between one human being who is suffering and vulnerable, and another human being who wishes to help. They begin therapeutic relationships and can instantly build trust in difficult circumstances. In my mind #hellomynameis is the first rung on the ladder to providing truly person-centred, compassionate care.
As healthcare providers and therapists, we should remember that hallways and waiting rooms are in-between zones – they exist between the “public” spaces outside the hospital and the “private” spaces inside. When I greet a patient in the waiting room now, I try not to ask “How are you?” as I assume the patient might find my inquiry confusing: Is she making polite chit-chat or is she starting the counselling session? I hope that chatting about the weather or their journey to the hospital provides a more neutral way to transition from the outside to the inside.
In thinking about my recent clinic visit, I realized that I also experienced a moment of grace. As the doctor entered the exam room, his hand still on the doorknob, he sidestepped social niceties and announced immediately, “The test looks fine. Everything is good.” In doing so, he brought a welcome and abrupt end to the anxiety I was feeling and smoothed the way to other conversation – that could include social pleasantries and discussing the specifics of my situation. At the end of the visit, after releasing me from the need for further medical surveillance, the doctor said, “We’re here if you need anything in the future” which made me feel both acknowledged and cared for.
This experience reminded me, on a personal level, that healthcare settings are full of in-between spaces and ambiguous interactions. One of our jobs, as practitioners, is to pay attention to these transitional zones and try to navigate them as gracefully as possible.