Treating the "Doorknob Syndrome" in Office Visits

Picture this: You're 30 minutes behind on your appointments. You're just getting ready to leave an exam room when the patient says, "Can I ask you one more thing?" Begrudgingly, you say yes, hoping it's an easy question about vitamins or, perhaps, the art in the waiting room. Instead, the patient's face crumples and he says, "Is it normal for this mole to turn red and start to bleed?"

Sound familiar? Such late-breaking questions are so common they have their own name: the "doorknob phenomenon," sometimes called the "doorknob syndrome" or "doorknob effect." And while some time-management experts might want you to make the patient come back another time, that's not the best way to practice medicine.

Instead, here's how to get your patient to open up earlier in the exam.

1. Have some compassion. A lot of doorknob conversations come up because the patient was too embarrassed about the troubling symptoms to volunteer them during the actual exam. Sound silly? Put yourself in the patient's shoes. If you had a skin growth, erectile difficulty, or sudden bouts of depression, would you feel comfortable talking about it?
2. Work on your communication skills. Some doorknob conversations are the result of the doctor's demeanor. That is, a doctor who seems rushed or impatient can make a patient feel guilty about taking up time. Ask your family and staff about how you come across: Are you brusque? Rushed? Even slightly condescending? Such characteristics make it hard for patients to open and they will tend to hold their concern until the very end.
3. Let your patient talk. An oft-cited study from the 1980s found that physicians start interrupting their patients after 18 seconds in the exam room. Such a steamrolling "I'm-the-expert-here" approach may seem like the best way to cut to the chase, but in the end, it can be self-defeating. Why? A patient who can't get a word in edgewise during the formal exam may stick it in just as she's reaching the door. And if it's urgent, you're duty bound to deal with it, even if it throws your schedule off.
4. Let your patient talk some more. Once he's told you what his first issue is, ask, "Is there anything else?" in a pleasant tone of voice. That simple question may give your patient just the entry he needs to get to his underlying concern.
5. Encourage your patients to write. Some physicians hand out forms on which patients can write their three most pressing questions for the day before going in to the appointment. This can help patients focus their thoughts. It also may be easier for some patients to write "lump on neck" than it is to ask what may feel like a silly (or terrifying) question.
6. Draw boundaries when necessary. Obviously, a patient who confesses to suicidal ideation or has a troubling lump needs to be dealt with compassionately, no matter when in the interview the subject comes up. But some patients may try to get an extra issue addressed to avoid making another appointment (an understandable tactic given everyone's busy schedules). For cases in which you think the patient is trying to economize on appointments, have some stock answers ready, such as: "That's an important topic. Let's make another appointment so that I can give it my full attention." That lets your patient know you care, even if you can't address the issue that very day.