The Doorknob Phenomenon in Clinical Practice
Am Fam Physician. 2018 Jul 1;98(1):52-53.
A 42-year-old woman returned for a follow-up visit to discuss ongoing management of migraine headaches. She looked somber as I entered the examination room, and she quickly said, “This new medicine is no good, either!” She reported that she had dutifully taken it as prescribed for the past month, yet she had continued to experience headaches on a nearly daily basis. I reviewed her headache log, and we discussed the situation. She was clearly having a very difficult time tolerating her pain. She finally agreed to try a new medication and to follow up soon. As she was leaving, she turned back to me and said in an exasperated voice, “If this doesn't work, I may just kill myself!” Is it appropriate to prolong the session to discuss this comment? Why do patients always seem to say things or ask questions when they are leaving the examination room?
By definition, the doorknob phenomenon or doorknob statement occurs when patients wait until the last moment in the clinical encounter—often while the physician is grasping the doorknob to exit the examination room—to utter something that, not uncommonly, provides crucial information. Physicians must then determine whether to pursue this new information immediately or to defer the new issue until the next visit.
The doorknob statement has been called an “exit line” to highlight its dramatic effect. It results in a cliffhanger—a moment of uncertainty about what will happen next.1 Physicians must decide quickly whether to address this new issue, thereby disrupting their tight schedule, or to say something like, “That sounds very important, but we'll have to discuss it when I see you next. Perhaps we can schedule a sooner follow-up visit.” In the initial moment of surprise, there is often a sense of powerlessness because the patient's comment occurs at the edge of the routine clinical visit in both space and time. Physicians' reactions to such unexpected comments may range from frustration to annoyance, resentment, or even anger. Remaining empathetic after being caught off guard will allow physicians to choose an appropriate response.
UNDERSTANDING PATIENT MOTIVATIONS
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6. Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing patients' unmet concerns in primary care: the difference one word can make. J Gen Intern Med. 2007;22(10):1429–1433.
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