Curbside Consultation

The Doorknob Phenomenon in Clinical Practice

 

Am Fam Physician. 2018 Jul 1;98(1):52-53.

Case Scenario

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?

Commentary

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

Doorknob statements

Address correspondence to Justin Faden, DO, at Justin.Faden@tuhs.temple.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Gabbard GO. The exit line: heightened transference-countertransference manifestations at the end of the hour. J Am Psychoanal Assoc. 1982;30(3):579–598....

2. Marwick C. Survey says patients expect little help on sex. JAMA. 1999;281(23):2173–2174.

3. Bostwick JM, Rackley S. Addressing suicidality in primary care settings. Curr Psychiatry Rep. 2012;14(4):353–359.

4. Muzina DJ. What physicians can do to prevent suicide. Cleve Clin J Med. 2004;71(3):242–250.

5. Gutheil TG, Simon RI. Between the chair and the door: boundary issues in the therapeutic “transition zone.” Harv Rev Psychiatry. 1995;2(6):336–340.

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.

This series is coordinated by Caroline Wellbery, MD, Associate Deputy Editor.

A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.

Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.

 

 

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