Thursday, December 09, 2004

The Doorknob Phenomenon

"Oh, by the way..." Medrants discusses the phenomenon of patients telling us a critical piece of information as they are literally walking out the door. Sometimes it's the main concern that motivated the visit. It immediately casts the whole assessment into a different light, and can make the correct diagnosis obvious (or wreck the diagnosis that you thought you'd already made).

Psychiatrists learn that words chosen in parting need special attention. New, significant topics might be first mentioned in the last few minutes, or as patients are reaching for their coats. Sometimes it's a bombshell. Sometimes patients have been struggling with a topic, and have been searching for a way to bring it up. It's called a resistance, and a defense mechanism, if the doorknob maneuver is used to avoid dealing with the issue. ("I should bring this up but I don't really want to get into it. There's no time to really talk about this now, right?") Shame and embarassment can contribute. Sometimes we have to wonder, is this a way to try to get more time and attention from the doctor?

During the visit, we're listening for what the patient says (and omits), the words chosen to say it, and the manner chosen to present it. We're taught to discuss "doorknob behavior" with patients, to probe doorknob issues. "I notice that last week you said something really important as you were just leaving. Can we explore that some more, right now?"

(update - of course, when the parting words are the first mention of domestic violence, as in the NYT article, then the doorknob is released, we sit again, and the next patient in the waiting room gets an apology. "Sorry, your doctor is running late." Now is a good time to have a nurse or a social worker available. More history is pursued, more details, and a safety plan is worked out. Then, more apologies to the next patient, who is waiting and wondering...)
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