Behavioral Health and the Doorknob Phenomenon

It happens every day, particularly in primary care practices. The patient shows up for an appointment, the provider does an examination, they discuss any questions, and the medical record is dutifully updated. Then, the patient gets up to leave, but before exiting, turns and says those infamous four words: “Just one more thing…”

The “doorknob phenomenon” has been written about going back decades in popular media. It was colloquially referred to recently as the “4 words that drive your doctor up a wall.” Some provider organizations even advise their members on how to navigate it. And yet, it persists.

It doesn’t always happen for one single reason. Patients with a long list of concerns may “bury the lede” and forget until the end. Or they know the medical team is running behind and feel pressured to prioritize other issues. Or they avoid a topic because of embarrassment or anxiety. The reasons vary, but it’s bound to happen to every provider from time to time.

In a typical appointment, providers may only have about 18 minutes with each patient, and that includes time for a physical exam, discussion, and satisfying the voracious needs of the EMR system. So, it’s no wonder that both patients and providers often feel rushed.

But sometimes the point or question raised with one foot out the door may be the most important one, and very often, it has a behavioral health component. There are strategies providers can use to help prevent the doorknob phenomenon or address it effectively when it arises: 

• Signal a judgment-free zone. Assure patients that discussing behavioral health issues is part of medical care and it’s a good idea for everybody. Try something like: “I like to take a minute with all my patients to check in about their behavioral health and ask about things like mood, alcohol use, sleep issues, and so on.”
• Front-load and prompt the patient. Some patients have previous notes or data in their medical records (e.g., diagnostic history, medication for anxiety or depression, struggles with substance use) that suggest it’s worth inquiring about their behavioral health status. So, something like, “Since your last appointment, have you experienced a change in symptoms related to …” can prompt a more meaningful conversation earlier in the visit.
• Advise for next time. OK, the doorknob question happened. No big deal. But let the patient know it’s helpful to jot down any concerns ahead of time using a note-taking app or to send a quick message through the EMR if there is something specific they want to address.
• Provide behavioral health support. Let the patient know they have options, including a referral to Concert Health to address behavioral health concerns directly. “Based on your symptoms, it sounds like you might be a good candidate for collaborative care. I’d like to refer you to a behavioral health clinician who can work with you directly on the things we’ve talked about. I’ll still be able to track your progress and monitor any medications. Would that be OK?”

If the doorknob question makes providers grumpy, it’s because a patient has just raised something potentially important and the provider likely has to choose between:

• Scheduling a separate appointment, which could take awhile to get on the calendar
• Extending the appointment to understand the issue more fully, risking delays to the rest of the day’s schedule
• Writing a quick prescription without a deeper understanding of the issue(s) or its causes

None of the options is ideal. When the provider instead refers the patient to collaborative care with Concert Health, they can be sure that a scheduler will reach out directly to the patient, and the patient will get an appointment within days. The collaborative care clinician will have the time to address behavioral health more thoroughly than a typical 18-minute visit allows. And they can be sure that a psychiatric consultant will be available to review and advise on all medications.

Oh, and just one more thing… The referring provider stays connected throughout, with Concert Health notes and recommendations flowing directly into the EMR and surfacing at the right moments.