The impact of first impressions during a physician visit:
Whenever I enter a room with a patient in it, I try to stop in the doorway, and before anything else happens, I take in the scene. I want a look before my impression can be biased by information or personality or anything but the overall clinical picture. Most doctors do this, or try to. It’s called the doorway survey, and it can be the most important moment of your appointment. That moment in the doorway provides the context for everything else that happens, steering your doctor as he or she tries to figure out which parts of your story to pay attention to, which parts to ignore, which parts need explanation, and which parts speak for themselves.
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Most of the residents graduating this year from my residency program are trying to do something away from clinical medicine, like Information Technology or education. I think the first thing they learned at the doorway is “I gotta get out of this lawyer-raped profession and do something that doesn’t involve seeing plaintiffs, I mean patients”.
Couple of comments:
1. In most cases, patients have been sitting in the exam room for quite some time before you get there, after some additional time in the waiting room. They’ve already encountered desk staff, nurses, and perhaps a resident before you step in. Each of those encounters has some bearing on that patient’s attitude, long before you get a chance to evaluate that “first” impression.
2. I would also be curious to know how a patient can make a great first impression when most doctor’s offices are about as soothing as your average Chuck E. Cheese. Additionally, I’ve been in several which place the patient with his/her back to the door (I assume in the interests of privacy). So a doctor walks in and sees the patient’s back. Not sure what kind of “overall clinical picture” you’re going to gain from that doorway survey.
My first impression is usually made with my nose, rather than my eyes.
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Man, you guys seem a little jaded tonight.
Perhaps the first impression is made in the hospital during an admission?
One of the professor I really respected in residency used to call certain presentations janitor diagnoses as the diagnosis was so obvious (systemic sclerosis) that the janitor could have made it walking past the patient.
The first impression is very valuable, but should be used cautiously so as not to fall into the trap of tunnel vision. (this homeless crack user who smells is most likely just having cocaine associated chest pain and not a PE)
Something else that is simple, but so important is the chief complaint in the patient’s own words. Not a retrofitted chief complaint, but the patient’s actual answer to why they came in, “Because she made me”, “I want to get detox” (a CC I got last night for osteomyelitis of the foot which was apparently of secondary concern to the homeless gent) “I have trouble going to the bathroom” (diverticulitis).
The CC can give clinical, social, and educational information. No morning report case is correctly presented without one.
b
As an Er doc, I know exactly that ‘doorway moment’. It reminds me of an attending whose entire charting used to be: “Looks good from the door” (pre-HCFA rules). He told me that “Doesn’t look good from the door” is a very bad sign indeed. I can tell you of the many times I have walked into a room, stopped dead in my tracks, and left without a word to get the charge nurse, respiratory therapy, etc.
It’s just that instant of perception: Sick or not-sick?
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