Friday, May 27, 2011

90 Second Rule

Any med student or doctor who's ever seen a patient knows that patients can talk a lot. As a physician, a necessary skill is learning to redirect patients and get them to actually answer your questions, rather than telling you about the time they went to Morganville for a new heel for their shoe with an onion tied to their belt (which was the style at the time). I see about twenty patients a day, so if I let them all tell their stories every day, I'd have to basically just live at the hospital.

In residency, there were a few residents who just didn't seem to get the hang of redirecting patients. Whenever they'd go into the examining room of a talkative patient, they'd inevitably need a "rescue page" or else we'd never see them again. Whatever else could be said about me, I have never ever required a rescue page. I am excellent at rudely interrupting patients and getting answers out of them.

As an intern, we got a lecture about how Interrupting Patients is Bad. About how doctors interrupt patients too damn much and we miss out on information. The lecturer said that there was some study where doctors were actually observed talking to patients, and the longest a patient EVER went on for without being interrupted, like the World's Record, was 90 seconds. So really, you shouldn't interrupt your patients because they're not going to talk longer than 90 seconds.

What is wrong with this advice?

Well, if you have multiple questions you need to ask the patient, allowing them to go on for about 2 minutes per question, sometimes without actually even answering the question you asked, takes for freaking ever. So patients must be redirected. That said, the 90 seconds thing ACTUALLY WORKS. This is when it is useful:

Say you are done seeing a patient. They have answered all your questions and you have done everything you can for them. Or it is the weekend, they're stable, and basically, they just want to ramble on for a while... except you have 50 other patients to round on and you're starting to panic that you won't be able to escape without being rude. What you do is: you let them talk. You just stand there, smile, and do not say a word. Do not prompt them in any way. Don't even say "uh huh." Just smile politely. You can probably nod, but it's better if you don't. After about 90 seconds or usually less, they WILL stop talking. And when they do, you bid them farewell and quickly get the hell out of there.

This has worked for me many times. I did it a few days ago with a woman who honestly seemed like she would never ever run out of steam talking about god knows what, but sure enough, she fizzled out after about a minute. Just try it.


  1. Does it work for nurses too? I don't know how many times patients are rambling about important things like, Crisco is better in pie crusts, as we are taking baby-steps backwards towards the door looking for a chance to say, call me if you need anything and stepping out. OK, 90 seconds I'll try it.

  2. My idol, the great Oscar London, M.D., advocated that when calling a patient you pretend the phone is a bomb that will explode if it isn't hung up within 2 minutes, and allow the tone of urgency in your voice to be quite clear.

  3. Thank you! This sounds so much better than slowly edging my way out of the room as they continue to talk after ignoring other cues that we are done. My mistake is that I continue to give feedback that I'm engaged in listening.

    So far, it is nearly always my "VIP" patients, including older physicians, who think I have 10 or more minutes to listen to them discuss something completely unrelated after we have wrapped up a visit. Regular Joe types, even talkative ones, tend to respect my time and understand that I have others to see. They can always have me paged if they need anything else.

  4. NP: I think it works for everyone....

    Grumpy: Great idea! i think I kind of do that anyway. If they start talking too much, I immediately start getting antsy. Although when I call patients/family at work, I just have notes in front of me and do work while they babble on.

    PGYx; Try it and tell me how it works. With a VIP patient, it's harder though. You may need to set up a pager alarm to get you out of the room.

  5. "Give me five bees for a nickel, you'd say!"

  6. Huh, wow. I wonder if that works outside of the hospital as well, hmm. hahaha.

  7. Surely I can't be the only one to have encountered excessively loquacious doctors too, though? It's one thing if you need to be done in a hurry and direct the line of conversation accordingly. But I have had a few doctors (mostly internal medicine or family practice types, though there's one notable OB I can think of) just GO OFF on a spiel about something and I'm thinking "uh huh uh huh yeah I know we covered this in high school health class...I have about 20 more questions could you please hush so I could maybe get ONE in before you run out the door?" It's clear that they enjoy "patient education" but sometimes it's redundant. For instance, if I just had my third baby and my first two were breastfed for over a year each, I probably don't need the WHOLE run-down on breast vs bottle, Dr. Talky. BTW, my kid is in the NICU soooooo... Anyhow right now I'd like to talk about my spinal headache please? PLEASE? oh...goodbye then.

  8. Oh yeah, I'm with T. I had a doctor who was supposed to be doing an initial full exam who WOULD NOT SHUT UP. I could not get a word in edgewise. It would be bad if we were talking about medicine but hey-- that health stuff NEVER CAME UP.

    "Oh, your name is Moose? I knew a Moose back when I lived in Buttmunch, Ohio, she was the church organist at Our Lady of Perpetual Obligation, and she made the best brownies and brought them every Sunday, and all the kids thought she was the best, everyone clammored to turn pages for her or sing in the choir. Do you sing? I used to sing in choirs until I went to med school and then I didn't have the time. Of course now I'm also married with 2.5 children, would you like to see their pictures? My youngest is just learning to walk and recently started chewing on high voltage wires. She looks so much nicer with curly hair," (pauses for an actual breath)

    Me: Hey, doc, I'd like to discuss my blood sugar control, and-

    "I've been reading that they dont' think sugar is related to how wired kids get, but I don't believe it. My middle kid at 17 cookies the other day and then colored dinosaurs all over the dining room walls with Sharpies. I had to spend 4 hours scrubbing trying to get that stuff off. There's so little stuff that will work on indelible markers. I suppose I shouldn't keep them in the house with small kids but I have so many other uses for them!" Blah blah blah blah.

    And then eventually, "So come back in 3 months so we can see how you're doing then!"

    Yeah. I don't think so.

  9. I will let you know how it goes. I may not care for so many VIPs once I start residency in a more urban system but it's a quality program so maybe I'm wrong. This year I've helped to care for many docs and even a Nobel laureate who was so unassuming I could never have distinguished him from any other patient of the medically compliant and non-cracked out variety. My very first patient as an intern was a retired physician who firmly corrected me when I made the mistake of first calling him "Mr." Jones.

    I do tend to spend more time with physician-patients as they tend to have more questions about details of their care, but once they start chatting like it's a social visit it's time for me to go. Like the rest of my patients, they should expect the highest quality care I can provide and answers to all their questions but I have no time to spare for a social visit beyond the extra time I already spend with them.

  10. Very good advice. I'll remember this.