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Submitted by KateM on


Yes, this rule has broad application!  Here's how it plays out in medical practice:

I am a much more efficient physician if you tell me, at the time you make the appointment who the patient is and what the concern (in general terms) is.

a) My Preparation - I can't have an intelligent discussion about something if I don't come prepared to the meeting.  I want to review your chart first.  I'm flattered that you think I can converse intelligently about every potential medical topic on the fly, but if you're coming in with something rare or unusual or out of my experience, I might want to look something up or run it by a colleague first (protecting your privacy, of course.)

b) Your Preparation - I know this is a sensitive topic for you (HIV testing, possible pregnancy, mental health concerns).  Even naming the words is a big step emotionally; it's easier to just request an appointment "for a personal topic."  But if you aren't ready to call it what it is, you may not be ready to hear what I recommend for it.

c) My Resources - When you say you need 10 minutes of my time, you may be underestimating what it actually takes for me to address your concern.  You may think I can write a prescription in a 10-minute appointment -- but evaluating why you need a prescription, and which prescription, and alternatives to consider might take much longer.   Or it might take 10 minutes of my time, but an hour of my assistant's time.  Only I can tell you how much time it will take me.

d) Your Resources - I know you hate to wait at the doctor's office.  And I hate to make you, and your fellow patients, wait.  If I know really what we're going to evaluate, I can do it more comfortably for you while I minimize the waiting time of patients downstream of you.  If we both come prepared, we might be able to get it done in one appointment, rather than having to schedule 1-2 additional appointments, which require you to miss more work and pay more money.   I appreciate how you only want to take 10 minutes of my time, but if I need to tell you that you have cancer, you will be glad that I insisted that we allot an hour.

mfculbert's picture

This helped clarify the way I can use Stackhouse in my leadership as well.  

gpeden's picture

"...I appreciate how you only want to take 10 minutes of my time, but if I need to tell you that you have cancer, you will be glad that I insisted that we allot an hour..."

While I understand your message here is efficiency, to it  comes across to me quite harsh and unfeeling. A whole hour to tell me I have cancer?  Glad you *insisted*? Yikes.

 If you don't mind me asking - what is your DISC profile (I am going to take a guess at high-D high-C?). I would recommend weaving a bit more compassion into your delivery.



DISC 7511

GlennR's picture

George, she wasn't saying that to the patient. She was explaining why she needed more than 10 minutes. I would think any patient would want to have more than 10 minutes with the physician after the initial diagnosis of any catastrophic illness.

It's not that she's going to take an hour to tell a patient that cancer is present. There's going to be a few minutes of shock, perhaps more of tears, then there might be a discussion of treatment options and answering whatever questions that the shocked patient and caregiver might have. Will it take an hour every time? Probably not. But having gone through this twice with both of my parents, I can tell you we appreciated the fact that the two specialists involved both were compassionate enough to make sure all of our questions were answered.

KateM's picture
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Glenn's right:   The above 4 reasons reflect my internal mental machinations when someone asks, "Do I have to say what the appointment is for?"  (It rarely comes up: most patients don't know, or think to ask, how long I've allotted on my schedule for their issue.  Mostly they just want to know when their appointment time is.)  Rarely, a patient will outright ask me, "Hey, why...?" and I'm delighted to explain, but I do it in much gentler/oblique language, like: "Sometimes we have to deliver unexpected bad news to a patient or family, and that's not something we want to rush."

George has me pegged correctly -- DISC 7215.   (It shows, doesn't it?)  It's not an uncommon profile for physicians, and those of us with this behavior pattern can come across as condescending or brutish.   I'm always trying to be compassionate and empathetic -- and one of the best ways I know to do that is to take the time pressure off me, by allotting adequate time for each patient.  Otherwise, I'm checking my watch with my hand on the door (and other annoying doc behaviors) because I've been too tightly scheduled. 

(We can quibble about how much time "should" be allotted to deliver a catastrophic diagnosis and plan subsequent care, but this is Manager Tools, not Medical Tools.)

I've never really tried to explain methodically why I need to know the patient's concern, but reading Mark's "Stackhouse Grazing Rights Rule" really crystallized it for me.  That's why I love his stuff - I'll intuitively have a concept I'm trying to communicate, then Mark will distill it down, into this little portable nugget of wisdom.

It sounds like my first attempt at systematic explanation of this process came across as harsh, and I apologize.

Mark's picture
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Really exceptional post, KATEM.  Thank you.

For those of you who aren't licensees, I send out a weekly note to all of them called "Things I Think I Think".  I mentioned this rule, Stackhouse Grazing Rights.  It's a personal rule.  I don't have enough data to recommend it.

Basically, it says, you can't ask for my time as a direct without telling me what you want.  (The name comes from a line in the movie The American President).

KATEM posted in response to that.  And this will be one of the best posts of 2013.