The Invisible Exit Sign

On the wooden door that leads from my examining room corridor out to the waiting room, a big red sign at eye level reads EXIT. This sign is invisible. Time and again, patients trying to leave walk up to the door, stare at the sign, then turn left, until somebody rescues them and shows them out.

The trouble actually starts sooner. When patients exit the exam room itself, another red sign directly opposite, also at eye level, reads EXIT, with an arrow pointing to the right. This, too, is invisible. At least half of the patients turn left and soon bump into a blank wall, on which I have placed a sign reading, THE WAY OUT IS BEHIND YOU. They ponder this sign—and the blank wall behind it. After a short pause for processing, the message gets through and they turn around.

Few of my patients are blind or illiterate, so why are my signs invisible? The reason is their unfamiliar context. When you don't know where you are, you can hardly see anything. To process data, our senses need the help of background cues.

How much this matters becomes obvious on trips abroad. When people speak to us in a strange language, for instance, we often can't even pick up words we know. Mumbling happens everywhere, but back home we can understand it because we get the rest of the sentence, know what facial expressions and gestures mean, and so forth.

Patients in our offices are travelers in strange lands. We are so at home that it takes effort to realize how lost the patients can get in matters of procedure and etiquette, not to mention medical advice.

Perhaps we and our staffs should think of ourselves as folks who greet tourists at a Visitors Bureau in a country where the people talk funny, act weird, and drive on the wrong side of the road. Here are a few tips:

▸ Checking in. People who are not experienced in HMO-land can be pardoned for assuming that if they call their primary care physician and he or she promises to send a referral, then the doctor has done the job. We know better, of course, but it's fair to be gentle rather than huffy with patients whose referrals have not yet been sent in.

▸ Taking a seat. In each of my exam rooms, in addition to the table, I have a stool and a chair. I sometimes enter to find a patient leaping to her feet and stammering, "Sorry, I'm in your chair!" It helps if the staff member who bring patients into the room tells them where to sit and shows them where to hang clothes. (Door hooks also are invisible.)

▸ Putting on a gown. That you should leave a gown open in back is not self-evident, especially if you're worried about your front. Proper gowning takes both instruction and demonstration. (Even that may not be enough. At my most recent colonoscopy, they told me to put on two johnnies, an upper and a lower—and showed me, too—but I still got them wrong. Both of them.)

▸ Lying down. As everyone knows, if you tell a patient to lie on his back, he will lie on his stomach. If you ask him to lie on his left side, he will turn right.

▸ Knowing what we do for a living. Just because we know what diagnoses we handle and which procedures we perform doesn't mean that our patients know. They ask me things like, "Do you take care of warts?" Even more often, they apologize because their rash got better or their bleeding spot fell off before they came, assuming that anything less than cancer or complete misery is a waste of my time. It doesn't take much effort to assure them otherwise, or to unintentionally embarrass them by acting bored and dismissive.

▸ Going for samples. Unless I tell them emphatically to stay put and that I will be right back, patients who see me leave to get samples are often overcome by fear of abandonment and come running half-clothed into the hall.

▸ Understanding instructions. When do you put the cream on? Must you wait after washing? Do you leave it on, or wash it off? And so on and so forth. Many of these directives, self-evident to us, are anything but that to our visitors.

▸ Exiting. You already know about that.

The bottom line is that when you don't know where you are, almost anything, no matter how simple and obvious, can be inscrutable. Or invisible.

On the wooden door that leads from my examining room corridor out to the waiting room, a big red sign at eye level reads EXIT. This sign is invisible. Time and again, patients trying to leave walk up to the door, stare at the sign, then turn left, until somebody rescues them and shows them out.

The trouble actually starts sooner. When patients exit the exam room itself, another red sign directly opposite, also at eye level, reads EXIT, with an arrow pointing to the right. This, too, is invisible. At least half of the patients turn left and soon bump into a blank wall, on which I have placed a sign reading, THE WAY OUT IS BEHIND YOU. They ponder this sign—and the blank wall behind it. After a short pause for processing, the message gets through and they turn around.

Few of my patients are blind or illiterate, so why are my signs invisible? The reason is their unfamiliar context. When you don't know where you are, you can hardly see anything. To process data, our senses need the help of background cues.

How much this matters becomes obvious on trips abroad. When people speak to us in a strange language, for instance, we often can't even pick up words we know. Mumbling happens everywhere, but back home we can understand it because we get the rest of the sentence, know what facial expressions and gestures mean, and so forth.

Patients in our offices are travelers in strange lands. We are so at home that it takes effort to realize how lost the patients can get in matters of procedure and etiquette, not to mention medical advice.

Perhaps we and our staffs should think of ourselves as folks who greet tourists at a Visitors Bureau in a country where the people talk funny, act weird, and drive on the wrong side of the road. Here are a few tips:

▸ Checking in. People who are not experienced in HMO-land can be pardoned for assuming that if they call their primary care physician and he or she promises to send a referral, then the doctor has done the job. We know better, of course, but it's fair to be gentle rather than huffy with patients whose referrals have not yet been sent in.

▸ Taking a seat. In each of my exam rooms, in addition to the table, I have a stool and a chair. I sometimes enter to find a patient leaping to her feet and stammering, "Sorry, I'm in your chair!" It helps if the staff member who bring patients into the room tells them where to sit and shows them where to hang clothes. (Door hooks also are invisible.)

▸ Putting on a gown. That you should leave a gown open in back is not self-evident, especially if you're worried about your front. Proper gowning takes both instruction and demonstration. (Even that may not be enough. At my most recent colonoscopy, they told me to put on two johnnies, an upper and a lower—and showed me, too—but I still got them wrong. Both of them.)

▸ Lying down. As everyone knows, if you tell a patient to lie on his back, he will lie on his stomach. If you ask him to lie on his left side, he will turn right.

▸ Knowing what we do for a living. Just because we know what diagnoses we handle and which procedures we perform doesn't mean that our patients know. They ask me things like, "Do you take care of warts?" Even more often, they apologize because their rash got better or their bleeding spot fell off before they came, assuming that anything less than cancer or complete misery is a waste of my time. It doesn't take much effort to assure them otherwise, or to unintentionally embarrass them by acting bored and dismissive.

▸ Going for samples. Unless I tell them emphatically to stay put and that I will be right back, patients who see me leave to get samples are often overcome by fear of abandonment and come running half-clothed into the hall.

▸ Understanding instructions. When do you put the cream on? Must you wait after washing? Do you leave it on, or wash it off? And so on and so forth. Many of these directives, self-evident to us, are anything but that to our visitors.

▸ Exiting. You already know about that.

The bottom line is that when you don't know where you are, almost anything, no matter how simple and obvious, can be inscrutable. Or invisible.

On the wooden door that leads from my examining room corridor out to the waiting room, a big red sign at eye level reads EXIT. This sign is invisible. Time and again, patients trying to leave walk up to the door, stare at the sign, then turn left, until somebody rescues them and shows them out.

The trouble actually starts sooner. When patients exit the exam room itself, another red sign directly opposite, also at eye level, reads EXIT, with an arrow pointing to the right. This, too, is invisible. At least half of the patients turn left and soon bump into a blank wall, on which I have placed a sign reading, THE WAY OUT IS BEHIND YOU. They ponder this sign—and the blank wall behind it. After a short pause for processing, the message gets through and they turn around.

Few of my patients are blind or illiterate, so why are my signs invisible? The reason is their unfamiliar context. When you don't know where you are, you can hardly see anything. To process data, our senses need the help of background cues.

How much this matters becomes obvious on trips abroad. When people speak to us in a strange language, for instance, we often can't even pick up words we know. Mumbling happens everywhere, but back home we can understand it because we get the rest of the sentence, know what facial expressions and gestures mean, and so forth.

Patients in our offices are travelers in strange lands. We are so at home that it takes effort to realize how lost the patients can get in matters of procedure and etiquette, not to mention medical advice.

Perhaps we and our staffs should think of ourselves as folks who greet tourists at a Visitors Bureau in a country where the people talk funny, act weird, and drive on the wrong side of the road. Here are a few tips:

▸ Checking in. People who are not experienced in HMO-land can be pardoned for assuming that if they call their primary care physician and he or she promises to send a referral, then the doctor has done the job. We know better, of course, but it's fair to be gentle rather than huffy with patients whose referrals have not yet been sent in.

▸ Taking a seat. In each of my exam rooms, in addition to the table, I have a stool and a chair. I sometimes enter to find a patient leaping to her feet and stammering, "Sorry, I'm in your chair!" It helps if the staff member who bring patients into the room tells them where to sit and shows them where to hang clothes. (Door hooks also are invisible.)

▸ Putting on a gown. That you should leave a gown open in back is not self-evident, especially if you're worried about your front. Proper gowning takes both instruction and demonstration. (Even that may not be enough. At my most recent colonoscopy, they told me to put on two johnnies, an upper and a lower—and showed me, too—but I still got them wrong. Both of them.)

▸ Lying down. As everyone knows, if you tell a patient to lie on his back, he will lie on his stomach. If you ask him to lie on his left side, he will turn right.

▸ Knowing what we do for a living. Just because we know what diagnoses we handle and which procedures we perform doesn't mean that our patients know. They ask me things like, "Do you take care of warts?" Even more often, they apologize because their rash got better or their bleeding spot fell off before they came, assuming that anything less than cancer or complete misery is a waste of my time. It doesn't take much effort to assure them otherwise, or to unintentionally embarrass them by acting bored and dismissive.

▸ Going for samples. Unless I tell them emphatically to stay put and that I will be right back, patients who see me leave to get samples are often overcome by fear of abandonment and come running half-clothed into the hall.

▸ Understanding instructions. When do you put the cream on? Must you wait after washing? Do you leave it on, or wash it off? And so on and so forth. Many of these directives, self-evident to us, are anything but that to our visitors.

▸ Exiting. You already know about that.

The bottom line is that when you don't know where you are, almost anything, no matter how simple and obvious, can be inscrutable. Or invisible.