The Janus Principle and Your Medical Practice

Primary Care Blog

Janus is the Roman god of doors and gateways but also the god of beginnings. Interestingly, good beginnings are required for good endings. The Temple of Janus had doors facing east and west, which allowed illumination of the temple at the beginning and the end of the day. Most statues of Janus show him with two faces facing opposite directions. The Janus principle in your medical practice is the idea of creating a favorable beginning of the doctor-patient interaction, which culminates in a favorable ending.

How do you get off to a good beginning? It all starts with the first impression. There’s a world of difference if the doctor enters the room and launches into medical questions versus the doctor who uses the first few seconds to talk about some non-medical topic, such as the patient’s family, work, or last vacation. This information can be obtained by keeping social progress notes on the written chart or on the first screen of the EMR. Now the doctor demonstrates his interest in the patient and not an organ system, a diagnosis, or lab or X-ray report. You can be sure that this registers in a positive way with your patient and well worth the few seconds it takes to demonstrate caring for the whole patient.

Closing the office visit is the natural conclusion of every patient interaction. Every patient visit needs to terminate with a successful close. You will know you have closed successfully when the patient agrees to your advice, promises to take the medication, obtain the studies you suggest, or accept the surgical procedure you recommended. Most patients leave without any physical evidence of their commitment to the doctor. The close is intangible but you can recognize the signs of agreement or rejection very easily.

The Janus principle focuses less on rote formulas, such as ending each visit with, “Is there anything else I can answer for you today?” It does take into consideration the general tone and feel of the conversation with care and attention to begin well and to close well. If it is done well, you have buy-in from the patient and a greater likelihood of enhanced compliance from the patient and improvement in patient outcomes. You increase the buy-in if you learn to listen to what the patient says and pay attention to both verbal and non-verbal clues, which provide you with the feedback of the success of your close.

Doctors have the luxury of asking probing questions. I am always amazed at the depth of questions that I am allowed to ask in areas that no other person could ask another individual. After meeting a patient for the first time, I am able to ask about their personal life, their sex life, and their bowel habits. No other professional could possibly accomplish this except a physician. In order to be successful at asking probing questions, we must appear genuine and that we are caring and avoid making the patient defensive. The best probing questions are open-ended and not answered by mere yes and no questions. It is a far better question to ask how the chief complaint is impacting the patient’s quality of life rather than is the pain mild, moderate, or severe.

Next make sure to validate or acknowledge probing question that you ask. This can be a head nod or use the echo technique of restating the last phrase of the patient’s response to your probing question. For example, if I ask a man about his ability to engage in sexual intimacy with his partner and he responds that the problem is upsetting his partner. I would counter with “How is this upsetting your partner?” This clearly lets the patient know you have heard his response and you are paying attention to the discussion.

Psychologists point out that 70% of the population respond better to suggestions than to warnings. Nearly 80% of patients’ buy-ins are made emotionally and then they use logic to defend their behaviors. You might approach the close by asking the patient what they feel about the lifestyle changes you might be suggesting they make. If the patient agrees to the plan of action, you can ask for agreed upon goals. Perhaps you can ask the patient to join the YMCA or a local gym and commit to an exercise program with the goal of losing two pounds in the next month or before their next visit.

This brings the Janus close to a successful conclusion. You use the probing questions, provided the patient with motivation, and then receive their commitment and buy-in resulting in improved compliance.

Bottom line: We have less time to spend with patients because of the greater volume of patients that most of us are going to be seeing in the near future. We will have to be experts at communication in order connect with our patients which begins with great openings and positive closings. The Janus close starts with a good beginning and then has a happy ending. 

Neil Baum, MD

Neil Baum, MD, is Clinical Associate Professor of Urology, Tulane Medical School, New Orleans, LA, and author of Marketing Your Clinical Practice: Ethically, Effectively, and Economically, Jones Bartlett Publishers.