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Dear Bill Missed Appointments

Q: If someone misses their appointment, how should we communicate with that patient? Any specific questions to ask this person upon contacting them, either by CA or DC?

A: The short answer? Use the telephone. Ask if they’re okay since you were expecting them at such in such a time.

The long answer is considerably longer. But here goes.

Missed appointments are merely symptoms. Ferreting out the correct meaning of the symptom not only varies from patient to patient, but from office to office. Instead of asking questions in the hopes of producing a confession out of the patient, here are some questions you could ask yourself:

• Did I explain and did the patient understand how I arrived at their particular care recommendations?

• Did I explain and did the patient understand how each visit builds on the ones before?

• Have I explained and do patients acknowledge that discontinuing care upon the immediate cessation of symptoms predisposes them to a relapse?

• Have I explained what patients should do when they’ve had enough care and want to discontinue?

• Have I made it possible for patients to discontinue their care guilt- and shame-free?

• Do I respect patients even if they value their health differently than the way I do?

• Do I have any interest in receiving referrals and subsequent reactivations from patients I see?

As you can see, missed appointments have far-reaching implications. How you deal with this issue reveals more about you and your intentions, than the patients who miss!

Presenting Your Care Recommendations

Chiropractors who routinely offer every patient the same three-times-a-week-for-the-first-four-weeks, and then two-times-a-week, etc. have some serious issues to reconcile:

It’s made up. This scripting, often memorized mindlessly by an entire generation of chiropractors dates back to the early efforts of Dr. Jim Parker. That doesn’t make it intrinsically wrong. But just realize it’s made up. It’s not a very powerful place to stand.

It’s fortune telling. You’re officially clueless as to how many visits will be needed, how frequent the visits should be and when they can be cut back. It may please the patient, but it’s a lie. How do you know how this particular patient will respond? You don’t.

It’s one-dimensional. Will the patient follow your recommendations? Will they perform other duties outside your office that can affect the speed of their symptomatic relief? Will they exercise, eat better and look for a less stressful job? What patients will or won’t do, regardless of what they promise, can be a significant factor in the equation.

It’s egotistical. These one-size-fits-all recommendations not only treat patients as mere mechanisms, it projects the attitude that you will single-handedly “fix” them. That may bolster your ego. It may even produce patient admiration. But it’s an approach that makes you the hero and obscures the fact that they’re doing the healing, not you.

Explaining the Cumulative Effect of Adjustments

To get drugs to work, most require more than a single pill. If you want to lose weight you’ll need to skip more than one dessert. If you want to bulk up it will take more than one or two visits to the gym. If you want to form a new habit you’ll need to persist for weeks and weeks. How many golf balls would you need to hit to embrace a new swing?

You get the point. You’ll probably want to link the need for repeated adjustments to something the patient is already familiar with.

Discontinuing Care Predisposes a Relapse

Chiropractic virgins in particular drag in their symptom-relief-only mindset that they’ve acquired by a lifetime of being steeped in the medical model. And since patients, on their first exposure to chiropractic, enter your office with the motive of visiting your office on a periodic basis for the rest of their lives, you’ll need to be patient. I assert there is little you can say or do to overcome this one. They must do it their way (discontinuing care once they feel better) a couple of times or so before they surrender to the fact that they have a problem that will require a some type of ongoing supportive care to avoid flare-ups.

Thus, the strategy isn’t based on the effort to convince them otherwise (they’ll have to prove it to themselves), but rather to better insure that they’ll return to your office when it happens rather than have you send their X-rays down the street because they’re too ashamed to face you again. You were right. They were wrong. Human nature being what it is, it’s just easier to never provide you with the opportunity for an “I told you so.”

When Patients Want to Discontinue Care

You probably have the procedures for embracing a new patient down cold. But few offices have a Goodbye Procedure. This is where some real breakthroughs are possible!

It’s well known that “once you go to a chiropractor you have to go for the rest of your life.” Yet few chiropractors are brave enough to face this 800 lb gorilla in their office, preferring to find the secret words that will seduce patients so they’ll never leave.

It hasn’t worked.

Because of this, many patients miss appointments as a conscious or unconscious way of announcing that they’ve had enough. How else can they? If they pull you aside after adjusting them, they figure one of two things will happen:

1. You’ll try to talk them out of it.
2. It’ll break your heart and reduce to tears.

It’s not pretty. So the easiest strategy for patients is to miss an appointment, hide behind caller ID and hope someone with some social skills (your CA) will break it to you without you going ballistic with anger or turning into a quivering mass. All this because of two things: 1) You care about their health more than they do, and 2) You haven’t explained how to extricate themselves from your office.

Now sometimes a missed visit has a more benign cause. A sick child prompted a change in routine. The boss is in town and needs a last minute report. A traffic jam has made her 45 minutes late for not only your office but also the entire evening routine. The list is endless. Grouse about the lack of social graces to call and let you know, but that’s the price you pay for working with the public. Some patients are considerate and others are not.

Making Your Practice Guilt- and Shame-Free

Guilt and shame are fascinating emotions. There’s the guilt thing, “I know I should care about my health more, but I have other pressing demands right now.” And there’s the shame thing, “I guess I should have done what the doctor suggested. She was right. I can’t bear to face her now.”

Both guilt and shame are emotions you helped produce by how you showed up with patients. By treasuring their health more than they do. By assuming that your professional standing is somehow jeopardized by poor patient follow through. Sadly, by holding on so tightly you end up pushing patients away. You’re correct. But you have an underperforming practice and patients unwilling to put their reputations on the line by vouching for you to their friends you could probably help.

Respecting Patients Anyway

We’ve each been granted the free will to maintain and optimize our soul temple, or to abuse and neglect it. This is something implicitly granted by our Creator. Baring ignorance, if you’ve effectively communicated the possibilities represented by having a nervous system free of vertebral subluxation, then move on.

Since 100% patient compliance only sounds wonderful (you’d be bored within a week), part of the joy must be in the creativity needed for the “dance” of education, inspiration and leadership. It makes their surrender to periodic maintenance/preventive/wellness care three episodes and a decade later all the sweeter. What’s the hurry?

Every patient shows up a bit differently in his or her journey. Most of it is due to the cultural indoctrination they get long before they meet you. Rejecting patients because they lack a sophisticated model of health and healing, or because they squander this gift of life, or because they make poor decisions, is a choice. It’s selfish, reduces future possibilities and makes patients (or the lack thereof) the problem.

You’re Still Their Chiropractor

If patient relationships chronically end on a sour note (you’re right and they’re wrong), then you are imprisoned by a constant need for new patients. You can’t even take a vacation for fear the loss of momentum would be too expensive. For all the talk about wellness care and correcting the cause and all the other hype, you have an allopathic practice no different from the MD down the street.

If you make your practice patient-centric rather than doctor- or compliance-centric, you have the opportunity to create the circumstances in which every patient sees you as their chiropractor, even if they’re not currently under active care. All your currently active patients, and that shelf full of inactives, know enough people to fill your practice to overflowing. Yet few chiropractors have the desire or interest in properly cultivating current relationships and nurturing dormant ones in a way that would produce reactivations or referrals. But this is what distinguishes a true practice from a mere new patient processing machine.

If any of this makes sense, here is some languaging you might want to integrate into your patient reports:

“My experience with other patients of similar age, condition and lifestyle suggest the best results are likely to be obtained with a schedule of three visits a week. We call this visit frequency the “sweet spot.” If we don’t see you often enough we don’t create enough of a momentum for healing. And, if we see you too often, your body doesn’t have time to accommodate the energy of the adjustment and it’s wasted. Three times a week seems to produce the best results in the shortest amount of time.

“Obviously, if you miss a visit it won’t be the end of the world. We won’t call out the National Guard, but you may get a call from Barbara to make sure you’re all right and not in a ditch somewhere.

“Please realize that in the same way you had your problem for some time before your symptoms appeared, your symptoms will be the first thing to leave. In fact, you’re likely to feel better before you are better. The underlying muscles and tissues that support your spine do their most profound healing with continued care after the symptoms subside.

“Naturally, if you want to discontinue your care once you feel better, you’re free to do so. However, I have an ethical obligation to warn you that it will predispose you to a relapse. When your problem returns I just ask two favors. First, please don’t blame chiropractic or me. And second, please return and resume your care. You won’t get a sermon and you won’t get a guilt trip. Your records will already be here, along with our genuine concern for you and your health. Deal?

“Now, a month from now, on your twelfth visit, you and I will have a much better idea how you respond to chiropractic care. At that time, we’ll conduct a progress examination that we can use to compare where you are with where you were and then together, chart a course for the future that will best achieve your individual health goals. For some patients we’re able to reduce the frequency of their visits or make other recommendations. It just depends... on you.

“You’ve probably heard that once you go to a chiropractor you have to go for the rest of your life. While I intend to see a chiropractor for the rest of my life, and we have a lot of patients who see the value of periodic checkups, that doesn’t mean you have to. But I’d like to ask a favor. When you’ve had enough, let us know. We have a little celebration that marks the official completion of each patient’s relief care in our office. It’s not a big thing, but we think it’s important. That way, patients don’t avoid me in the grocery store or cross over to the other side of the street when they see me coming. Can we shake on that?”

It takes three or four minutes to say, but may take you months or years to own in your muscle. You’ll hear yourself mutter something about the inmates running the asylum. You’ll likely experience discomfort with just imagining doing and saying something different.

But this is the “practice” part of having a practice. To know the truth will set you free. And the truth is, you are powerless to control patients. Caring more, trying to control, improving your confrontational skills, and even justifying it all in the name of it’s “in their best interests” takes a tremendous emotional toll on chiropractors. Ironic, since it can be largely avoided by

1. Enforcing clear boundaries as to what is yours and what is theirs.
2. Talking about missed appointments at your report of findings.
3. Avoiding the temptation of making missed appointments about you.
4. Embracing a long-term vision to enhance the likelihood of reactivations.

So, how should you communicate with patient who misses? Are there any specific questions to ask the patient upon contacting them, either by CA or DC? Sure. Just remember that by then just about anything you say or do will be too little, too late.

Comments (2)

Bill Laughlin:

I like everything you say here, Bill. I've been practicing over 20 years and it is absolutely the truth, even though these can be "hard" to hear and implement.

I'd like to see an updated "Don't Shoot the Messenger" video in which a doc can present the current and future hard realities to patients who love their DC and want to continue care but are reliant on Medicare. You mention these things but also hint at heading towards a 100% cash practice which isn't do-able for me.

There are ways to finesse (work within) the Medicare system without being dishonest. It'll never address wellness and will likely continue to stress our offices out, but in loving and serving the elderly and early-boomer patients, we are stuck with it.

I hope you'll be addressing this also in a new pamphlet. Thanks for all the brilliance over the years, just being yourself, the observant and enlightened chiropractic patient!

Jodi Burick:

Dear Bill,

We are fed up with Medicare. On our journey to convert to cash, they are the first to be dumped, although that was not our original plan. To make a long story short, they held up our payments for about 6 months due to an address issue that took mountains of paperwork and numerous phone calls to correct. It was the last straw. We finally got a partial payment yesterday and after 14 years, we are ready to cut the cord from this dying animal. My question is what is the best way to explain to our Medicare patients that we will no longer accept Medicare? They unfortunately do not have the option to receive reimbursement when we decide to stop playing the Medicare game. The doctor has spoken with each patient about this, but did not have all the information about the unique rules/requirements of Medicare (either you are in or you are out, no reimbursement for patients) I am working with your "converting to cash" letters, but was wondering if you had any specific suggestions to include in this letter. Thanks for your help.

WDE: Unfortunately, I do not keep abreast of the regulations concerning Medicare, which seem to vary from state to state. I hear conflicting stories about what you can and cannot do in regards to Medicare. And the penalties for doing it incorrectly seem to be onerous.

My advice is to consult with the attorney that supplies legal advice to your chiropractic state association.

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From January 7, 2007 12:59 PM

This page contains a single entry from the blog posted on January 7, 2007 12:59 PM.

The previous post in this blog was Las Vegas Take Two.

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