The Exit Dialogue

by William D. Esteb

What if every patient you'd ever seen were still under some type of regular wellness care? How many patients would you be seeing every day? Every week? Hundreds? Thousands?

Within chiropractic, there seems to be an almost pathological interest in new patients. And while chiropractic must continue to extend its reach, when it comes to the economics of advertising, direct mail campaigns, and other artificial stimulants used to reach new patients, an improved exit dialogue could help reduce the tremendously stressful process of soliciting new patients.

The exit dialogue is a term used to broadly describe the process, tone, and attitude shown by the office to patients who leave the office without getting the "big idea," discontinuing care when pain relief is achieved. Most offices train their staff to telephone patients as they begin to consciously or unconsciously miss their appointments. It usually involves an unwilling staff member who attempts to convince the patient of the need for more visits. "The doctor wanted me to call..." or "It's important that you..." etc. Not only is this process stressful for the C.A. (ask them, they hate it!), it's the kind of desperate manipulation that has given the profession a black eye. ("Just like my friend said, once you start going you have to go for the rest of your life!) Ask yourself if squeezing one, maybe two more visits out of a patient will change their overall health picture? Have you ever created a wellness patient by badgering patients on the phone with an aggressive recall program? Probably not. But it forever tarnished their image of chiropractic and your office.

Gritted teeth

This short-sighted technique is extolled by some practice management specialists and directed to doctors interested solely in the financial return which is afforded by seeing patients for a few more visits. And while the office does receive that additional income, what is the price? Irritated patients. Poor public relations. And a quiet promise through gritted teeth never to return to your office, avoid you in the grocery store, and never refer their friends. All this from a patient who cautiously entered your practice and happily got as much or more than they expected from chiropractic!

If your motivation isn't financial, it's hard to convince patients of it. After all, they're feeling great. Since your patient education efforts didn't "take," the only reason for continued care in their minds is your financial gain. We are automatically suspicious of those who suggest they are "only looking after our best interests."

This phenomenon explains the results of a startling study conducted in California. In a survey among individuals who had received chiropractic care, a resounding 90% indicated they had experienced positive results. And while that's not too surprising, any other business in the world would love a success rate like that. But the next piece of information is enough to curl your toes. Especially if you're practicing the negative exit dialogue described earlier. When these same chiropractic patients were asked if they would go back to their doctor if their problems returned, 80% said they wouldn't!

If you and your staff know that treating patients in such a manipulative, self-serving manner is just wrong, consider an alternative approach.

Whether we like it or not, each patient has an internal "doctor" who governs lifestyle choices and health attitudes. Your ability to help patients redefine their concept of health and offer a new model of wellness can be aided through various patient education programs. At some time, this internal doctor, sensitive to the perceived severity of the original condition, personal finances, office location, staff relations, scheduling, and dozens of other real-world factors, decides it is time to discontinue care. And while this moment may not parallel the doctor's optimum recommendations for care, it is, and always will be, up to the patient to decide this issue.

Sometimes when this decision has been made, the doctor or someone on the staff is made aware of it. The patient may volunteer something like, "I'm really starting to feel better," or "I think the doctor has really helped me with my condition." Often after comments like these, the patient begins showing up erratically or is unwilling to make future appointments. And while you have the professional responsibility to discover why they have suddenly become insensitive to the appointment time you've reserved for them, it does not require or justify strong-arm methods to intimidate patients into keeping their appointments!

Allow the patient to "fail"

The preferred technique is honest, ethical, and non-confrontational to the patient. The staff simply asks the patient something like, "We missed you last Tuesday. Is there a way we could make our scheduling more convenient for you?" Here the patient either reveals a real scheduling problem, covers their real intentions of dropping out, or spills the beans and says they don't think they need to continue care. You can rarely change their decision at this stage. Again, you might get a reluctant visit or two, but the patient has already made up their mind. Little is served by making the patient feel like a failure for not fulfilling your agenda for optimum care. More than likely, without rehabilitative care their original problem will return. The question is, are they going to return to your office when it does, or start over somewhere else because they feel like they've let you down or are afraid you'll say, "I told you so."

If the patient has made up his or her mind to discontinue care, this is a time for you and your staff to swing into action. Not to recapture the patient, but to congratulate the patient and affirm their decision for seeking your office in the first place. It's a celebration of the success of treatment, the relationship that has grown, and a notice that your responsibility has ended. Typically this is done in a short phone call by the doctor and a follow-up letter. The letter is simple, friendly, and to the point. Perhaps something like this:

Dear (Patient),

It's been a pleasure to serve you during your treatment in our office. I hope your experience with us has been a good one, and that we have been able to demonstrate our real concern for you and your health.

We've noticed you've missed a number of appointments recently and we interpret this to mean you've received as much benefit from chiropractic care as you deem necessary at this time. Therefore, since you have chosen not to complete the recommendations I have made, your case file has been placed on an inactive basis. While you have an outstanding balance of $000.00, we will leave your account open until this financial commitment has been fulfilled.

Please remember your records will always be here and we would welcome the opportunity to serve you in the future should any problems arise. Please call if I can answer any questions or be of service to your friends or family.

We have the unique opportunity to see many patients with a variety of conditions and health objectives, so it is always exciting to see another patient achieve their individual goals. On behalf of my staff, I extend our warmest thanks for allowing us to participate with you in the recovery of your health.

Sincerely,

P.S. If we have misread the meaning of your recently missed visits, please give us a call so we can get back on track.

Does it seem odd to congratulate a patient for making a decision that short-circuits long-term rehabilitative care? Just remember that's your objective--not necessarily the patient's. If deep down the patient's real objective was merely symptomatic relief, regardless of what they told you, and that has been achieved, it seems perfectly natural to the patient to discontinue care. Recognizing this, the question then becomes one of whether to extract a few extra visits, permanently ending the relationship, or passing up the short-term financial gain in favor of enhanced professional image, the possibility of receiving referrals from this patient, and ultimately their reactivation when their problem returns.

An effective exit dialogue is more of an attitude than a particular event. Pressuring patients has been a way to "zing" an uncooperative patient or a defense mechanism some doctors justify when they realize they didn't fully educate the patient.

With the available research and scientific findings in existence today, there isn't a higher calling within chiropractic than providing the opportunity for long-term spinal rehabilitative care. While the doctor is always in charge of the therapeutic picture, the patient will always be in charge of compliance. An effective exit dialogue simply echoes your long-term professional perspective and keeps your clinic's front door open and welcome mat out for every patient you see.

Buy the book
A Patient's Point of View
Originally published in 1992
240 Pages
US $19.95

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