The Social Skills of Recalls
by William D. Esteb
Ten years ago I met Paul Myers on a weekend skiing trip. At the time he was an accountant working for a large electronics firm. Two years ago I bumped into him leaving the office of a mutual friend. In the small talk I learned that he had changed careers and was now selling computer-generated 35mm slides. He suggested that we get together for lunch.
After 10 years and with little in common, I had no desire to have lunch with him. What would we have to talk about over an hour-long lunch? The only motive I could figure was he wanted to sell me something--probably some of those new computer-generated slides he was pitching my friend!
To avoid having lunch with him, I refused to set a date on the spot, suggesting he call me the following week to set something up. Maybe he would forget. But much to my dismay, he called. Pretty persistent fellow. Trapped, I hoped to delay it as long as possible and set a time and place for the following week. I dreaded the approaching lunch date.
The morning of our lunch I called to cancel. "Something's come up, I'm not going to be able to make it for lunch," I lied.
"No problem," he said without dropping a beat, "how about Monday?"
I don't want to have lunch with this guy! Can't he see that I don't want to have lunch with him? Is he so insensitive he can't pick up on the signals I'm sending him?
"Monday will be fine," I mumble disinterestedly after a long pause.
All weekend I dreaded the upcoming lunch. Why was he pursuing me? What was his agenda? What was his motivation after 10 years? The more I thought about it, the more suspicious and resentful I became. I was angry he wasn't picking up the clues I was sending.
On Monday I called Paul to cancel a second time. "Well, how 'bout Wednesday," he answered cheerily, somehow oblivious to the pattern that was developing.
After a long pause I blurted, "Paul, I don't think our time would be best served by having lunch together."
Too abrupt? He wasn't reading the clues I was sending him. I remembered this event of two years ago when I recently saw (and avoided) Paul in a grocery store. I couldn't help but see the similarity between my experience with Paul and the well meaning but insensitive tactics often used to urge patients to continue care beyond their own sense of need.
In either case, lunch or encouraging a patient to continue care, the intentions may be honorable and even in the person's best interest, but my perception was that Paul would probably put the squeeze on me to buy his slides. I wasn't interested in his sales presentation.
The wrong method
After years of practice and a full appreciation for the life-threatening aspects of the Vertebral Subluxation Complex, the humanitarian doctor wants to do everything possible to encourage patients to remain under care. The motive isn't wrong--the methods are.
There are a set of generally accepted social skills used in our culture that come into play. At a party, there are ways of excusing ourselves so we can talk to someone else. When we're shopping, we can usually lose the persistent sales clerk with an, "I'm just looking today." Our sensitivity to these verbal and sometimes nonverbal clues allows us to successfully interpret and negotiate a variety of social settings. As valuable as these skills are, they don't show up on the curriculum of any college--except at the School of Hard Knocks.
Missing appointments or an unwillingness to set a specific time for the next appointment are two of these social clues. In "Patientese," they're often saying, "I found what I was looking for when I originally consulted your office and I no longer perceive a need for chiropractic, thank you very much." Or you may be dealing with a dialect that translates into, "The pain is gone and I no longer see a good cost/benefit ratio between the cost of your care and what I'm getting here."
Playing catch-up ball
What can be done to sensitively respond to these messages while encouraging the patient to continue chiropractic care beyond the relief of symptoms? Reacquainting patients with the progressive nature of Subluxation Degeneration or instituting some type of wellness fee structure as their interest is waning might help, but that's "playing catch-up ball" by the time missed appointments start happening.
The opportunity to "reposition" patients beyond pain relief to include chiropractic as part of their continuing health care resources has long since passed. Not that repositioning is a one time event; it isn't. It's an ongoing effort, so by the time the original symptoms have cleared up (and ironically, insurance coverage has ended) the patient has the fullest possible understanding of the rehabilitative and preventive side of chiropractic. Last minute, pressure-filled encounters after the patient has already used the appropriate social skills to say good-bye are counter-productive.
If patients don't perceive the need for continued care, a doctor or staff member's attempt at coercion on the phone makes patients angry. For the uneducated patient, the only motive for continued care is the doctor's interest in getting more insurance money out of the case. And fear tactics have a diminished effect because patients are "feeling fine." Resorting to a "do-as-I-say" approach rarely works with today's better educated baby boomer. And, "The doctor wants you to come in for one more visit," sounds as suspicious as it really is.
First, is it worth it? Do you really want patients hanging around who no longer offer the satisfyingly steady improvement and the glowing "doctor as savior" attitude they had when they emerged from pain? Is it worth clogging the practice with patients who have exhausted their insurance coverage and don't need a full set of X-rays with an 800% mark up? Is it worth replacing the easy-to-delegate-arm-twisting patient management with something more in keeping with the way you'd want to be treated?
Talk chiropractic on every visit
The alternative to these Neanderthal management techniques requires systematic, ongoing patient education. Of course a systematized patient education program is a great start, yet it can never replace an ongoing "low-tech" educational dialogue with the patient. How many patients are missing an opportunity to learn and be influenced by your experience and knowledge because it's easier to talk about the weather and sports scores, punctuated by a few grunts from the patient and an, "Inhale, now exhale"?
If I were in practice and I knew education was the only way to make a fundamental change in someone's attitude, whether it be a health attitude, chiropractic attitude, visit attitude, or payment attitude, here's what I'd do:
Systematize your talk
Since educating a patient is a process, not a destination, I'd systematize the process by outlining a plan in advance so I wouldn't have to invent it in real time. I'd make a list of every major topic I'd want the patient to know: the five components of the Vertebral Subluxation Complex, the phases of Subluxation Degeneration, that sort of thing. That's a quick nine topics. Add to that hypomobility, hypermobility, compensation reactions; you get the idea. Identify 52 chiropractic subjects every patient should know and understand. (This would be good for training staff members to answer questions too.) The idea is to pick a new topic each week (or each day if you're ambitious) and post it on the sign-in sheet or on the door of each adjusting room. "Welcome to the office of Dr. Soandso. Today is Hypermobility Day." This gives the doctor and staff "permission" to introduce the topic in every conversation with every patient. Each patient's health problem would always be related to the day's subject. Patients would know it was coming and expect it. It doesn't lengthen the visit because you're simply filling the usual "dead air" while you are performing your normal clinical routines.
Does this take extra effort? Of course. You've already mastered all the easy ways to build your practice. The "gimmicks" in a growth-oriented office aren't gimmicks--they're hard work requiring the willingness to delay gratification for months or even years. It takes more than a great recall script to build a maintenance practice of cash paying patients! In fact, it takes more than a set of videotapes, a few brochures, and a dynamite report of findings.
Sure, a recall program is easier. Especially if you can delegate it to someone who won't raise a fuss when their conscience tells them they've crossed the line from a professional, "We-reserved-some-time-for-you-and-missed-you" to a socially unaware form of badgering. What type of patients (or customers) succumb to badgering anyway? Ask Paul Meyers.
Buy the book
A Patient's Point of View
Originally published in 1992
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