Dr. Jeff Segal: The patient has become belligerent, difficult, challenging. Doesn’t have faith in you. If the patient doesn’t trust you any longer, that’s the beginning of the end of the doctor-patient relationship. Recognize it. Treat it. Take action.
Voice Over: Welcome to the Growing a Successful Orthopedic Practice Podcast. Join us every episode to hear from fellow medical practice administrators, staff, and physicians, as we break down current issues, affecting the industry, and share real stories from guests on their way to growing a successful orthopedic practice. Let’s get started.
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Keith Landry: Hello everyone. I want to welcome you to another episode of Growing a Successful Orthopedic Practice Podcast. I’m Keith Landry. Thanks for being with us. And we’re continuing this series with Dr. Jeff Segal who’s just absolutely brilliant. This is our third podcast with him. Today we’re going to talk a little bit about terminating patient relationships when they just don’t work anymore. Sort of a tough topic, but you know what? I love you, babe. But I just got to leave you.
Dr. Jeff Segal: Yes. That’s the way it works. The customer is always right, but not everyone has to be your customer.
Keith Landry: That’s right. I have some friends in other professions where they fire a client every year at the beginning of the year.
Dr. Jeff Segal: It happens. I wish we had the insight upfront to catch every red flag coming in. We don’t, that’s why you need to sometimes take action. Not a frequent occurrence, but one that causes a great deal of anxiety.
Keith Landry: Fantastic. Let me tell folks a little bit about you if they didn’t catch our last two podcasts. Dr. Jeff Segal is literally a genius. When people say it’s not brain surgery, he knows what that’s all about. He was a practicing brain surgeon for 10 years before, oh, just doing a little change in career to become an attorney and master that field as well. And he is the CEO and founder of Medical Justice. He started that in 2002. Medical Justice is a physician-based organization, focused on keeping doctors from being sued for frivolous reasons. Dr. Segal also founded eMerit to help doctors protect and preserve their reputations, particularly online. And of course he was a practicing physician so he knows about that firsthand. I want to thank you for being here today and sharing all your awesome insights with us.
Dr. Jeff Segal: Great to be with you. Thanks.
Keith Landry: You bet. So anybody that’s been in the orthopedic world for a while, a practicing physician, even a practice manager is familiar with the scenario where sometimes it’s just not the right fit, be it for the patient with the doctor, or really for the medical group with that particular patient. Do you recall a scenario where you had to nicely break up with a patient?
Dr. Jeff Segal: Every doctor will go through this. It could be that you have nothing left to offer the patient, or you don’t have the skillset to fix the problem the patient has, or the magic’s gone. Meaning that the patient has belligerent, difficult, challenging. Doesn’t have faith in you. If the patient doesn’t trust you any longer, that’s the beginning of the end of the doctor-patient relationship. Recognize it, treat it, take action.
Keith Landry: How do you prepare both your staff and the patient for this? In other words, is there some documentation that should go on behind the scenes before you have that conversation, to cover yourself from a liability perspective?
Dr. Jeff Segal: So we’re going to start first for what do you do upfront. The first thing is to decrease the odds that such a patient will enter your practice. Recognize who that patient is, find the red flags. If you identify them, then gently persuade them to go to your competitor down the block, because once they’re in your practice, you own them and you may have to take action down the road.
Let me give you an example of a particular patient that I believe is a red flag. Patient comes in, and you typically see this when you’re starting your career, when you’ve got a big ego and you haven’t had the humility associated with follow-up care. So anyway, patient comes in during your first year of private practice and they say, “Doctor, I was butchered by these three other surgeons before you, but I’ve heard so many wonderful and positive things about you. I am so sure I’ve found the right doctor.” Now you probably would be flattered by that because they’ve already said you’re better than these three other people who have been out in private practice for a number of years. And somehow they found you and they believe you walk on water. Don’t walk, run from this patient because you will be the fourth doctor. And when they visit the fifth doctor, you’ll be that next butcher. So that’s an example of how to pay attention to the verbiage.
And there are all other sorts. I mean, if the patient comes to your practice and is difficult on day one before you’ve operated on them, or subjected them to risk, it’s unlikely they’re going to be nicer to you down the road. Or it could be that the patient is lovely to you, the doctor, but an ogre to your staff. And your staff might be telling you, “Look, this person is a horrible human being. They are not pleasant to anyone. You’re not seeing what we’re seeing.” Listen to your staff. You can’t be in all places at all times. Pay attention. So, a take-home message. If you can avoid a challenging patient or recognize who that individual is sooner rather than later, you won’t have to worry about dismissing them from your practice because they never entered your practice.
Keith Landry: You know what, we could end the podcast now. That was the payoff right there.
Dr. Jeff Segal: Yeah. But they all slip through. It doesn’t matter how long you’ve been in practice. If you see 1 to 3000 patients a year, they slip through. Over time, not as many should slip through because you don’t have to operate on everyone. I’m telling you, you don’t have to operate on everyone. At the end of the year your balance sheet won’t look any different than if you send this patient to another practice.
But the point is, is that the doctor-patient relationship is built on trust. It’s built on faith. They’ve got to believe you can help them. You’ve got to believe that you can help them. If the patient is saying, I don’t trust what you’re doing. I think you’re doing a horrible job. They’re constantly yelling and screaming at you, that’s not a productive relationship. Now look, anybody can have a bad day. I’ve had bad days. I’m sure you’ve had a bad day. And patients when they’re stressed out can have a bad day. Most people deserve the benefit of the doubt, but if it turns into a character flaw and that’s all they’re doing all the time, it’s a nonproductive relationship.
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Keith Landry: So you’re terminating it and you’re having the conversation. I guess we can talk about that in a moment, but how do you button it up to protect your practice and yourself before you do it? Is there something you got to put it in the notes or what do you do?
Dr. Jeff Segal: So there’s a formal process associated with termination of the doctor-patient relationship, and then there’s a way to do it stylistically, okay. So let’s talk about the formal process.
You can’t just abandon your patient. You can’t say, you know what? I hate you. I’m moving on. Goodbye. I’m sorry. I’m in the middle of a chemotherapy protocol. Good luck with you. Go find your new doctor on the internet. You can’t do that for obvious reasons. Because the patient can charge you with abandonment. They can file a complaint with the board of medicine and they will frown upon that type of behavior. Or, they potentially, if they’re injured and can’t find another doctor, they can probably sue you for abandonment. So you want to do it very formally.
Typically, if you’re not in the middle of a treatment plan, you send them a note which says, “Look, you’ve lost faith in my care. The doctor-patient relationship is built on trust. We respect everyone’s autonomy to decide what type of care they want to get and from whom. Accordingly, I’m terminating the doctor-patient relationship. I’m ready, willing, and available to continue care for urgent or emergent conditions for the next 30 days, or until you find another doctor, whichever comes first. You can find the list of doctors at the county medical society.”
So what have I done with all of that? I’ve nailed down all of the little details that have to go into a formal termination document. So (a), it’s in writing, meaning that they’ve got to be notified about it, (b), you’re not doing it immediately for all conditions. You’re doing it immediately for elective conditions. But for the most part, you will be there to assist with emergencies or urgent conditions, so you’re not immediately abandoning your patient. Number three, you’re giving them an option on how to find another doctor and you’re wishing them well. So these are all of the things that go into the formal notification process.
Now, of course, there are exceptions to the rule. And 30 days is kind of the across the board description. But if, for example, you’re in an area where you’re the only oncologist for two hours, you may need a more formal handoff. Maybe even find the patient a followup appointment with an oncologist, just to make sure that they don’t fall through the cracks. But most of the time, the 30-day window is adequate. So that’s the document. That’s the legal document.
Keith Landry: I love that advice about helping them find another doctor, because it’s just not going to be as likely to be able to hold you liable if you went out of your way to help them find the next bit of care they get.
Dr. Jeff Segal: Yeah. So there are times that the patient doesn’t want you to take care of them anymore, but they haven’t gone anywhere and you may not be able to fix their problem. It may be that it’s beyond your skillset, so you can make an introduction or a referral. And you may not have even terminated the relationship, but you help them along their journey to find another individual who can do this. And sometimes if the patient, and we see this in the cash pay aesthetic space, not infrequently, where patients had a facelift, they’re unhappy. They’re so bummed out with this doctor. They keep coming back just to yell at him. And the doctor believes he did everything properly so he may very-well send this patient even on his own dime to a colleague to evaluate this patient, to at least let this individual know that all the i’s were dotted, t’s were crossed, everything done appropriately. There are a thousand ways to manage this, but you don’t want to fly solo on this. Sometimes it helps to bring along a colleague.
Now, one thing that we didn’t talk about, we talked about the document, but what about stylistically? How do you do it? I mean, if you can, you want to avoid getting into a fist fight. This is not a cage match. You’re really just trying to help the patient along and help them find a new doctor. And if the patient truly has lost faith, and we can go back to the cash pay field where they say, “Look, I know you’re not happy with the facelift I just performed. For that, I’m sorry. We’ll just have to agree to disagree. Nonetheless, I still respect the fact that you would like to be evaluated for a revision procedure. I’m not that guy. I think it may be a good idea for you to get a fresh start with someone that you know and like, and to that end, I’m willing to pay for the first visit to get you there.
There are a thousand ways to do this. My point is, is that instead of saying, you’re a horrible human being and you can’t see the wonderful work I’ve done for you, you’re basically just saying, I think you would be well-served with a fresh start with someone you like and trust. It’s not saying that you did anything wrong. It’s just that you’re now looking out for the patient. That’s a much more diplomatic path, and I think if you engage in a diplomatic path, you’re more likely to get the outcome you are looking for.
Keith Landry: Dr. Segal, those are absolutely brilliant insights. And how can folks get ahold of you?
Dr. Jeff Segal: They can go to our website, medicaljustice.com. That’s medicaljustice.com. Or email us at email@example.com. Or finally, we actually pick up the phone: (877) med just. (877) med just. M-E-D J-U-S-T. That’ll do it.
Keith Landry: All right. Thank you for being with us. I want to thank everybody for tuning into another episode of Growing a Successful Orthopedic Practice Podcast. We’ll talk again soon.
Dr. Jeff Segal: Thank you.
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