An upset doctor called us a couple of weeks ago.  She had, just a week or so earlier, dismissed an adolescent patient from her practice due to missed appointments and poor clinical cooperation.  This doctor, who is not our client, was upset with me because she “followed all of the instructions you gave us at a lecture last year” yet had just received a scathing letter of denunciation from the parent of the patient who was threatening to sue if the patient was not immediately reinstated.

I asked for copies of all the records of communications between the practice and the parent.  What I received was scary!  There was no documentation of even a single telephone call to this parent regarding either the missed appointments or the poor clinical cooperation.  There was no record in the patient’s clinical or other records that the parent had ever been communicated with regarding either of these problems.  Neither was there documentation of even a single letter to the parents about these two issues, other than the terribly worded letter dismissing the patient from the practice.

What there was, were emails, lots of emails from the Appointment Coordinator!  Each email was polite and asked the parent to please call to reschedule the missed appointment or to remind the child to brush his teeth or follow certain clinical instructions.  Not once was there a mention of the clinical and other problems associated with failure to follow clinical instructions or the failure to keep scheduled appointments.  Not once was there an increase in the degree of assertiveness or an increase in the sense of urgency in the tone and content of the messages.  I read each of the emails and it was impossible to tell if the message was to a patient who had missed a single scheduled appointment or to a patient who had missed four consecutive scheduled appointments as this patient had.  The very first email sent was almost identical in tone and content to the last email sent.

Then “out of the blue,” from the perspective of the parent, comes a letter dismissing the patient from the practice!

This doctor has exactly a 0% chance of prevailing if this parent decides to sue.

Dismissing a patient is not something to be avoided “at all costs.”  If a patient/parent is engaging in behavior that will damage the clinical well-being of the patient or will make your intended result impossible to achieve, or is engaging in behavior that is damaging to the well-being and quality of life of the doctor or the team, and all reasonable steps have been taken and have failed to resolve the problem, that patient should be dismissed from your practice.  However, you must be able to prove that you took those reasonable steps! This practice took no reasonable steps at all – not even one – to solve their problem with this patient and the fact that they had tried to resolve the problem by sending polite email messages simply taught the patient/parent that the doctor was not that concerned and that missed appointments, poor tooth brushing, and broken brackets were really not much of an issue at all.

Our clients are taught that email is never to be used as a tool for problem solving!  Trying to get a delinquent person to make their payment or trying to get an uncooperative patient to cooperate via email messages is simply not effective.

So, is this message about the proper dismissal of a patient or is it about the proper use of email?  The primary message was in the last paragraph.  Stay away from emailing patients/parents if what you are trying to do is resolve a problem.  Email is quick and easy and fast and cheap, and in a busy practice that makes email quite attractive.  Email is also impersonal and ineffective.  The secondary message is that if your goal is to correct poor behavior whether that behavior is delinquency, missed appointments, poor clinical cooperation, or whatever, that correction will only come with a series of well documented direct communications with the responsible party, either by telephone, by letter, or face to face (never by email!).  Those communications must increase in intensity in proportion to the severity of the problem and must eventually get to the point of informing the responsible party that continuation of the problem will result in dismissal of the patient from the practice.  This issue of solving patient related problems was covered in more detail in my May 23, 2014 article.