Laying Down the Law With Patients

While it’s clear that our patients have expectations – sometimes valid, sometimes unrealistic – we have expectations too!  And how often is it that our patients disappoint us because they don’t do what we expect of them? While this blog article could turn into a full-on gripe session about those darn patients and how they constantly let us down, I believe how we think and what we do or don’t do, have a great impact on how our patients act and if we want them to change, we have to change first.

Here’s the deal; First, there are some things that we don’t get a vote on and there are other things we do. Second, how can we hold our patients to accountable to any expectations if we don’t come right out and have an honest conversation about them? Expectations are reasonable only when they are clearly conveyed, discussed and agreed-to by both parties.

So, what are the valid expectations? In our opinion, we believe there are only four things you can ask of your patients. I think you will strongly agree;

1) SHOW UP – and on time

I could devote a book to this subject. How often does a patient let you down by no-showing, or arriving late (and thinking it’s OK, I might add)?  How dare they? First, this is a professional business arrangement. It can’t be treated casually. Having your patient sign a form with your “office policy”  is not good enough.  (How many people read it anyway?) You must look your patient in the eye and tell her you have reserved this time with “fill-in-the-blank” just for her, you will be fully prepared when she arrives, and ready to get started. “Can I get your commitment to that?” THAT will get their attention.

What doesn’t work?  A recall system or any other communication that conveys the message that you “request the courtesy of  — hours notice in the event of cancellation”. You’ve, in essence, given them a ticket to reschedule. And putting them in the penalty box by “fining” them for not showing will just put a strain on the relationship without addressing the problem.  Instead, speak to the obvious;

“Bob, we were expecting you this morning for your appointment with Dr. Norris and honestly, we are disappointed you didn’t make it. We had that time set aside just for you.”

How can you assure this won’t happen in the future?:

“ I can arrange your next visit in one of two ways; a deposit of $fill-in-the-blank will reserve your time or, I can call you on a day when an opening avails itself to see if that will work with your schedule.”

Same thing with people who habitually show up late.  Speak to the obvious;

“Lisa, I’m glad you finally made it. I only have 35 minutes of time left before my next patient arrives so, I promise I will get as much accomplished as I can. It might mean we will need to schedule another time to have you come back to finish what we can’t take care of today.”

Message: you’re late, I run on time. I will not inconvenience my next patient, you will still pay for your full appointment, and you might have to come back again. Reasonable? I think so.

2) PAY AS AGREED

Aside from insurance claims, there should be no reason for you to have any outstanding accounts with patients. Period. How is it that practices get into the accounts receivable business with patients in the first place?  Unspoken or unclear understandings about 1) the fee and 2) the terms for paying the fee.

No dentistry should be performed without an actual discussion about the cost associated with the treatment recommendation, what the patient will be expected to pay, how that fee can be made, and a mutual agreement with the patient on the terms. Something as simple as:

“Gentry, the fee for the treatment you have chosen is $fill-in-the-blank and our first preference is that be paid  (in full at the first appointment or a % to reserve the appointment and remainder on the first appointment, etc.). Will that arrangement work for you?” If it does, great. You are done. If it doesn’t, you find an alternative that works for both of you.

Remember, it is better to NOT do the dentistry than to do the dentistry and NOT get paid.

3) BE HONEST

What would we want our patients to be honest about?

#1 on the list: Let us know how you are feeling and what you are thinking.

You can’t read your patient’s mind. You need to know if he is apprehensive, if he isn’t sure the treatment you’ve recommended is right, or if finances are an issue. That is why having a dedicated and gifted facilitator on your team can help you connect with patients at a deeper level and help them voice what might otherwise be left unsaid.

#2 Lifestyle, health issues or recreational/prescription meds. These have a huge impact on what your recommendations might be and the outcome.

#3 Don’t make an appointment if you don’t intend to show up, or agree to treatment if you aren’t sure, etc.

These could be uncomfortable conversations. Coming right out and asking your patient to be honest may imply that you think they are lying. So, how do you convey this very important value? You can suggest the ways in which you hope they will tell you the truth. If you use context to frame the idea, it will make the conversation go more smoothly;

“Some people are reluctant to share personal lifestyle information with us such as their recreational drug use or the state of their health but these issues have tremendous impact on how we might treat someone or the outcome of treatment. I want you to encourage you to be as open as you can with us and know that we will respect your honesty and never make judgments based on what you tell us. In exchange, we will never mislead you or withhold information that we believe is in your best interest.”

Or encourage honestly by speaking to the obvious…

“Something tells me you aren’t fully committed to the treatment we have recommended. Before we go any further, please share with me what you are thinking and what concerns you still have.”

4) BE GOOD NATURED

We’ve all had them. The patients who show up on your schedule and you break out in a sweat. You plan a strategy to be in the lab when she arrives. You avoid engaging her in conversation and ignore the terse comments. In my opinion, that is NOT OK. If there are patients in your practice who are bullies, they need to be called on it.

When my kids were little and one of them would come to me complaining, “Mom, Casey’s chasing me”, my reply would always be, “Then stop running”. The same is true with nasty-tempered patients.

Yes, it is uncomfortable to address someone when they are behaving badly but it can be done with grace and one of two things will happen: it will either defuse the situation and she will recognize, apologize or explain herself OR she won’t get it and the relationship will end. Either way, you win.

Here’s the grace part:

“Hilda, I get the sense that you aren’t very happy about something, and if it’s something we’ve done to make you that way, we would want to know about it. What’s going on?”

You will know very soon by her response where to take the conversation next.

“ Goodness, I had no idea. Thank you for being honest with me. Let’s see what we can do to make it right.”

Or

“You know, Hilda, it is becoming clear that despite our best efforts, we may not be able to make you happy. I am more than willing to transfer your records to another provider if you like.”

Conveying your expectations makes such good sense because it prevents a myriad of problems before they occur. And you will find that there are many remedial systems that can be eliminated when you front-end your relationships with a conversation about expectations.

Having direct conversations with patients about these expectations requires team members with courage, confidence and finesse. It requires level thinking, maturity and most important, time. That is a big investment but pays off quickly by eliminating many of the issues that cause us stress. 

“Confirmation” Calls and Cancellations

I’ve been thinking about some of the systems many dental practices create and considering the high cost of these mostly remedial efforts. We believe that in many cases, the systems we create in our practices are designed to fix problems we created ourselves! If this hypothesis is true for you, you are likely paying huge costs to address situations which might have been avoided in the first place.

The confirmation call is a classic example of this syndrome. When we institutionalize the confirmation call, we create a very expensive remedial system. In many cases, the  confirmation call is like the sign on a blue highway:

LAST EXIT BEFORE TOLL

First, let’s examine the word “confirmation”. I wonder how many patients think about an appointment as “tentative” or “penciled in” until it is “confirmed” by a phone call a day or two in advance?  If you, indeed, consider the appointment confirmed when made, any call after that is simply a reminder. When you call a patient to “confirm their appointment” on a particular date and time, it equates to giving them the option NOT to come because it implies the appointment was tentative. I wonder whether, upon receiving such a call, a patient might quickly assess her schedule and bank account balance to determine whether she still finds it convenient and affordable to come for her appointment?

So why do you make confirmation calls? My clients tell me it is primarily to insure that patients remember to come for their appointments because open time on the schedule is costly and frustrating. If that’s the case, it seems like the best place to address this issue is at the time the appointment is made and insure you do everything to identify your expectations and ask your patients to honor their agreements with you.

When you make an appointment with (not for) a patient, you have negotiated a contract which must include agreement on the following issues:

1.The procedure to be performed
2.An understanding of why the procedure was recommended and why the patient has asked you to perform it
3.The fee for the procedure and how you and the patient have agreed the fee will be paid
4.The date and time as well as approximate duration of each of the appointments in the sequence
5.That these arrangements are confirmed at the time they are made – you agree to be on time and fully prepared to deliver on your promise and simultaneously the patient agrees to show up on time and fully prepared to deliver on his promise.

When the appointment-making process has been done well, confirmations become unnecessary and far fewer appointments will be changed or canceled for reasons that have to do with unexpressed expectations you have from one another.

So, what is the true cost of confirmations? Certainly more than the high cost of administrative time and energy to make phone calls and handle changes. The cost is in underdeveloped and unclear relationships. These relationships tend to be as unclear about what concerns or problems the patient is asking you to solve, how the practice recommends solving them, and the costs you both will pay to get there.

I hear some of you thinking; “But what if they are forgetful or WANT a reminder?”

Certainly some patients may request a reminder because their lives are hectic and their organizational skills are not great. But only those who specifically request this reminder should be called. Those patients who have control of their lives and keep a personal appointment calendar don’t need a reminder.  So, how will you know the difference and how will you change what you are currently doing? You ask.

Let’s examine this a step further.

We’re not suggesting that you drop “reminder” calls if your patients have been trained by you to expect them. You must honor all agreements, implied or explicit. On the other hand, If you choose to make a shift to eliminate the burden and volume of “reminder” calls, you must let every patient know that there will be a change in the way you handle them in the future.  There must be a deliberate discussion about what will be different and why you are making the change. Then you must come to an agreement or, in a few cases, agree to honor their special request to handle their situation differently.

You can begin saying something as simple as,

“Rene, I know you have become accustomed to our calling (the evening, two days…whatever) before your appointment, but since we consider this appointment confirmed when made, I’m wondering if there’s any reason you have for wanting us to call and bother you with a reminder. You can be assured that we will be prepared to see you at this time.”

You could go one step further;

“Rene, you are probably used to getting a card in the mail and a reminder call several days before your next hygiene appointment. Well…”

“… we’ve found that sometimes we don’t connect with our patients and then they aren’t sure whether they still have an appointment…”
or
“…we have found that making the calls requires a full time person and we simply don’t want to have to raise our fees when it’s not necessary…”
or
“…we have found that a lot of our patients don’t want to be bothered with a reminder call that interrupts their day…”

“…so, we have chosen to handle our confirmed appointments a little differently in the future. Unless there is some reason why you would need a reminder (email/text/call), I won’t bother you with one. I want to assure you that we are completely committed to this time and we will be prepared and ready for you when you arrive. Will that work for you?”

That doesn’t mean that the tentative or reluctant patient will keep an appointment just because you’ve delivered that message, however. You must come to know your patients more thoroughly and understand all of their expectations, fears, preferences, wants and concerns. Only then will we be able to make appropriate appointments.

Next, how to handle the patient who calls to cancel their appointment…