That Time I Discharged a Patient

Dr. Tea  0:01  
Owners of a direct care practice are more likely to experience higher job satisfaction than the insurance based practice. And it's no wonder why direct care is independent of insurance. Patients pay the doctor directly for their expertise. The doctor gets full autonomy in how they care for patients and how they get paid. We've chosen this path for the love of medicine. This is the direct care way. 

By listening to this podcast, you may even start to believe you too can have a successful direct care practice. Come listen with an open mind as I share my personal journey on how I pivoted from an insurance based practice to direct care right in the middle of a pandemic. And the valuable lessons along the way. This podcast may be the very thing you need to revitalize your medical practice on your host owner of a direct care podiatry practice, Dr. Tea Nguyen

Hey there, welcome to another episode. This is a fun one, discharging patient. Okay, maybe I shouldn't say that with too much excitement. But listen, hear me out for the next 20 minutes or less. In direct care, we do have the ability to select for patients. And some may see that as a criticism, and others see that as a benefit. For me, I'll share with you a story of a patient that I had to discharge from my direct care practice. When I shared this story with our Facebook group, comments came in like, oh, you even have difficult patients in your direct care practice How strange. It's not strange people are people at any income level, they're going to be difficult, they're going to be pleasant. There's a variety pack. But I can assure you that in a direct care practice, the frequency of difficult patients or challenging circumstances are much less. And that really comes down to a couple of things.

fewer patients to see, which means you have fewer opportunities to how challenging circumstances. In the insurance model, we see lots of patients, we can see up to 30 or 40 patients in a day. Which means those are 30 to 40 different opportunities, plus their family members and their caretakers, and everyone that's involved in their care. Those are opportunities to become challenging. Whereas in a direct care practice, my ideal day is no more than 12 people in a full day. And even now, I continue to scale back to see five people in a half day. So that means fewer opportunities to have challenging situations. Now, I don't really love the term, challenging patient because these are circumstantial. They were challenging in that situation. But I'm sure that they were loving people in different circumstances, right. So I'll share with you this patient that I had recently, this was a person who was referred to my office by another patient, it was their family member, they knew that the practice was cash base that I was opted out of their insurance, they knew the cost of things before I even saw them. 

And when I did the comprehensive evaluation, a few things came up. So I offered procedures to resolve those problems. In my mind, I felt I was giving the patient the best service there could be to address all of their foot and ankle problems in one visit. Traditionally, in my insurance based model, I would have had to split up these appointments. So that number one insurances will pay and not bundle the cost. And number two, because it would push patients back because the appointment times were scheduled so tight. They were 15 minutes apart and often double booked. Does that sound familiar? But now in my direct care practice, standard appointment times are 30 to 60 minutes. So there is a large buffer for me to talk with patients about things that maybe come up that didn't come up in their evaluation. So in this scenario, I provided what felt like perfect care that consenting was easy. The aftercare instructions were clear expectations were decided and talked about in depth, and then he left the office without a complaint, paid his bill. And that was it. I thought everything was fine. In my practice, it's standard procedure for my staff to call the patient the following day, to follow up on their new patient experience, and to check in to see how they're doing after a procedure. 

It was in this phone call that revealed a lot about this individual. And also reason why I try not to do surgery, the first time I meet a person, if I don't know them that well, the patient complained, he said, I am surprised by this bill. I am surprised by this bill more than I am of the service that was rendered. So because my staff took the call, I didn't have the opportunity to speak with the patient directly. So I advised her to schedule the appointment, so I can speak with him by phone at his next availability, because I wanted clarification. I wanted to hear what his concerns were, so that I can improve the processes they have in place. I'm very receptive to things that patients have to say. But when he was offered that phone appointment, he refused. And he just waited two weeks after the appointment to see me in the office for the post op care. So I thought, hey, maybe it wasn't such a big deal. I'll just address it then. And I had tried calling him back multiple times, with no answer. So then I see him at the appointment. And I check on him, I evaluate his wound. 

And everything went fine physically on the physical level. So I asked him, I heard there was a concern, what can I help you with? Where can I provide more clarity? In your care? I said, I took care of everything in one appointment to save you a trip and you had agreed, I gave you the price before I performed the procedure. And you didn't say anything about it. What part of the process were unfavorable to you? So he said to me, what hurts more was the price of your services than the actual procedure? So I listened, I listened to what he had to say. And so I asked him curiosity. So for everything that I did, in your one hour appointment, what do you think I should have charged you? Because I like to lead with curiosity. Right? So what do you think, my one hour plus the staff that I have to support? What do you think that amounts to? And don't forget, we live in California rent is ridiculous. 

But that's beside the point. And he responded, of all the doctor's appointments I've ever been to, I had never paid for more than $80 out of pocket for medical care. And this got me thinking, is this person arguing about a bill because he didn't want to pay? Because he paid it. And he walked out of the office satisfied. Everything was done. The evaluation, the procedures, the comprehensive valuation, all of his questions were answered. He had the whole nine yards. It was concierge level care, although I don't call myself concierge care. But I did my very best. I was clear, I was thorough, and even tried to save him an appointment time by performing a procedure on the same visit. And yet, he was dissatisfied. And it was really unclear why other than it was because he had to pay out of pocket. So despite what was valuable to me, he did not value those things. Not one bit. 

So I was surprised because you would think if you're dissatisfied, you would say something. But he didn't. That's okay. So I asked him, What would you like to do? Now I want to solve this problem that we have. He said, Well, I want my money back. And I thought about that for a second actually had thought about this before his appointment, I was gonna go in with the plan, like, should I just return his money and let him go? Or am I gonna haggle, which is not really my style. And then I decided this, it was a mutual decision, that he was not a good fit for my practice. And I was not a good fit for him as his podiatrist, expectations were not realistic, because first of all, he didn't really explain to me what the expectation was, other than I thought you would be cheaper. 

And that was never discussed. So the fact that this came on after the fact, that was a problem for me. If I can't trust him, and he doesn't trust me to be his doctor, then we're kind of just sitting around torturing each other, right? He's going to not want to pay a whole lot and I'm not going to be able to pay my bills. And then I'm going to have an added layer of stress of liability and so on. I told him, You know what, I'm going to return your money on the premise that I will discharge you from this clinic. I will also inform your primary doctor of this plan, and we can just go about our way. How does that sound to you? And he said, Fine. That sounds fine. There was no argument there was really nothing confronting about that situation, I was very clear of my intention. I said, I apologize that you didn't feel that you had received the best care. And then I left it at that. So the process of discharging a patient is quite straightforward for me, you know, inquire your malpractice insurance, of course, but it was the agreement. And I sent him a letter saying this is not a mutually beneficial relationship, the procedure has healed, I have informed your primary care doctor, which I did, I texted him and said, This is what happened. And their response was very respectful and said, I understand. And that was it. 

So the pathology reports, all that gets forwarded to the primary care doctor. And this incident is so rare, this is the first time I've ever sent this primary care doctor a note of discharging a patient, but I had to take my business seriously. And I had to really pay attention to who I allowed in my space. And so that's what I want to share with you, it's really important that if you are to go into private practice, whether you're insurance based or direct care, and especially in direct care, you have to identify your ideal patient. Now, that doesn't mean to select out for rich people, which I don't know why people earnestly think a cash practice is intended for rich people, it's not, you want to identify your ideal patient, people who are willing to pay cash for medical services are of a variety of income. I have people who are farm workers, who work seasonally who are small business owners, all the way to people who run multi million businesses, the spectrum of income level, I don't even ask, so I don't really know. But I know what they do for work. And so that's what I can report, your ideal patient is out there, you just have to know who they are so that you can speak to them in a language that they can understand. Plus, knowing who that person you're speaking to, is this avatar is going to put you in your zone of genius. 

So imagine you having to constantly talk to a person you can't stand, or you're just chronically frustrated with. And then you start developing marketing tools around this frustrating avatar. So now you're just speaking to people who will gravitate to that language. And that is exactly the opposite of what you should be doing in your direct care practice. Identify your ideal patient so that you speak to the person you want walking in your door. For me, it is the individual who cares about their health, enough to pay out of pocket. It is not the person who complains about a copay for an insurance that they chose. And figuring out who your ideal patient may take some time, it may look very messy upfront, because, you know, we treat a variety of people. But in business and marketing world, you do have to define this ideal patient, so that you know where they are. And you follow them. They're in your marketing plan. I mean, not physically follow them, but be where they are, say what they're thinking. So that they believe that you are the ideal doctor for them. Plus, you start to generate this energy around people you like, who likes you. And it's a magnetic energy, it's a magnetic interaction, that all of a sudden you build this practice of people you love, and they love you. 

And it's such a rewarding type of practice to have. So essentially, focusing on your people is where you should be spending your energy, not on people who you don't really want to attract. So needless to say, this type of patient I discharged certainly was not a good fit for the practice. So I didn't spend more time than that on the discharging process, and then letting that situation go. Because I needed to focus on my people, people I can serve, who do appreciate what I have to offer who are willing to pay. Another thing I want to share about this experiences. Don't make discharging a patient mean, anything more than it not being a good fit. Like don't get tied down to I get these types of patients all the time. It must mean I'm a terrible doctor. Don't do that. That was not said. This patient said to me, he just didn't want to pay, essentially. And so that's all it was. It was a budget issue. But then I've had patients who have paid 1000s times more than him and are very happy with the service I provide. You see, so don't make it mean more than it is. It's just not a good fit. Now, they may decide to write a nasty Google review or a Yelp review. You let him be, you have no control over what they do once they leave your office, they may even put a front when they're in front of you, but you have no idea what they're saying about you when they leave. So let it be, that's not your energy to be absorbed in, you don't really know what's going on in their mind the stressors that they have, or what their priorities are at the moment, and you know, what their priorities paint change down the road. There have been cases where patients went through a divorce, needed money, and they tracked back to who they could get money from, by suing their doctors. 

These are real stories. So scary. I don't mean to scare you. These are just realities. Don't make it mean anything more than it is all right. Take this as a learning opportunity. This is how we develop our emotional intelligence. And you might be wondering, what is that emotional intelligence as defined by the Internet is the ability to understand, use and manage your own emotions in positive ways to relieve stress, to communicate effectively, empathize with others overcome challenges in defuse conflict. So I really liked that I could not have said that better myself how I like to see emotional intelligence is a tool you need to have to preserve your own well being. So that doesn't mean that you can't have the feelings of frustration and disappointment, it just means that you recognize it. You understand where it came from, and that people have stuff going on. That's kind of none of your business. So let them handle it in their way. They might even be disrespectful to you, they might be deflecting their own issue on, they will impose their problems, too, you know that that's their problem, not yours, be Zen, let it be. 

On my recent coaching call session, I had a client asked me, I don't want to attract that kind of client. When I was sharing with her what types of patients I see in my direct care practice, because she was employed in a hospital setting. So I asked her to clarify, I said, What do you mean, what, what do you mean by that kind of client? Because I have clients have different income levels. And I don't really know what that income level is. Because I don't ask what their income is, I just know the kind of work that they do. And if they're gonna pay their bill that day, that's all I know. Because if you mean, that kind of client as a difficult client, then I'm sorry, you probably shouldn't be in a service based industry. Because difficult clients come in all income levels, period. And I can compare and contrast my insurance based practice, from when I started the insurance based practice four years ago, to when I pivoted into a direct care model. 

When I was insurance based, it was volume driven. So the more people I saw, the proportion of difficult situations was also high versus indirect care, it's fewer patients to see, therefore fewer difficult situations. But also in the direct care model, there is a bit of a self selection for people who pay out of pocket, right, those who pay out of pocket are much more invested in getting better than those who don't pay much at all, or who just thinks they're entitled to so much, but they pay so little for it. And this is not a judgment against people who truly cannot afford medical care or just basic necessities for a living. This is about people who don't want to pay for medical care. And that's okay, because there is a system built for that population. Whereas in your direct care practice, you can build your practice for a certain population to you can certainly serve for charitable causes for people who can't afford, but that shouldn't be your primary source of activity. 

If you're running a business and a business, you need to be very selective about who you can serve, so that you can pay your bills, right so that you can preserve your energy for people you can help. And there's going to be people you can't help at all, no matter what you do. I'm going to leave you with a quote, too, because I just thought of one. And I might have already said it before it came from Babe Ruth. He said the loudest booths come from the cheapest seats. But what I really wanted to share was this quote, just because you were invited to an argument, it doesn't mean you have to attend. Know who you can help, who you can't help and be mindful of your energy, because it's a finite source. Just like your time.

Thank you so much for being here with me today. If you enjoyed this episode and want to hear more, please like, share and subscribe so more people like you can have access to another way practicing medicine, that direct care way. Let's connect by my info in the show notes and send me your questions. It might be the topic for future episodes.

 And lastly, if you remember nothing else, remember this. You are in control of your life. See you next time.