Stop being a doormat for your patients

One of my goals is to help doctors be happier in their day jobs. This does not mean you put on a fake smile, and grin and bear it through your day. What it does mean is you consciously set your boundaries for what you need. Stick with them and let others know. Because the truth is, you teach people how to treat you.

This is not only reserved for your spouse, your teenage daughter, or your yardman. This is for all people. Seriously. Everybody.

Here’s an example: Let’s say you have a patient who notoriously doesn’t listen to your sage advice. For a long while, you have been trying to get her to quit smoking, to exercise, eat better, or be consistent with her blood pressure medication. Or maybe you have simply recommended she apply an ointment to her eyelid for three weeks to improve some inflammation.

But, each time this patient comes in, it’s the same old story: She didn’t have time to eat right or walk around the block three times a week. She didn’t like that the ointment felt greasy (even though she was only supposed to use it at bedtime), so she stopped it after two days instead of two weeks. She didn’t really put any effort out to quit smoking. All her family smokes. Why should she quit, when she’ll be surrounded by second hand smoke?

Haven’t you all heard this before? Let’s face it: We can’t really put their feet to the fire or a gun to their heads to make them do as we suggest. But we can draw the line in the sand. We can say, “I’m sorry, but I won’t be able to schedule your cosmetic procedure until you quit smoking because studies have shown — and I have seen in my practice — that patients who continue to smoke heal poorly.”

Or, we can say, “Because you are not taking your blood pressure medicine properly and you aren’t trying any of my suggestions about exercise or stress reduction, I am going to instruct my office to only schedule your appointments with me at 8am on Mondays. That will require you to make an additional effort to get here early and wade through the traffic. I will be available to you for emergencies, but I reserve my prime time appointments for my patients who work with me to improve their health issues.”

And finally, we can say, “Go back and try that greasy ointment for another 12 days, as I originally requested. You still have inflammation of your eyelid because you didn’t use the medication as I prescribed it. We can’t know if the treatment didn’t work if you don’t actually do the treatment, now can we?”

What happens when you quit being Dr. Doormat? You release the negativity that surrounds patients who are not compliant. Sometimes, your patients will start towing the line. Other times, they go elsewhere and start the same story with another doctor. Sometimes, you must release the good to make room for the great. If they go, your practice is freed up (as is your heart) for patients who are sincere in improving their health, and who will work with you to make a difference in their health.

It’s time to roll up your sleeves and roll up your doormat.

Starla Fitch is an ophthalmologist, speaker and personal coach.  She blogs at Love Medicine Again and her upcoming book, Remedy for Burnout: 7 Prescriptions Doctors Use to Find Meaning in Medicine, will be available this summer. She can also be reached on Twitter @StarlaFitchMD.

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  • Dr. Drake Ramoray

    A few points to make.

    1. Most of us don’t do cosmetic procedures

    2. I can’t see all of my patients at 8 AM. /s

    3. If my doctor talked to me the way you suggested about not trying the ointment I wouldn’t go back.

    If your goal is to weed out non-compliant patients from your practice then your suggestions would be effective but not terribly professional. If they repeatedly don’t accept your advice then just dismiss them (a paper trail of non-compliance and previous warning is probably helpful) instead of treating them differently and withholding certain aspects of care. They are either a patient in your practice or not. This doesn’t take into account medico-legal ramifications if I was to just say hey Ill see you couple times a year and for emergencies for your uncontrolled diabetes. Good luck with that in court after the patient has a stroke.

    While I think the advice you give (particularly how you go about it) is terrible, I think patient dismissals from practices will be more common as these pay for performance schemes are implemented, especially in under represented specialties with long wait lists for access.

    • NPPCP

      Exactly

    • rtpinfla

      The importance of detailed documentation for a non compliant patient cannot be emphasized enough. A colleague of mine, a excellent and caring internist, had a very non compliant diabetic with chronic and progressive renal insufficiency. He practically begged this guy to control his glucose, all to no avail. He wrote very detailed notes referencing these conversations and his concerns for all the risks that go along with uncontrolled diabetes. The patient finally moved away.
      Several months later a letter from the patients attorney arrived, calling this very good internist, amongst other things, a menace, a danger, and a few other not so nice things. The attorney wanted copies of the health record in preparation for a lawsuit- seems the patient needed dialysis. All records with detailed notes were forwarded and the patient and his attorney was not heard from again.

      • buzzkillerjsmith

        Absolutely. I have one type 1 pt, heck of a nice guy, 30 years old, who simply will not control his sugars. He won’t even check them, going by how he feels instead. I have documented several times that I have advised him to keep his glucose under control and have discussed the macro and microvascular complications and so on and have offered an endo consult, which is going pretty far in this area of 4 month waits to see an endo (sorry, Dr. D.). He just won’t play ball. No known complications so far, thank goodness.

        He can try to sue me, but he won’t win if he does–not in this rural area. He probably won’t ever try, but you never know.

  • DinoDocLucy

    My response is to sit them down for a heart-to-heart talk that starts, “Why do you keep coming to see me if you don’t do what I suggest?” The first time I did it, the patient was terrified I was going to dismiss him, and was very grateful that I wasn’t. But it was an interesting — and far more effective — conversation, more so than many previous ones.

    • buzzkillerjsmith

      Don’t have heart-to-hearts. You’ll learn.

  • buzzkillerjsmith

    Huh? All my pts are non-compliant. It’s part of their charm. I also like nutty people. Years ago when I was struggling with one guy, my mentor said to me, “He’s a loon. Enjoy him.”

    When my doc, who is an NP, tells me I should do something, I usually don’t.

    I used to worry about non-compliance, but time cured that. Non-compliance is a way of life. Try it!

    But if you work for CorpMed, don’t anger your pts. Of course if you work for CorpMed, you have no hope anyway.

  • EmilyAnon

    I’m really surprised there are so many noncompliant patients around. Why do they keep making appointments if ignoring previous advice. I don’t know any such people. I take my appointments seriously, am usually quiet and show appreciation. I have never challenged (although I do google a lot later) or asked provocative questions. I come here to do that. Well, once I did ask one of my docs if he cleaned his stethoscope between patients. He scoffed and was grumpy for the rest of the appt.

    Actually, I’m sure none of my doctors would ever believe I’m the author of some of my “pointed” posts here.

    • Dr. Drake Ramoray

      “Generally speaking, it was estimated that the compliance rate of long-term medication therapies was between 40% and 50%. The rate of compliance for short-term therapy was much higher at between 70% and 80%, while the compliance with lifestyle changes was the lowest at 20%–30% (DiMatteo 1995).”

      Insulin falls in the 20% category as well (data more recent 2005 I believe).

      Yes the data is old but I remember similar numbers discussed when I was in training. I gave the author the benefit of the doubt in assuming chronic non-compliance that puts the patient at significant health risk, as opposed to missing meds rarely.

      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503662/

      • Lisa

        I can believe those statistics about compliance with long-term medication. I just completed five years of tamoxifen and two different aromtase inhibitors for breast cancer, I hated taking the drugs because of the side effects and struggled with compliance even though I was firmly convinced of their benefits.

        I suspect many medications have side effects that make compliance difficult; the fact that you don’t notice the effects of not taking the medication immediately makes it easy to go down the path of not taking the medication.

    • Patient Kit

      I’m a relatively compliant patient. But I do ask some provocative questions and need my docs to explain the “why” of their treatment recommendations. Why do you want to do a Pap smear when I no longer have a cervix? Why don’t I need chemo? If I am in the 10% of women whose ovarian cancer is found at stage 1 and I have a 90% chance of surviving for 5 years, what are my odds of falling into that 10% that doesn’t survive 5 years? I swear, I usually get a smile, a “Good question!” and a good answer that I can understand (without talking down to me). I try to make my questions snappy and as few as possible though. I know my docs are busy peeps and respect their time. But Im not going to comply to something I don’t understand. So, why? why? why? :-D

  • PedsDad

    I’ve used 8 am slots for patients who no-show or are chronically late…but for non-compliance? Really? Maybe you need to not take it quite so personally when a patient doesn’t follow your instructions. Maybe you need to see your job as to advise patients how to get to better health…but not to measure yourself by your results. Try those things and you’ll be much happier in practice. Then, try sitting down with those non-compliant patients and ask questions and find out how you can move them millimeters closer to you.

    But if your job satisfaction is based on how many of your patients follow your instructions, no matter what the obstacles… you probably should go into a QI job where they all seem to think all patients can and will follow all guidelines.

    • guest

      I beg my kids’ pediatrician for 8 am appointments. If we get a later appointment, I know he won’t be on time for it, as he will be running behind, and that makes it difficult for me to get motivated to go to all the trouble it takes to be on time.

  • Lisa

    I love 8 AM appointments. I get in and out and don’t have to take much time off work.

    While you can warn patients of the consequences of non-compliance, you can’t make them comply by brow beating them or by being patronizing.

  • PrimaryCareDoc

    Yeah…not a big fan of punishing patients. Seriously, giving someone a “bad” time slot because they weren’t a good boy or girl?

    Thanks, but no. I’ve got two kids already. I don’t need more. I went into internal medicine to take care of adults, and intend to treat my patients like the grownups they are.

    Most patients are going to be non-compliant to some degree. Because taking a daily medication sucks. It’s a reminder that your body is not perfect in some way. It’s not my job to force people to take the meds. I explain why I think they need them, and they make the decision.

    The only patients I dismiss for “noncompliance” are the ones that are rude and obnoxious about it.

    • EmilyAnon

      “It’s not my job to force people to take the meds. I explain why I think they need them, and they make the decision.”

      There was one incident of patient non compliance that I found unbelievable. My chemo nurse told me that a patient refused chemo. The unbelievable part wasn’t the refusal, but the reason. She didn’t want to lose her hair.

      • PrimaryCareDoc

        I actually don’t find this unbelievable or even that unreasonable. Losing hair is a big deal. I don’t know anything about that patient’s situation, but they might have had a profession that depends on their appearance. For others, the bald head caused by chemo carries a huge stigma, whether real or just perceived.

      • Lisa

        I doubt if you were getting accurate information from the chemo nurse, who was probably telling you about the the other patient as a cautionary tale – ie, don’t be a fool like her.

        I think it was unethical of the chemo nurse to discuss another patient with you.

        • EmilyAnon

          “I think it was unethical of the chemo nurse to discuss another patient with you.”

          That chemo nurse didn’t reveal any more information on that patient than doctors regularly do on this blog when they post a story. And, no, it wasn’t a cautionary tale that I might forgo chemo. On the contrary, when I was told I had advanced ovarian cancer, I asked the doctor, what can I do to fight it. I tried everything. That was 10 years ago.

          • Lisa

            The difference between the what doctos say on this blog and in real life is that in real life you might be able to figure out who the chemo nurse was talking about. I am presuming you and the other patient have the same oncologist, so there is some overlap.

            Why did the chemo nurse tell you the story, for what purpose?

          • EmilyAnon

            ” I am presuming you and the other patient have the same oncologist, so there is some overlap. ”

            Why do you presume that?

            I am treated at a huge hospital with dozens of oncologists on staff, who in turn probably have hundreds of patients each, all of whom probably rotated through the 25 patient infusion room at some time. With all my treatments I never had the same nurse twice. I was always in a private bay with closed curtains, so patients rarely observed each other. No identifying transgression occurred because no personal details were revealed when the nurse told me the story, which, as she was a locum, could have happened at another facility or even years earlier for all I know.

            I don’t know why the chemo nurse told the story, maybe she was just chatty, but I always remembered it.

          • Lisa

            Okay, I retract my statements.

            I live in a relatively small community and I often see someone I know in waiting rooms. I guess that has colored my point of view.

          • Patient Kit

            I’m being treated in a big NYC hospital so I can understand where Emily is coming from on this issue. But I can also imagine that it must be very different being treated in a small town environment. This is one of the great things about online communities. We get to meet peeps who we would likely otherwise not meet and get to understand different experiences better. Technology can be a great thing or a horrible thing. It’s all in how people use it. EMRs, bad. KevinMd, good.
            :-p

          • Patient Kit

            I’d just like to say how very happy I am that you are still with us, 10 years after being diagnosed with advanced ovarian cancer. I was terrified when I was diagnosed with early stage OC, so I can only imagine what you’ve been through, my Survivor Sister! Sharing your story gives us newly diagnosed much hope.

          • EmilyAnon

            Thanks, Patient Kit, for your kind words.

            Just wondering if you’re familiar with the Ovarian Cancer National Alliance Support Community (online) If not, drop by. It’s lively, informative with lots of great ladies comparing their stories, praising, complaining, kind of like here.

            https://www.inspire.com/groups/ovarian-cancer-national-alliance/

          • Patient Kit

            You know, I’ve been on that site but just to read. Thanks to you, I just went and registered so I can participate/contribute. Another site that I should register for is HysterSisters. I found a link there to a 2-hr video of a real surgery similar to mine (robotic hysterectomy) although mine was a little more complicated. I thought I might get a litlle squeamish watching real, not simulated, surgery — but I couldn’t stop watching. It was fascinating. I kind of wish I watched it before my surgery instead of months after. The video was on a hospital website in Iowa. My surgeon didn’t suggested watching it. It took a HysterSister to make me think of watching it. Thanks very much for the Ovarian Cancer National Alliance Support Community suggestion. My name will be Kitchop there (a nickname for PatientKit). ;-)

      • penguin50

        EmilyAnon, you seem to happily assume that chemotherapy benefits any cancer patient who receives it. This is not true. Some of us cancer patients who must weigh the decision whether to receive chemotherapy are told that there is only a TINY chance it MIGHT be of ANY benefit whatsoever, even though the side effects will be as fierce as they are for other patients who—given their particular circumstances—can be confident that the treatment will extend their life. In some cases, patients lose a whole lot more than they gain by receiving chemotherapy.

        • Lisa

          I declined chemo therapy. I don’t think my oncologist labeled me as non compliant.

          • Patient Kit

            My GYN oncologist recommended that we NOT do chemo post-surgery. He explained that, in my case, the risks of chemo far outweighed the benefits — that there could be very serious side effects but chemo would not increase my already good odds of surviving 5 years. The decision was not made without some discussion, with both the hospital’s Tumor Board and with me. (My OC was Stage 1a, Grade 2.) He’s monitoring me every 3 months for recurrence and I’m comfortable with the decision not to do chemo.

            I also think that a lot of cancer patients don’t understand that chemo is often not a cure but will only buy them a certain amount of time, like a few months. I’m not minimizing the value of a few more months but doctors need to make their patients understand that that is what they are opting for a lot of times, not a cure.

        • EmilyAnon

          “EmilyAnon, you seem to happily assume that chemotherapy benefits any cancer patient who receives it. ”
          Show me where I said that. Happily or otherwise.

      • JR

        Sometimes Nurses or other caretakers ask “why” and the patient gives a half hearted answer that doesn’t really describe the complicated decision making and consideration of risks and values that went into the decision.

        • Lisa

          I’ve done that when questioned by somebody who doesn’t really need to know why I made a particular decision. I don’t want to givie the long, drawn out explanation, which I am not sure will be understood anyway, so I give a flip answer.

  • southerndoc1

    Somebody’s in the wrong profession.

  • JR

    Medicine is changing.

    Once upon a time, the general public did not have access to medical information. The public had to go to doctors to get it OR spend hours of research at a library.

    Now, information is available to everyone with a quick google search. The public can’t run their own tests or get their own prescriptions, so they go to the gatekeeper of the treatment they desire: The doctor. Patients frequently have a pre-conceived notion of what they want.

    This problem is just going to grow. There are now companies offering testing directly to patients without a doctor’s involvement. Blood pressure can be measured at a machine at the grocery store. The public is pushing to have more medications, like the pill, to be non-prescription. Retail stores are the ones listening to patient desires by offering specific services, such as vaccines, conveniently.

    More and more young people are demanding that doctors be partners in their care. Not parents. Not dictators. Partners.

    This doesn’t mean a doctor’s opinion isn’t valued, it’s just that many patients want to hear the doctor’s opinion and include that as part of their decision making, not replace their decision making with the doctor’s opinion.

    • rtpinfla

      I used to consider myself as a knowledgable expert that people with would seek out for my opinion regarding what the problem is and how to best resolve the problem. Sometimes this is still the case
      More and more, I feel like I am perceived as a barrier to what the patient insists they need based on Dr. Google.
      My opinion seems to matter less and less. Sadly, I’ve grown weary of trying to convince patients that they don’t need an antibiotic for a tension headache (they insist it’s a sinus infection) or needless tests to prove that have “gluten intolerance” whatever that means. I simply give in more often than not nowadays. I usually tell them I don’t think the meds or tests will help but I still do it. If I don’t they will find another doc that will and then write that I am a terrible doctor and human being on healthgrades dot com.
      I am happy to partner with a patient to get to the desired outcome. The problem is, too many patients think they know way more than I do based on their google search.
      You are right aboutn one thing, this problem is going to keep growing.

      • Lisa

        My doctors’ opinions matter to me. So when I ask for a test, it is to provide more information so I can make up my mind about their recommendations or to explain persistent symptoms that aren’t being explained to my satisfaction. I am not willing to put up with something as part of being old.

        • rtpinfla

          Sorry but there is exactly the issue. For example-I tell a patient they have a tension headache and not sinusitis so an antibiotic is useless. I also tell the patient why I think this is the case (wrong symptoms for infection, trigger points in cervical muscles or TMJ, etc.) and why further testing is not needed. So then a patient says “Well your opinion matters, but but I wanta CT scan of my brain and sinuses so I can make up my mind about your recommendation. Google says it is probably a sinus infection or a brain tumor.. In other words, “I don’t think you are correct and will continue to think you are wrong until I get the test I think I need”. Either you value my opinion or you don’t. I am happy to discuss the relative merits of a test/treatment and take no issue with that. I do get frustrated when a patient already has their mind made up and no amount of reasoning will dissuade them.
          Like I said, I pretty much just do the test now with a smile on my face.

          • Lisa

            I wasn’t talking about testing to determine if a diagnosis was correct or not. I was talking about testing to determine if the treatment they are recommending was warranted.

            Example, my oncologist recommended chemo therapy after it was determined I had multi-centric breast cancer. I had the results from one oncotype test (tumor A) but asked for a second oncotype test on tumor B. My oncologist was sure my insurance wouldn’t pay; I told him if that were the case I would pay for the testing. It turned out that tumor B was less aggressive than tumor A and I really wouldn’t benefit from chemo therapy. And insurance paid for the testing.

            Another example, after my breast cancer diagnosis my hip started bothering me. I complained about pain and was sent off for x-rays, which looked fine. I took more anti inflamatories and tried not to worry about a bone met. After several years of increasing pain and other symptoms and repeated x-rays which showed no problem, other than some mild arthritis. I asked for an MRI. It turned out there was a large labrum tear and I had severe arthritis. The x rays just didn’t show the extent of the damage.

            What do you do when your treatment recommendations don’t help the problem? Do you decide the patient is being non-compliant or do you consider further testing to see if your initial diagnosis was correct?

          • rtpinfla

            I generally look further. I assume ifa patient keeps coming back with the same problem they aren’t the issue, I am the issue (e.g. what am I missing). I rarely, if ever, jump to non adherance (I never liked the term non compliance) until all other pssibilities have been explored. it sounds like you are a pretty reasonable patient with your requests. We’d get along just fine if I were an oncologist.

          • Lisa

            I am very glad to hear you’d look further.

            One of my pet peeves is being told that I am low risk (as a cancer patient) or the side effect I am complaining about is nothing. I don’t mind treating the symptom conservatively as an initial approach, and am very happy if that approach works. But if that doesn’t work I want to know what is causing the symptom.

          • JR

            It seems the problems you are describing (headaches and bowel problems) are, in general, problems that are really hard to pinpoint the cause. It’s really a lot of trial and error to figure out, and frequently all that can be done is symptom management. It must be really frustrating be faced with a patient that can’t be helped.

            I don’t know what your patients want, but I know before my diagnosis this is what I wish my provider would have done/said:

            1. Admitting that It’s really hard to diagnose what is causing these symptoms. It takes commitment and trial and error.

            2. Chronic problems frequently need multiple appointments to pinpoint and to manage.

            3. Explaining that less risky/invasive procedures may ultimately be best for the patient, and aren’t the place you’d prefer to start – but there may be a time in the future they are appropriate.

            4. Give the patient homework. Talk to family about their health to get a more complete health history. Tracking symptoms when appropriate. Join support groups or try different kinds of symptom management.

            That basically deflects the need for a dangerous test while still letting the patient know you’re willing to work with them.

            Note this is just my personal opinion and I know it won’t help with everyone, but I hope it’s helpful to you. I feel that when a patient really focuses on a test it means that they are worried and scared, but don’t want to show it to their doctor. I think in many cases it’s fear that drives the need for the test, and the false security the negative test result will bring.

      • Patient Kit

        As the saying goes, knowledge is power. As a patient, I am very happy to be able to do my own extensive medical research online these days. It makes me a more informed patient, able to ask my doctors more informed questions, have more informed discussions with them and it makes me more prepared to understand what they are telling me about my condition and the treatment they are recommending.

        That said, we live in a time of infinite available information and misinformation. You have to be able to evaluate what sources are reliable and which info is relevant at all and specifically to you. And you have to read and sort through a lot, not just the headlines. Unlimited info does not equal knowledge. You have to know how to interpret the info and what to do with it. We vary in how well we can do that. But controlling access to info is a thing of the past and that is, largely, a good thing.

        I value my doctors’ opinions very much. I know that they have extensive medical education and training that I don’t have. But I also know more about myself than they know and I don’t blindly trust time-crunched doctors, especially doctors I don’t know well and don’t have a good, long relationship with. What I want from my doctors is a partnership in decision-making about my healthcare.

  • Martha55

    I don’t smoke, maintain a healthy weight, exercise regularly and take my prescriptions as directed.

    But I love a glass of good wine and aged cheese…will I be punished with 8am appointments for drinking alcohol and eating high fat dairy?

    I also love good food, especially desserts…will I be punished with 8am appointments for eating too much sugar?

    I’ve tried meditating but I just can’t stand it..will I be punished with 8am appointments for failing to deal with stress?

    My doctor recommended I get a mammogram…will I be punished with 8am appointments for saying no?

    How will I know I if I will be punished for a choice that I make. Will there be a list?

  • mvchrist

    Very good post. As physicians, we seem to always be expected to think our patients can do no wrong. We’re expected to never call them out on their poor decisions. But that’s human nature right? No one wants to be told they’re wrong, no one wants to hear that they might be the cause of their problems. But as physicians, we MUST do this. We are obligated to inform our patients of these things because many times, it is the very reason they have their problems. And if the patient does not wish to comply, we have an obligation to tell them they are wrong. Sometimes that needs to be in the form of “You are being stupid!” People’s lives are at stake! I get furious at people for their noncompliance. Why? Because I care! If I didn’t give a crap, I would just tell them to get lost, you don’t want to listen to me? Fine, then I’m done seeing you. Perhaps that is justified but since I care to be a good physician, I want to make my patients better. So I will tell them my honest opinion and I hope it will make them wake up and do the right thing.
    In the end, this is about being responsible. We as physicians are responsible for offering good medical advice/care. Patients are responsible for their decisions, good and bad. That includes following through with their care plan. If you cannot hold up your end of the bargain, there is no room for complaint.

  • Robbie

    I just wanted to add that Dr Oz ate lentils. He is seriously non-compliant and should never get another procedure from his Doc, ever, because of it. I guess Dr LaPook is just a doormat.

    ” It didn’t take long before he began grumbling about the inadequacy of
    my prep. My colon was littered with the lentils I had heedlessly eaten
    the day before. I had been a mediocre patient, the kind I lecture
    about-and to-in my practice and public life. As I lay on the gurney, a
    snapshot of thousands of conversations I had had in my office with
    patients on whom I was about to operate formed vividly in my mind.

    My
    emphasis in those situations is always pointed: I look them in the eye
    and tell them I need their help, that this is a combined effort and that
    we will get through this together but that we both have
    responsibilities. I always feel frustrated when my patients seem to
    think that precise medical instructions based on years of experience
    don’t apply to them. I was now that person.”

    http://www.huffingtonpost.com/2011/06/08/when-dr-oz-became-mr-oz_n_873371.html

  • Suzi Q 38

    “…….. Sometimes, your patients will start towing the line….”

    I did not know that there was a “line to be towed.” You sound a bit parental, LOL.

    “….Other times, they go elsewhere and start the same story with another doctor….”
    Definitely, by mutual agreement. Not every doctor is good for all patients, and vice versa. Don’t assume that the patient will start the “same story.” Maybe the patient will seek out a professional that is more to their liking
    and may improve their care when you failed.

    “…..Release the good to make room for the great???”

    I have never been “dumped,” although I have “dumped a doctor or two.
    Losing a patient or client to another physician is rarely good for business.

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