Stop rewarding bad behaviour

6 minute read

Next time a patient messes you around, ask yourself if they’d treat any other service provider that way.

If you are a GP who cares primarily for vulnerable populations, or is salaried, this article is likely not for you. 

For everyone else, who is moving away from universal bulk billing for their own sanity, practice viability, profitability and struggling with boundaries, read on if you wish. 

I am primarily a procedural and mental health GP and have been for most of my career post fellowship. My background is in O&G and sexual health, mental health and skin cancer work. 

The mental health and procedural work are usually extended appointments beyond skin checks and biopsies and a single no-show or late cancellation per day can significantly impact my day and business overheads over months and years; did I mention they also annoy me immensely as these spots are hard, if not impossible to fill at short notice.

So I have very firm policies which people occasionally still push back against after initially agreeing to them. 

Last week, on a premium Saturday spot, I had a new patient no-show for a 45-minute appointment. Given we take a non refundable hefty deposit, I offered them a 30-minute empty spot four hours later the same day to which they were 10 minutes late. 

They needed a procedure done, I raised their no-show, then tardiness and my policy including my one reschedule and then “you find another doctor” rule. They apologised, said it would not happen again prior to booking their “final chance” appointment three weeks later. 

Five days later: “I need to reschedule my appointment”

I emailed to discharge them from the clinic. Yesterday I received an email expressing their disappointment at being let go “before we had commenced treatment”. 

I began my series of articles around money and medicine about a year and a half ago, talking about how much money we lose as doctors in private practice by letting things slide due to poor boundaries. 

Each week, I get DMs from people I don’t know, asking for advice – “read my articles”, I say. 

Whenever I’ve implemented boundaries around attendance, late cancellations and no-shows in the past, or simply said no, I’ve been called names – rude, nasty, difficult, greedy and more. 

While I understand that it is often the patient’s attempt to deflect their own failure to communicate and be organised onto me, the fact remains that by and large, as an industry, we allow this behaviour every time one of us lets it slide. 

We agonise over raising prices/fees. 

We agonise over saying no to antibiotics for viral URTIs due to fear of losing “customers”.

We agonise over saying “you’ve only booked in for a 15-minute appointment and I dislike running late for the next patient so you’ll have to book another appointment for the remaining concerns”. 

We agonise over questions about our billings and charging gap fees and saying no to requests to be bulk billed as we wind up consults. 

Every single day, it can feel like death by a thousand cuts. 

For my part, given the immense toll on me, I have decided that I choose not to work with such people, who usually cancel because they can. This behaviour may not be malicious but it has an impact on my own desire to stay in my job, avoid burnout and to be paid for my time in clinic.

Recently I had a therapy patient who’s been seeing me for six months refer to herself as driven and a “high achiever”. I replied to her, in all seriousness, “that is good, because I don’t work with people who aren’t committed to doing the work, because we won’t get you results.” 

At some stage we have lumped all patients into people we need to rescue, at any cost, including from their own mistakes, when the more psychotherapy work I do, on myself and with patients, the more I am convinced that boundaries are essential to any healthy relationship including and especially the therapeutic one. 

Unlike our psychology brethren, who are firmly taught about transference and countertransference and healthy boundaries, the rest of us in health and medicine are not. Many, if not most of us, no doubt chose medicine in order to help others. Many of us likely have unmet desires to help others at any cost because it is how we feel good about ourselves. Some of us have rescued patients when it may have been better to let them face the consequences of their own choices. 

At some point we have to ask, if we have any self-awareness at all, if we are responsible for the burnout we face daily, and the entitlement we see in clinic regularly. 

Does anyone go to the dentist or orthodontist and expect NOT to pay? Or haggle over fees? 

Does anyone book a holiday, with non refundable accommodation, and NOT attend due to “Johnny’s soccer game”? 

Life is about priorities and at some point my feeling is – barring social determinant factors, which I am not referring to here – patients behave the way they do and take those of us who are easily accessible the way they do, because they can. 

When we say no, they don’t like it. More often than not, we care more about being nice than being kind and saying “no, you breached our policies and I won’t have you back”. 

As doctors and especially as general practitioners, we are learning everyday through the frustrations we are facing at the moment – around fees, around availability in our downtime and around patients who won’t show up and expect to be accommodated anyway. 

As my MDO keeps reminding me the last time I checked, we are under NO obligation to say yes to any patient whom we don’t wish to see, barring a true emergency. None. 

This week, and last week and the week before, I have begun culling my books of the patients who are simply more trouble for my mental health than they are worth. Maybe I’ll go under and end up doing endless ED locums. Time will tell!

Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.

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