Patient dismissal: The when, why, and how

The prescription abuser, the never-payer, the no-shower, the surly swearer, the stubborn self-diagnoser - when these problem patients show up at your practice, they grate on your nerves, bring out the worst in you, and ruin your day.

What can you do? Patient dismissal is a drastic step that most doctors are loath to take. But some patients go beyond "difficult," to abusive; some physician-patient relationships fray beyond repair; some patients just will not follow their treatment plan; and some patients do not pay their bills.

Internist Toni Brayer, the regional chief medical officer at Sutter Health, a large network of physicians and hospitals in Northern California, says that while dealing with tough patient problems is part of being a good doctor, there are some things that physicians and practices should not tolerate. One physician Brayer knows, for instance, recently discharged a patient who repeatedly demanded a specific treatment for his thyroid condition. Not only did the physician disagree with the treatment requested, the patient failed to take his prescribed medication, neglected to follow up with testing, and repeatedly missed appointments. "It creates a really unsafe environment for the patient and frankly, great [legal] risk for the physician," Brayer says. "The doctor cannot in good conscience go against good medical practice."

Yet instead of discharging patients like this, many physicians suffer through unpleasant encounter after unpleasant encounter without taking any action, often to no one's benefit. If you're one of them, consider this: Not only will failing to discharge the patient cause you stress and potentially endanger the patient, it could also cause some serious legal issues for you down the road. "I can hardly think of a time where a [malpractice] case went to trial and the physician did not say to me, 'I knew that this patient was bad news,' or 'I hoped that she would go away on her own,' or 'I didn't take the time to figure out how I could terminate the patient,'" says Susan Keane Baker, a consultant in risk management and patient relations based in New Canaan, Conn. "It's not the patient who's terminated that keeps the doctor up at night. It's the one who should have been terminated but wasn't."

Before you dismiss a patient, you should take all reasonable steps to make the relationship work. But if those good-faith efforts fail, don't be afraid to take action to discharge the patient. Just be sure you do it in the right way.

Before you discharge

Some of the key scenarios in which discharging the patient may be necessary are when a patient:

• Is dangerous, threatening, or abusive;

• Fraudulently uses controlled substances;

• Files a lawsuit against you;

• Refuses to follow recommended medical treatment;

• Frequently misses appointments without notice;

• Repeatedly fails to pay bills despite his ability to pay and/or your efforts to provide him with a suitable payment plan.

But there is no universal legal standard for determining the appropriateness of patient dismissal in different scenarios, says Steven Kabler, attorney at Denver-based Jones & Keller. "From a malpractice and medical board standpoint, a physician can basically discharge a patient for any reason he wants, as long as it is nondiscriminatory and doesn't violate [the Emergency Medical Treatment and Labor Act] or other laws, or puts the patient's health, safety, and welfare at risk," says Kabler.

But those are big qualifiers, requiring a working understanding of different areas of the law. It's best to have a patient-dismissal policy in place that your attorney has reviewed.

Keep in mind that dismissal should be a "last resort," says James Saxton, attorney and chair of the healthcare litigation and risk management group at Stevens & Lee, a law firm based in Lancaster, Pa. Prior to dismissal, it is critical to first take steps to attempt to remedy the situation, and carefully document those steps in the patient's chart. For instance, if you are contemplating discharging a patient for nonpayment, consider offering additional payment options, such as payment by credit card or a mutually agreed upon payment plan. Or if you suspect that a patient is abusing prescriptions, the basis for the suspicion (if not hard evidence) should be discussed with the patient and documented, says Saxton. Following that discussion, if the patient's behavior continues to support suspicion of abuse, the patient may then be discharged from the practice, he says.

Beyond the legal implications of discharge are the ethical considerations. "The physician-patient relationship is extraordinarily important," Saxton says. "It's important to the patient, it's something that they rely on, it's something that's special in the law. We tell physicians all the time they're going to have challenging patients, they're going to have personality conflicts, but they're an important part of it … and they should work hard to try to make it fit."

Dismissal time

When a patient's behavior does not change despite your efforts and warnings, then severing ties may be your last option. But tread lightly. There are guidelines on the timing and process of patient dismissal, as well as simple best practices for any professional who deals with the public, especially one vulnerable to lawsuits.

If you do not follow them, you could be in trouble. A disgruntled discharged patient, for instance, may attempt to sue you for abandonment. A "good relationship between the patient and physician often is what protects the physician from professional liability claims," Saxton says. "If you terminated them in sort of the 'wrong way' - you've left a bad taste in their mouth - you might be exposing yourself to a claim."

Discharged patients may also issue complaints to your state medical board, says Kabler. If the board were to determine that in treating the patient you did not meet "the generally accepted standards of medical practice," penalties could range from a letter of concern to public admonition to a revoked medical license. "Keep in mind that the relationship between a physician and patient is for the benefit of the patient, and regulatory bodies regularly view it that way," says Kabler, who formerly served as general counsel to the Colorado Board of Medical Examiners.

That's why it's essential to ensure that you are familiar with all of your state's requirements related to dismissal before beginning the process, says Robin Diamond, an attorney and registered nurse who serves as senior vice president of patient safety and risk management at The Doctors Company, a nationwide malpractice insurer.

If you do not have a dismissal policy at your practice, Saxton recommends seeking counsel with an attorney to help you develop one. "It's not a big expensive project, but a good healthcare attorney can unemotionally set the stage for the physician and keep them out of the potential pitfalls," he says. Once a policy is in place, it's not necessary to contact the attorney each time you decide to discharge a patient, but Saxton does advise seeking counsel when less common or difficult dismissal situations arise.

Baker says it's also a good idea to contact your professional liability carrier to determine what its policies and recommendations are for patient dismissal. Again, you do not need to contact the carrier every time you choose to discharge a patient, but you should ask the carrier to inform you if it makes changes to its policy or sample letter. That way "you will have the correct information about what exactly is involved with terminating a patient," she says.

Finally, check your contract with the patient's insurer to be certain you are complying with it, says Diamond.

Inform and document

Next, document in the patient's chart the reason for dismissal as comprehensively as possible, says Kabler. In the event that the patient makes a complaint or claim, thorough documentation will help prove to a third party that you had a "valid reason" for patient dismissal, that the reason was not discriminatory, and not in violation of any laws. The documentation should also be straightforward and objective, says Saxton.

In addition, notify all of your staff members of your decision to discharge the patient and instruct them how to handle any contact initiated by him, says Baker. "You don't want a staff member to inadvertently reopen the physician-patient relationship if a patient calls and says, 'I would like an appointment,'" she says. Remember that the rules of patient confidentiality still apply: Staffers should be told only what they need to know to do their jobs.

Another good policy is to identify one staff member to handle all of the discharged patients' questions, requests, and complaints, says Kabler. That way, as soon as the patient contacts the office, your staff will forward his inquiry to the employee who knows how to handle the situation appropriately and calmly.

The break up

Finally, notify the patient of his dismissal by providing him with a dismissal letter. This letter should reflect your concern for the patient and your hope that he will find a new physician who will better meet his needs, says Saxton. "Take a little extra time to make sure if a third party looked at your letter that they would say, 'This doctor is professional and is compassionate about terminating this relationship with the patient.'"

In the letter, include:

• The reason for dismissal. If the reason is supported by objective data (for instance, the patient repeatedly failed to fill prescriptions, evidence he was not complying with his treatment plan), include it in the letter. If the reason is more subjective (for instance, the patient is rude to staff members), use a more "general" approach, says Diamond. For instance, she suggests writing, "My concern is that you and I no longer have a therapeutic relationship, and I can't treat you and do for you what I need to do as your physician."

• Record release information. You must provide the patient with a copy of his medical record, says Kabler. In the dismissal letter, state how the patient can request a copy and/or how he can request it to be sent to another provider. If he asks you to forward it, have him sign a release indicating that he wishes you to do so, says Diamond. If you normally have a fee for copying and sending the record, it's best to waive it. "Absorbing that [cost] as a matter of good will is probably good strategically," says Saxton.

• Referral guidance. Instruct the patient to find a new physician and provide him with contact information for nearby hospital or medical society referral services, says Baker. Do not specifically recommend another physician, as the patient may claim that in following your advice, he visited the physician and his health suffered as a result, she says.

State laws vary regarding the required method of delivery for dismissal letters, says Saxton. Make sure you send the letter using the appropriate method. If the letter is sent via first class mail, in addition to the required method, the letter is presumed received.

Finally, save the delivery confirmation, put a copy of the letter in the patient's record, and send a copy of the letter to your professional liability carrier, if it requests it, says Baker. "If you should need it, you want to be able to access it quickly."

In limbo

Your dismissal letter must also include information regarding the notice period. This is the amount of time you will continue to provide the patient medical care after sending him the termination letter, to give him time to find another provider. States usually have statutes or recommendations for physicians regarding the duration of this period, usually ranging from 15 days to 30 days, says Diamond.

In Colorado, for instance, the medical board's policy is that physicians should provide emergency or necessary care to patients for 30 days after termination, says Kabler. During the 30-day period, Colorado physicians may refuse the patient's requests for nonemergency treatment, and may cancel any of his previously scheduled non-emergent appointments.

Though such policies are usually nonbinding, they are smart to follow, says Kabler. Medical boards will likely use those policies to determine whether you followed the standard of care, should a question or complaint arise, and in the event of a malpractice lawsuit, you don't want to seem callous. But if it is not practical for the physician to provide the patient with the recommended notice period - for instance, if the patient is dangerous - the board will likely take that into account, Kabler says.

Also, if it's likely that the patient will encounter difficulty finding a new physician - for example, if he requires highly specialized care or lives in a rural location - it's smart to provide him with a longer notice period than required, says Diamond.

Be sure to include the final termination date in the dismissal letter.

Complications

In general, the dismissal process and the dismissal letter should remain consistent regardless of the reason for termination, says Baker. Still, there are a few variations to consider:

When closing your doors or cutting back. Follow the standard termination process. However, consider providing patients with notice sooner than required, says Kabler. This will make the process easier for both of you.

Also, consider creating a website or altering your current website to provide patients with discharge information and a link or e-mail address to which they can send medical record requests.

If you encounter a record for a patient you have not treated in a significant amount of time, follow the standard termination process, says Diamond. "Never assume that … the patient doesn't still believe they're in a relationship with [you]," she says.

When a patient is "difficult." Follow the standard termination process. If the patient is having a problem with a staff member, remove the employee from the patient's care during the termination period, says Kabler. If the conflict is with the physician, another physician at the practice may treat the patient during the notice period. If the patient requests the primary physician specifically, "it's OK for the physician to say no, unless the replacement physician can't provide the care that's necessary," says Kabler.

Finally, send a copy of the patient's medical record directly to him at the very beginning of the termination process through certified mail. "Be proactive," says Kabler. "Difficult patients always present difficult issues later."

When a patient sues. Just because a patient makes a claim against you doesn't mean the physician-patient relationship is terminated. Though it may be difficult, follow the standard termination process and continue providing the patient with emergent care until the final termination date, says Kabler.

When a patient doesn't pay. Follow the standard termination process. Do not withhold the patient's medical record pending payment, says Baker. You will also need to determine how to deal with the patient's unpaid bills. Think twice before sending a collection agent after him. It might push the patient to make a claim or complaint, she says. "Sometimes you make decisions, and if you considered the bigger picture, you just wouldn't make the same decisions."{C}

In Summary

If you're convinced you must sever the physician-patient relationship, follow these steps:

• Ensure your practice has patient-dismissal policies in place that comply with your state's laws.

• Thoroughly document the reason for the patient's dismissal in the medical record.

• Send the patient a letter of dismissal, providing an adequate notice period.

• Inform staff members of the patient's dismissal and instruct them how to handle any contact from the patient.

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Social epidemics and the role of physicians

In the first blog, I discussed infectious epidemics and the recent social epidemic of loneliness. In this second blog, I will briefly mention the burnout epidemic, which has received ample attention in our literature and professional meetings. I will discuss the epidemic of social media toxicity and its impact on our children.

The burnout epidemic

I hear physicians asking questions that I have been heard in surgical lounges and medical dining rooms. Some of these questions I've frequently heard include:

• Did I choose the right profession?
• Would I recommend a medical career for my children?
• Should I make a career change?
• Is it time to retire?
• Should I have stayed in private practice instead of being employed as a physician?

These are just a few questions indicating that medical practice blahs impact many of our colleagues.

Burnout can have many negative consequences for physicians. Burnout can lead to depression, anxiety, chronic stress, irritability, decreased self-esteem, and even increases the risk of suicide. It is noteworthy that the suicide rate among physicians is greater than in other professions and also higher than in the general population. It is also of interest that there are higher rates of alcohol use among physicians experiencing burnout.

Burnout can lead to decreased job performance, increased absenteeism, and decreased enjoyment of our practices. It can also lead to increased medical errors and increase the risk of a malpractice suit. This will ultimately affect patient satisfaction and can impact our online reputation. This decrease in enjoyment also motivates physicians to leave the practice of medicine at an earlier age.

Finally, burnout can also negatively impact our health and well-being. Burned-out physicians are at an increased risk for cardiovascular disease (Appels and Schouten, 1991; Toker et al., 2012; Toppinen-Tanner et al., 2009) and other health consequences, including hypercholesterolemia, type 2 diabetes, coronary heart disease, hospitalization due to cardiovascular disorder, musculoskeletal pain, fatigue, headaches, gastrointestinal disorders, and respiratory problems. (Salvagioni et al., 2017).

Suggestions for beating back burnout

We can start small and make micro-adjustments that will improve our attitude towards our practices and make our situation more tolerable. For example, if you are a middle-aged physician and entering data in the EMR is daunting or emotionally painful, consider asking for a scribe to do the data entry. Now, we have software programs that use AI to convert voice to text, which may eliminate the need for scribes.

If we are having difficulty starting our office clinic at 9:00, we should consider negotiating different work schedules so we can start and end our day on time.

If working 60-plus hours a week is difficult, consider opting out of evening and weekend calls. Of course, this will reduce compensation.

Another suggestion is to leave your comfort zone and the boredom accompanying burnout. A personal example from my practice occurred after I performed my 3000th penile implant. I found I was bored with the operation and not having that dopamine rush which usually follows a successful operation. I changed my focus from men's health to female sexual dysfunction, which is a condition in its infancy. I attended lectures and meetings on the subject. This shifting of gears allowed me to leave my comfort zone and reduce my boredom.

A final suggestion is to consider a career change. Change can be challenging, exciting, and rewarding. When I speak to doctors who have changed careers, I often hear a response after six months in the new career: "I should have done this sooner!" For physicians considering a career change, I recommend reading Sylvie Stacy's 50 Unconventional Careers for Physicians.

Epidemic of social media

In the previous blog, I mentioned that Attorney General Vivek Murthy issued a report identifying loneliness as reaching epidemic proportions. In the spring of 2023, United States Dr. Murthy released an advisory called Social Media and Youth Mental Health, in which he said there is growing evidence that social media is causing harm to young people's mental health. The American Psychological Association (APA) issued its health advisory in 2024 requesting that the surgeon general place a warning label on social media platforms about the health hazards of excessive use of social media. This could be similar to the label required on cigarette packages warning about the dangers of smoking.

Social media use among young people is nearly universal now, based on surveys from the Pew Research Center. In 2022, up to 95% of teenagers surveyed (ages 13 to 17) reported using social media, and more than a third use it almost constantly.

Pew has also tracked which social media platforms (or "apps") teenagers use. In 2023, it found that the majority of teenagers—9 out of 10 for ages 13 to 17—use YouTube, followed by TikTok, Snapchat, and Instagram.

There are indicators that social media can cause profound mental health and physical harm to teens using social media. Murthy's advisory was based on a review of the available evidence. His report stresses that the brain is going through a highly sensitive period between 10 and 19 when identities and feelings of self-worth are forming. According to the report, frequent social media use may be associated with distinct changes in the developing brain, potentially affecting such functions as emotional learning and behavior, impulse control, and emotional regulation. The issue is the amount of time adolescents spend on platforms, the content they are exposed to, and how their online interactions disrupt activities essential for health, such as sleep and physical activity.

Over the last decade, increasing evidence has identified the potential negative impact of social media on adolescents. According to a research study of American teenagers 12-15, those who used social media over three hours each day faced twice the risk of having adverse mental health outcomes, including depression and anxiety symptoms. Although the minimum age most commonly required by social media platforms in the U.S. is 13, nearly 40% of children ages 8–12 use social media. That signals how difficult it can be to enforce these rules without parental supervision

Eating disorders are yet another concern. A review of 50 studies across 17 countries between 2016 and 2021 published in PLOS Global Public Health suggested that relentless online exposure to largely unattainable physical ideals may trigger a distorted sense of self and eating disorders. This is a particular problem among girls.

In addition, people who target adolescents—for instance, adults seeking to sexually exploit children, to financially extort them through the threat or actual distribution of intimate images may use social media platforms for these types of predatory behaviors.

According to Murthy's advisory, excessive social media use can harm teens by disrupting important healthy behaviors. Some researchers think that exposure to social media can overstimulate the brain's reward center and, when the stimulation becomes excessive, trigger pathways comparable to addiction.

Excessive use has also been linked to sleep problems, attention problems, and feelings of exclusion in adolescents—and sleep is essential for the healthy development of teens, according to the advisory.

The role of physicians in curbing use of social media

The American Academy of Pediatrics (AAP) offers a free digital tool called the Family Media Plan to help parents create a customized media use plan for their family. In addition to setting the age at which you plan to start giving your kids phones or internet access, this plan can be used to establish rules and educate children and teens about being careful about privacy settings, avoiding strangers online, not giving out personal information, and knowing how to report cyberbullying. Most pediatric experts agree that elementary school-age children should not have internet access using a device with all the social media apps.

One strategy is to make a social media plan for your family before the teenage years. Parents might consider starting with a dumbphone, or a cell phone that doesn't have email, an internet browser, or other features found on smartphones. The experts suggest delaying full access to smartphones for as long as possible. Go slow and start with a device allowing parents to add more apps as their child matures.

Experts suggest educating patients about the dangers of social media and steps they can take to control their children's use of it. This includes setting clear age-appropriate access limits, maintaining open communication, monitoring screen time, keeping devices out of bedrooms, and discussing online safety practices. Parents should also model responsible social media behavior themselves.

Experts are still debating the ideal age for a child to join social media, so parents should carefully consider their child's maturity level before granting access.

Responsible parents should set limits on screen time, designated social media hours, and specific platforms allowed.

Parents should discuss online safety, cyberbullying, privacy concerns, and responsible digital citizenship openly with their teens.

It is important to regularly check a teen's online presence but do so respectfully without invading their privacy.

Consider encouraging parents to keep phones and other devices out of the bedroom, especially at night, to promote healthy sleep habits. Research shows a relationship between social media use and poor sleep quality, reduced sleep duration, and sleep difficulties in young people. For teens, poor sleep is linked to emotional health issues and a higher risk for suicide.

According to the Surgeon General's report, on a typical weekday, nearly one-third of adolescents report using screen media until midnight or later.

Parents should try to create a culture at home where all phones are turned off by a certain time and at least one hour before going to bed. In my home, I had a policy that phones were not permitted at the dinner table or when the family went to a restaurant.

Parents should practice responsible social media use to set a positive example for their teens. For example, parents should not use cell phones at dinner time, and if they must take a call, it is polite to get up and walk away from the dinner table to talk.

Bottom Line: The healthcare profession has done an admirable job controlling infectious epidemics, including the AIDS virus, and creating vaccines for COVID-19 in a record six months. Now, we need to move on to social media epidemics: loneliness, burnout, and social media epidemics are as dangerous as infectious epidemics. Physicians need to take an active role in identifying these issues and discuss loneliness and social media use with patients and their families. Finally, physicians need to be concerned with their own mental health and find solutions for burnout in their own lives, which ultimately impacts the care we provide our patients.

_________________________

Neil Baum, MD, a Professor of Clinical Urology at Tulane University in New Orleans, LA. Dr. Baum is the author of several books, including the best-selling book, Marketing Your Medical Practice-Ethically, Effectively, and Economically, which has sold over 225,000 copies and has been translated into Spanish.

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2025 offers a remarkable opportunity for concierge physicians to thrive

In health care change is inevitable, but for independent and employed physicians already facing financial headwinds that threaten to topple their medical practices, and the uncertain direction of a new administration, 2025 may feel particularly daunting. You don’t need a crystal ball to predict challenges ahead, but it may require a different kind of vision to see the ever-shifting regulatory, reimbursement and technological landscape as a path to genuine transformation. Almost five decades of experience advising physicians on career strategies has reinforced my view that chaotic times can bring enormous opportunity. Here’s why I believe converting to a concierge medicine practice offers physicians one of today’s (and tomorrow’s) most viable ways to remain or become independent, autonomous and empowered to practice their best medicine.

Challenge: Rising costs, declining reimbursements

There’s tremendous urgency for change as the environment grows increasingly unfriendly for doctors in private practice. Now representing just 22% of all practices, (Physicians Advocacy Institute Report 2022-24) the independent physician is in real danger of disappearing altogether. The combination of increased costs to operate a traditional practice and continual cuts to Medicare reimbursements have contributed to an overall 29% downward slide in Medicare compensation over the last two decades, according to the American Medical Association (AMA).

Reform may lie in the fate of multiple bills now in Congress. As I write this, the proposed 2.8% cut in the 2025 Medicare Physician Fee Schedule is set to go into effect on January 1st, 2025 unless the Medicare Patient Access and Practice Stabilization Act is passed, eliminating the cut and introducing a 1.8% increase. Additionally, bills to implement site-neutral payments have been proposed to remove one of the major financial incentives driving hospital consolidation, and much-overdue conversations are beginning to enact permanent inflationary payment updates to Medicare reimbursements. Commercial payers, caught in a harsh spotlight emphasized by December’s tragedy, may feel pressure to follow suit with measures to help relieve the financial burdens felt by physicians and patients. But will it be too little and too late?

I believe a better solution is offered through concierge medicine. In the more than two decades since its inception, this model has protected doctors from the tightening vise of declining reimbursements on one side and perpetually rising operating costs and inflation on the other. It has defined economic and professional freedom for our physician clients by providing them with a reliable, predictable, and most importantly, sustainable revenue base of membership fees. The pandemic offered further evidence of the model’s undeniable success, enabling our affiliated doctors to provide personalized care and prompt attention to their smaller patient panels without financial concerns from the sharp reductions in office visits and procedures. Post-pandemic, their practices have continued to grow, frequently necessitating the addition of a new physician to the team to meet increased patient demand.

Challenge: Restoring physician satisfaction

Reported levels of burnout have thankfully fallen below 50% for most physicians in the latest Medscape and AMA surveys, but as everyone agrees, there is still much work to do. Of particular note is that doctors involved in front line primary care, such as internal medicine, family medicine, pediatrics and OB/GYN are still experiencing higher rates of burnout. All physicians, however, including specialists in cardiology, endocrinology, rheumatology, neurology and pulmonology, continue to face ongoing financial, professional and personal pressures, and limited options for change. They can seek employment by a hospital system, join a larger multi-specialty group, leave medicine altogether - or convert to an alternative practice model.

At Specialdocs, we’ve long championed the concierge medicine solution, proudly bearing witness to its lifesaving impact for our affiliated doctors across the country. Whether a beleaguered physician mom struggling to achieve work-life balance, a discouraged midlife doctor reluctantly preparing for early retirement, or a young doctor frustrated with the impersonality of practicing in a large hospital system, conversion to our model has ushered in a new era of unparalleled career satisfaction.

Challenge: Adapting to rapid developments in technology

Technological practice advances have been a decidedly mixed bag for physicians over the years, bringing the success of remote monitoring for chronic conditions and convenience of telemedicine, but leaving the universally disliked imprint of cumbersome EHRs. It’s understandable that artificial intelligence, still in nascency, is alternately viewed as friend or foe in health care.

In 2025, the power of AI will likely increasingly be deployed to ease the administrative burden by streamlining tasks such as coding, scribing, and management of prior authorizations and reimbursement denials. With the ability to process and analyze information far more quickly than the human brain, AI’s potential to enhance diagnoses and treatments certainly feels exhilarating. But we must proceed with caution as being too early an adopter is frequently tantamount to being wrong. Hence, the imperative for well-defined guardrails around AI will become even more imperative in 2025, as well as a firmer understanding of what cannot be achieved– chief among them, replacing the sacrosanct physician-patient relationships built over a lifetime.

Challenge: Delivering value-based care

Since 2010, the shift from fee-for-service to value-based care has been widely promoted and pursued. However well-intentioned, value-based care may be the latest example of health care programs that overpromise and under deliver to all its constituents. A recent survey illustrates patients’ rising dissatisfaction with the U.S. health care system: for the first time in Gallup’s two-decade Annual Healthcare Poll, more than half of Americans rated the quality of health care as subpar, with 31% saying it is “only fair” and a new high of 21% calling it “poor.” Further, more than 7 out of 10 Americans believe the health care system has major problems or is in crisis.

I have long maintained that concierge medicine is the only model that really delivers on the pillars of value and quality in health care by benefiting physicians, patients, payers/employers and the health care system. Our physician clients treasure the rare gift of time to truly personalize their care; their patients value timely appointments and being seen before a serious illness develops; payers see fewer claims from concierge patients because of shorter hospital stays and decreased readmissions; and everyone benefits from the dramatic reduction in visits to the ER or urgent care facilities.

2025 can be a year of progress, action and optimism if you seize the opportunity for change.

______________________________

Terry Bauer is the CEO of Specialdocs Consultants, a pioneering company dedicated to transforming physicians’ professional lives since 2002 with a change to its industry-leading concierge medicine model. 

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Epidemics then and now: Managing loneliness, burnout, and social media toxicity

This is the first of a two-part blog series on epidemics, both infectious and social. In this first blog, I will provide a brief history of infectious epidemics and discuss the epidemic of loneliness. I will then provide suggestions for identifying loneliness in our patients and recommendations for helping them solve their loneliness issues.

Epidemics and pan epidemics have occurred for thousands of years. It is interesting how societies have tried to find explanations for infectious diseases that have afflicted large numbers of communities and caused the death of millions of humans. Some scapegoated the gods or their enemies. Others blamed planetary alignments. For many, though, it was just bad air.

Yet even as waves of disease appeared repeatedly, it took centuries for science to fully understand the invisible world of microbes. Until that happened, people under pandemic siege tried to explain the overwhelming death they saw differently. Some used simple observations, while some turned to fervent beliefs. Others viewed the cataclysm through the lens of their long-held biases, while still others processed the carnage through superstitions and bizarre theories.

Medical science has been at the forefront of identifying the causes of these lethal infections and has found ways to prevent these infectious diseases. Now, we have non-infectious epidemics that are social problems. Three of these social epidemics include toxic levels of screen time, especially by teenagers, physician burnout that is at an all-time of greater than 50% and the epidemic of loneliness impacting many middle-age and older Americans. Surgeon General Vivek Murthy declared that we are experiencing a loneliness problem that has reached epidemic proportions.

Loneliness and rebuilding patients' social muscle

The Surgeon General reports that one in two older Americans is living with loneliness. Don't think that this issue only impacts older and senior Americans, as the same report indicates that young people face a 60-70% risk of loneliness. A survey of college students revealed that nearly 80% of college students admitted to having a problem with loneliness. People suffering from loneliness and isolation are at a greater risk for depression, anxiety, and even suicide. Those who suffer from loneliness are also at risk for physical ailments. For example, those who are experiencing loneliness have a 29% increase in heart disease, a 30% increased risk of stroke, and 50% increase in dementia in older people, and an overall increase in mortality that is equivalent to those who smoke cigarettes daily.

Loneliness escalated after COVID-19 as our "social muscle" weakened. We have lost the desire and ability to reach out and communicate with others. Like any skeletal muscle, it weakens and atrophies when we don't use it, but it gets stronger when we exercise it and put it to use.

Suggestions to identify loneliness

Loneliness is a subjective experience, and there are no objective metrics, blood tests, or imaging studies to identify it.

Begin by asking patients how often they feel lonely or if they have companionship. Consider any underlying health or functional limitations that may predispose to loneliness. For example, medical treatments can address mobility or hearing problems, which can lead to loneliness.

Including interventions for managing loneliness

Interventions may consist of working with patients to improve their social skills, enhancing their social support, or referring them to experts who can help solve the issue of loneliness.

Educate patients and their caregivers regarding the adverse health outcomes associated with loneliness and social isolation.

Social prescribing (SP) is an effective option for managing loneliness.

SP can help lonely people by connecting them with community resources and activities that involve interaction with others.

If we identify that a patient is suffering from loneliness, we can refer them to a counselor who helps them find relevant services and groups. These groups can include art classes, walking clubs, or exercise classes.

SP can help people feel more socially connected and improve their communication skills. It helps people manage their illnesses and reduce their use of healthcare services. Evidence suggests that SP can reduce pressure on primary care providers (PCP) and save costs (GY Reinhardt, D Vidovic, and C Hammerton. Understanding loneliness: a systematic review of the impact of social prescribing initiatives on loneliness. Published June 2021, National Library of Medicine.) Fewer people may choose to visit PCPs and other healthcare professionals. In one study, 66% of participants reduced the number of times they visited a GP. (Thompson, L. J, Camic, P M. and Chatterjee, H. J. 2015. Social Prescribing: A Review of Community Referral Schemes. London: University College London)

SP can be beneficial for people who are lonely or socially isolated, especially those with chronic conditions that are made worse by loneliness.

SP differs from traditional healthcare because it focuses on a patient's needs holistically, rather than the band-aid solution, i.e., just prescribing medication.

Advice to patients

Explain to patients that feeling lonely is not something to be embarrassed about. We all feel lonely occasionally, regardless of life experiences, age, or background.

Unfortunately, there is no one way to effectively deal with loneliness.

There is support available from charities. Mental Health America is a valuable resource for finding support groups in every state.

Encourage patients to reach out to friends by picking up the phone or sending them a text message. Patients experiencing loneliness may think their friends and family are too busy to talk or get together but encourage patients to make the first step to connect.

One of the best ways for patients to make new connections is to join local groups or classes based on their interests. Volunteering is another excellent way to get involved in the local community. It is a great way to meet new people and for patients to develop new skills and interests.

Technology has made it possible to stay in touch with friends and family and make new friends. Free courses are often offered in libraries and community centers to help seniors develop digital skills.

Encouraging patients experiencing loneliness to go outside regularly, whether in the garden or in the park, is a great mood booster. Spending time outdoors can help lonely patients feel more connected to our neighborhood and the natural world. (Also, sunlight and vitamin D help strengthen their bones)

We can encourage those patients who are lonely to participate in a religious community.

Share with the patients that joining a church, synagogue, or other religious communities correlates with better health outcomes and longer life, higher financial generosity, and more stable families—all of which are desperately needed in a nation with rising rates of loneliness, mental illness, and alcohol and drug dependency.

Don't forget to discuss nutrition and healthy eating with lonely patients. Ensure they eat healthily, are active, and get adequate sleep.

Focus on the good things in life

When we feel lonely, we can sometimes get into a negative frame of mind. Thinking about the good things in our lives or remembering happy times, such as a holiday, can help us feel more positive about ourselves and the people around us.

Bottom Line: I have mentioned just one social epidemic, loneliness, that the healthcare profession should take a role in identifying and providing suggestions for helping our lonely patients resolve this modern epidemic. In the next blog, I will discuss two more social epidemics: burnout and social media toxicity.

________________________________________

Neil Baum, MD, a Professor of Clinical Urology at Tulane University in New Orleans, LA. Dr. Baum is the author of several books, including the best-selling book, Marketing Your Medical Practice-Ethically, Effectively, and Economically, which has sold over 225,000 copies and has been translated into Spanish.

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The season of gratitude extends beyond Thanksgiving

By Rachel V. Rose, JD, MBA
Fact checked by Keith A. Reynoldsly



According to Webster’s Dictionary, “gratitude” means “the state of being grateful [or] thankfulness.” In light of the Holiday Season and my clients’ experiences with different health systems and hospitals, as both providers and family members of patients, I embarked on a research path to see if there was a correlation between gratitude and both quality of care (perceived or real) and patient satisfaction scores. It turns out that there is a strong connection between gratitude and positive outcomes on reputation and revenues.

According to a 2019 article, What Role Does Patient Gratitude Play in the Relationship Between Relationship Quality and Patient Loyalty?, raises a variety of considerations. Some items to ponder include:

• The health care environment is competitive. If patients (or family members) have an adverse experience, they can choose to go else where and often tell their neighbors about their experience.
• Patient gratitude, patient loyalty, and quality are intertwined.
• There are three relationship quality tactics that those participating in the health care sector should not ignore. For example, “a stronger physician-patient relationship can not only generate a significant impact on the patient’s loyalty to the hospital but it can also make patients more likely to introduce the physician to others.”

The proposed research model was framed with the three quality tactics in mind.

Given the notion of the impact of patient satisfaction scores on reimbursement in some value-based models, gratitude is an item that, if it is genuine, can organically lead to greater reimbursement. Gratitude, like any perceived “currency” also has the place of misuse, as the article Gratitude in Health Care: A Meta-narrative Review suggests.

“Critiquing moral economics, she [Claudia Card] maintains that unpayable debts in this paradigm, where reciprocity is not practical or desirable—as is often the case in health care—make the sense of obligation problematically unresolvable. This position is supported by the research we reviewed that engaged with the meta-narrative of social capital: while economics metaphors are prevalent in the discourse of gratitude, the way it plays out in practice in health care is much more psychologically and philosophically subtle than the metaphor of ‘capital’ suggests.”

Overall, genuine gratitude only has positive benefits – to patients and providers alike. “That gratitude may have a positive impact on quality of life and reduce psychological distress” is something everyone can and should be thankful for.

__________________________________

Rachel V. Rose, JD, MBA, advises clients on compliance, transactions, government administrative actions, and litigation involving healthcare, cybersecurity, corporate and securities law, as well as False Claims Act and Dodd-Frank whistleblower cases. She also teaches bioethics at Baylor College of Medicine in Houston.

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Medicare-supported GME residency positions look to grow the physician workforce and expand health care access

The Centers for Medicare & Medicaid Services (CMS) published its official list of teaching hospitals that were rewarded new Medicare-supported graduate medical education (GME) positions, which were created under Section 126 of the Consolidated Appropriations Act, 2021 (CAA, 2021). The new residency positions—of which there are 200—are intended to contribute to the growth of the physician workforce, allowing for easier access to care for patients across the United States. Approximately 70% of the newly awarded positions will be in primary care and psychiatry residency programs, according to the CMS.

“These new residency positions will have a tangible, positive impact on a diverse mix of communities across the nation, including traditionally underserved areas,” David J. Skorton, MD, president and CEO of the American Association of Medical Colleges (AAMC) said in an organizational release. “Medical school enrollment has continued to grow, but a commensurate increase in residency positions is necessary to help ensure that there are enough opportunities for medical school graduates to complete their training and practice independently.”

According to projections published by the AAMC in March 2024, the U.S. will face a physician shortage of up to 86,000 physicians by 2036. Specific to primary care, the AAMC projects a shortage of 20,200 to 40,400 physicians by 2036. The projection has most of the specialties included under primary care in shortage by 2036, with the exception of general pediatrics, which is expected to be near equilibrium. At the time of the report’s release, Skorton cautioned that, “Without funding beyond current levels, the [GME] growth trajectories hypothesized in this year’s report will not materialize.”

According to the new AAMC release, Congress voted to expand Medicare support for GME—the only increases since the Balanced Budget Act of 1997—in 2021 and 2023 year-end spending packages—(CAA, 2021 and the Consolidated Appropriations Act, 2023 (CAA, 2023).

CMS first announced the distribution of new Medicare-supported residency position awards in 2022 and has distributed new positions each year since. In what is officially the third distribution of positions provided by the CAA, 2021, 109 teaching hospitals across 33 states received slots, which go into effect on July 1, 2025. To date, CMS has distributed half of the 1,200 positions made available under the two laws.

“Teaching health systems and hospitals that choose to train medical residents incur real and significant mission-related costs, beyond those typically associated with providing care,” explained Jonathan Jaffery, MD, chief health care officer of AAMC. “These residency positions are crucial to helping America’s academic health systems and other teaching hospitals invest in more physician training, increase access to care and better serve patients nationwide.”

In their statement, the AAMC applauded CMS’s efforts to address the high-priority workforce shortage, while also urging Congress to build on the progress made through the CAA, 2021 and 2023 by passing the Resident Physician Shortage Reduction Act of 2023 (S. 1302/H.R. 2389). The legislation would gradually increase the number of Medicare-supported GME positions, which would thereby enable progress toward a sustainable physician workforce—one to meet the nation’s patient care needs.

“The AAMC, our members, our partners in the GME Advocacy Coalition and Congressional champions have worked tirelessly on increasing the number of Medicare-supported GME positions to help address the physician shortage and improve health for patients nationwide,” Danielle Turnipseed, JD, MHSA, MPP, chief public policy officer of AAMC, said in the organization’s release. “Both the CAA 2021 and 2023 were important initial steps toward helping to alleviate the national physician shortage and chip away at the cap on slots that has been in effect for almost 25 years. Additional Medicare-supported GME slots are needed to ensure we have qualified physicians to meet the growing and ever-changing health care needs of patients everywhere.”

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Are you working on a 2025 medical practice strategy?

As you sit down with your physician partners, practice manager, and perhaps consultant over the coming weeks contemplating direction for 2025, I thought it may be beneficial to offer a few pointers to help you along the way.For starters, you should pause to reflect upon new competitors in your catchment area, as well as current competitors and new initiatives they are taking on.For physician practices, a competitive analysis is a means to assess who your competitors are, what value they provide, understanding their (and your) strengths and weaknesses, and where your practice fits in. A good competitive analysis is a scouting report of the actual market terrain that your practice must navigate in order to be successful. While analyzing the competition is an essential component of your strategy, most medical practices don't conduct this type of analysis systematically enough. However, a thorough competitive analysis is indispensable.

Gather a list of your practice's competitors. Most of the time, such a list is comprised of who your practice considers to be its chief competitors. However, there may be other healthcare organizations that indirectly compete with yours, perhaps ones outside of your catchment area that offer services such as telemedicine or niche treatment modalities that are aiming for the same patients. You will also want to include information on healthcare entities that may be entering your market in the coming year. Once you have compiled the list, you can highlight those practices that will be the greatest challenge.

Analyze the competition's services in terms of features, value, and target patients. How do they market them? How do patients see your competition? How do referring physicians view your competition? Take an honest look at their offerings. Is your quality commensurate? Do you have similar offerings? What is the unique value you provide that competitors don't or can't? Emphasize these benefits in your marketing.

Compile a list of competitor strengths and weaknesses and remember to be objective. You'll do your practice no good if you allow bias toward your own physicians, staff, and services to cloud your judgment. Try to see the competition's practice as though you were them. What makes their practice so great? If they are growing rapidly, what is it about their practice that's promoting that growth?

Observe how your competitors market themselves through advertising, collateral material, and perhaps the use of physician liaisons. You will have to go to many different sources to get a complete picture. It takes practice and a little shrewdness on your part to piece together a complete picture of strategies and objectives, so the use of a qualified consultant may be to your benefit. Focus on the facts, be persistent, and trust your intuition to help you.

Determine the current market demographics for your practice. If the market is flat, then the competition for patients is likely to be fierce. Your practice will find itself scrambling to win market share. The outlook portion of your analysis may seem like forecasting, but it's really a measure of trends. By the time you've done most of your research, you'll have enough information to determine what the outlook really is.

By evaluating yourself against your competition, you'll likely find new ideas for your practice. While compiling a competitive analysis is an interesting piece of work, it can indeed be challenging. Consequently, you may want to seek the help of a healthcare consultant to guide you through this process. You'll learn a lot about your market and in the process become a more valuable resource for your patients and referring physicians.

Next steps

From there, you will want to get into an abbreviated strategic planning process. That is, development of a plan (with timelines and objectives!) for what you plan to accomplish for 2022. Strategic planning is an essential business activity. However, several common mistakes must be understood so that physician owners can guard against them. Pointing out these mistakes is not a criticism of the process but acknowledgement of improper implementation. Medical practice leaders must recognize both the benefits and the potential pitfalls of strategic planning, because it is their responsibility to ensure that strategic planning is conducted properly to achieve the desired goals. Here are four of the most-common planning mistakes we find:

1. Attempting to forecast and dictate events too far into the future.

In part, this may result from the natural desire to believe we can control the future. It is a natural tendency to plan on the assumption that the future will merely be a linear continuation of present conditions, and we often underestimate the scope of changes in direction that may occur. Because we cannot anticipate the unexpected, we tend to believe it will not occur. In fact, most strategic plans are overcome by events much sooner than anticipated by practice leaders.

2. Trying to plan in too much detail.

This is not a criticism of detailed strategic planning but of planning in more detail than the conditions warrant. This pitfall often stems from the natural desire to leave as little as possible to chance. In general, the less certain the situation, the less detail in which we can plan. However, the natural response to the anxiety of uncertainty is to plan in greater detail, to try to cover every possibility. This effort to plan in greater detail under conditions of uncertainty can generate even more detail. The result can be an extremely detailed strategic plan that does not survive the friction of the situation and that constricts effective action.

3. Tendency to use planning as a scripting process that tries to prescribe actions with precision.

When practice leaders fail to recognize the limits of foresight and control, the strategic plan can become a coercive and overly regulatory mechanism that restricts initiative and flexibility. The focus for staff members becomes meeting the requirements of the strategic plan rather than deciding and acting effectively.

4. Tendency for rigid planning methods to lead to inflexible thinking.

While strategic planning provides a disciplined framework for approaching problems, the danger is in taking that discipline to the extreme. It is natural to develop planning routines to streamline the strategic planning effort. In situations where planning activities must be performed repeatedly with little variation, it helps to have a well-rehearsed procedure already in place. However, there are two dangers. The first is in trying to reduce those aspects of strategic planning that require intuition and creativity to simple processes and procedures. Not only can these skills not be captured in procedures, but attempts to do so will necessarily restrict intuition and creativity. The second danger is that even where procedures are appropriate, they naturally tend to become rigid over time. This directly undermines the objective of strategic planning — enabling the organization to become more adaptable. This tendency toward rigidity is one of the gravest negative characteristics of strategic planning and of strategic plans.

Strategic planning is one of the principal tools used to exercise operational control because it will help you to decide and act more effectively. Remember though, that strategic planning involves elements of both art and science, combining analysis and calculation with intuition, inspiration, and creativity. To plan well is to demonstrate imagination and not merely to apply mechanical procedures. Done well, strategic planning is an extremely valuable activity that greatly improves practice performance and is an effective use of time. Done poorly, it can be worse than irrelevant and a waste of valuable time. The fundamental challenge of strategic planning is to reconcile the tension between the desire for preparation and the need for flexibility in recognition of the uncertainty of the healthcare industry.

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