When Patients Leave.

Abstract

I thought the visit went well. I walked in with a warm hello, shook hands, introduced myself, sat down, and began to listen. No computer screen was open, no interruptions occurred, and I was present. I heard the story, performed an examination, and then we discussed the diagnosis, prognosis, and treatment options. The patient and her daughters had many questions, and I tried to address them all. We warmly smiled at each other, set up a plan for new imaging, and scheduled a visit thereafter to finalize our next course of action. Except a week later I noticed my patient was no longer on my schedule and the nurse told me that she called to cancel her follow-up appointment. She was going elsewhere. No need to call back. Fresh out of a fellowship that routinely saw patients for clinical trials and second opinions, a patient leaving after my first opinion felt like a personal failure. Why would she not stay? Was I too pessimistic, too optimistic, too confusing, or not confident enough? Did I seem too young or too new? I spent days ruminating in my spare time, wishing it were appropriate to call her and ask why she chose to never return. While having a conversation with her referring urologist about a different patient, the topic was not broached by either one of us. With no clear resolution available, I tried to push the unsettling feeling away. At the time, I did not appreciate that the experience would not be unique, that many patients who would choose to leave my care would do so without my fully understanding why, and that learning from those experiences is challenging. Patients who leave fall into two general categories: the more frequent cases of those who come once and never return, and the more rare, but also more painful, instances of those who switch physicians after a relationship has been established. Sometimes it is easy to accept these events—coming for a confirmatory second opinion, moving care closer to home, or seeking a clinical trial elsewhere are practical and understandable. In oncology, delivering bad news or broaching the notion of hospice may sometimes trigger anger, resentment, and a belief that the doctor is giving up, leaving little doubt as to the cause behind a patient switching care. Often though, the reason a patient does not return is murky, personal, and difficult to discern. A 1930 address by a South African physician reminded the younger doctors that “when they grew older they too would puzzle why patients left them for some inexplicable reason...but examining the various reasons and considering the inevitability of the course of events may make us more content andmore sociable members of both our profession and the community at large.” Mymore seasoned colleagues echo this sentiment, saying that it gets easier, that one simply accepts the fact that some patients will leave, that not all relationships work out. Yet, even they seem dejected, frustrated, and puzzled when speaking about patients who have left their care. A 1963 study from the United Kingdom examined the psychologic consequences to primary care physicians when patients left them. The authors found that “doctors were quite disproportionately upset when their patients left them, not because their livelihood seemed endangered, but because it constituted a threat to their self-esteem.” A patient leaving led to “vague uneasiness to deep disquiet.” Confronting the loss of a patient not due to illness but to choice, to feel suddenly interchangeable and distrusted, is difficult and uncomfortable. There are few data on the rate or motives behind patients leaving a doctor. A 1957 paper discussed 13 reasons patients may change physicians, emphasizing a failure to inspire confidence, establish rapport, and demonstrate friendship for the patient. A more recent qualitative analysis of patients’ online comments about their physicians suggested that a multitude of factors—including the interpersonalmanner and technical competence of a doctor, but also system issues that are outside the direct patient-physician interaction—are important in forming a patient’s opinion of a physician. The attributes that are desired in a physician were characterized in a survey of 192 patients seen by various specialists in the Mayo Clinic system. The patients described an ideal physician as someone who is confident, empathetic, humane, personal, forthright, respectful, and thorough. Although some physicians are