Dear Bill,

"I generally see new patients daily for the first week of care. A new patient missed one of those visits and resisted efforts to reschedule a day and time. How do I respond without showing up as a parent?"

There are a couple of issues in play that you might want to consider.

Are Your Initial Care Recommendations Credible?

It can mean many things when a patient misses. Even though they nod at the right time or seem engaged when you make your initial care recommendations, they may be thinking:

• "Why does it take so many visits?"
• "There's no way I'm coming in here that many times."
• "Oh no, here we go."
• "Wonder what I can do to reduce the number of visits?"
• "Not sure I can make all those visits, but let's see how it goes."

And the list goes on. Few patients will be bold enough to divulge this internal dialogue of theirs, after all, they hardly know you. And you seem deeply committed to taking on their problem.

One thing you could ask them is, "Do you see any potential obstacles to your being able to keep this visit schedule?"

That doesn't mean they'll reveal a transportation issue, childcare problem, general skepticism or some other barrier. But it's worth testing the water.

Finally, be sure you can adequately explain your recommendations should a patient ask, "Why five visits the first week?" or "Why three times a week?"

"Because I've always done it that way," sounds flimsy and relies too much on your limited social authority.

"Because a famous chiropractor started recommending three visits a week back in 1955 and the profession has adopted it as a standard of care," isn't very compelling.

"Because I said so," may be what you want to say, but that's practically the trademark of being parental.

If you've never had your recommendations directly questioned by a patient, it doesn't mean they don't have questions. You might want to neutralize their concern by volunteering something like:

"These recommendations are designed to produce the best results in the shortest amount of time. Your visits need to be frequent enough to create the momentum necessary to make spinal changes. But sufficiently spaced so your body has time to process each adjustment, so it's not wasted.

"Since we don't know how quickly your body will respond to chiropractic care, or what you'll be willing to do between visits to support your care, I recommend we take this aggressively, seeing you three times a week for the first four weeks.

"That's when we'll conduct some of the same examinations we did yesterday comparing where you are with where you were and where you want to go. Then together, we can intelligently chart a course forward that makes the most sense to achieve your individual health goals."

The key is to explain that your initial recommendations are carefully considered and not a made-up, one-size fits all. Never be caught off guard by such a basic question.

Getting into the habit of volunteering your clinical reasoning for the frequency of visits is a great preemptive strategy. 

But there's another dimension to consider.

What Meaning Are You Attaching to a Missed Visit?

When a patient misses, especially in the early stages of care, many chiropractors make up a story. Here are some common ones:

How disrespectful – This usually emerges from patients who ghost you without the courtesy to call to let you know. If you're inclined to take their lack of civility personally it can be difficult to hide your contempt.

Hamper their results – At first blush you have a purely clinical concern. But for many it merely covers up their concern that their reputation will be blemished due to the patient's poor or slow recovery.

Creates more work for the staff – In many practices, when patients miss, the front desk team must unleash the bloodhounds to track down a wayward patient. And today, thanks to caller ID, these overtures are easy for patients to avoid.

I thought we were in love – Things were going so well. I thought you were onboard for the full program. I'm hurt. You lied to me.

What did I forget to say or do? – If you have the tendency to make everything about you, you're likely to replay the report of findings repeatedly in your head. How could I have done it better? What did I forget to mention? What could I have done to prevent their lack of follow through?

But probably a more accurate story would be this:

Something else became a higher priority – Could be that something came up at work. There was a traffic accident. "I'm already so late I'm not going to bother." "They're so busy I won't even be missed." "I'm feeling better anyway." Etc.

And as for not being polite enough to ring your office to explain, many patients anticipate a guilt trip or being shamed into more visits if they were to call. They've made this assumption based on how deeply invested you appear to be. They're letting you down but telling the truth will be awkward. Better to just "slip out the back, Jack."

A missed visit can many different things. They may simply be testing the waters to see what happens. They may be announcing their intention to discontinue their care. They may be delighted with the results they've already achieved— thinking it will be permanent.

Be mindful how you respond. You don't want to use a sludge hammer to swat a mosquito!

Thanks for the question.

Ask Bill your question.

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