What do you think it means when a patient unexpectedly drops out of care without even a thank you or goodbye?

The meaning you attach to this phenomenon can dramatically affect your emotional well being. Does it mean...

The patient is merely unappreciative and impolite?

The patient is delighted and got what they wanted?

The patient resents what appears to be financially driven recommendations?

Someone influential has urged the patient to discontinue their care?

The patient has exhausted the financial resources they're willing to devote to their health issue?

The patient is ashamed that they don't care about their health as much as you seem to?

The patient anticipates an awkward exchange if they announced their last visit?

Any one of these is a possible explanation for a patient ghosting you after weeks of perfect visit follow-through. Some explanations have nothing to do with you. Determine the ones that do.

Hello and Goodbye Practice Procedures

You probably have your "hello" procedure down cold. Your first- and second-visit procedures are well-thought out and facilitate the onboarding of new patients.

But what many practices lack is a "goodbye" procedure. In other words, what is the preferred way for patients to end their episode of care?

Patients can't look to medicine for guidance since most medical practitioners are usually seen only once with an occasional follow-up visit a couple of weeks later. Clearly, consulting a chiropractor is different.

Without an explanation from you, patients are left to their own devices. Which is why you should discuss the dismissal process at the beginning of their care.

Counter-intuitive, I know. In fact, no other recommendation I make at my speaking gigs receives as much push-back as this one.

Two Common Fears of Chiropractors

"Discussing the dismissal process merely becomes a self-fulfilling prophecy," some chiropractors complain.

I'm quick to point out to these chiropractors that after years of never discussing the dismissal process, leaving it up to patients to invent their own, has not reduced patient drop out. Such chiropractic practices still have hundreds, often thousands of inactive patients. These were patients forced to bring their care to a close without the guidance, direction or support of their chiropractor.

Apparently, overlooking this aspect of your patient communications doesn't improve patient retention. In fact, by not broaching this topic with patients it clouds the relationship at the very time in which their symptomatic improvement should produce a more celebratory tone.

Instead, it forces patients to invent their own escape procedure. Which often involves making future appointments they have no intention of keeping. Which needlessly occupies staff resources, tasked with tracking down AWOL patients and getting them back on the straight and narrow. While not particularly creative, these days with caller ID, it's the most common go-to strategy for patients.

But there's another fear.

"Discussing the goodbye process at the beginning simply gives patients permission to drop out," some chiropractors worry.

Problem is, you're not "giving" patients permission.

Patients are volitional. They constantly exercise their free-will agency. You're not giving them permission to drop out of chiropractic care—they already have it!

In short, you can't give them something they already have.

Apparently, this is a vestige of "doctor's orders" or a reliance on some type of cultural authority that used to be afforded doctors.

How quaint.

Worse, taking patient follow through personally is often a sign of poor boundaries. It's unsustainable and is usually an unreciprocated emotional investment that sets you up for frustration, anger and eventually burnout.

A Suggested Goodbye Procedure

Ironically, an effective goodbye procedure should be explained as part of your hello procedure. Explain how they should end their episode of care at the beginning of their care. 

Waiting until later introduces two risks. The most obvious is that you'll "forget" to discuss it, or the patient ends up dropping out before you have a chance to broach the subject. The other is that discussing it after they show symptomatic improvement can be interpreted as a plea to continue their care indefinitely. Which is often imagined to be financially motivated since they already got the relief for which they originally sought your care.

In other words, there is little upside to waiting.

If I were in practice, I'd employ a two-visit onboarding process—even if both visits were on the same day. Visit one would be the pre-care interview and examination. Visit two would be the report of findings and first adjustment.

The goodbye procedure would be covered as part of the second-visit report of findings.

The Road to Recovery chart was designed to facilitate this process. (Watch the short video or read the suggested scripting.)

After describing the three recovery tracks (quick improvement, worse before getting better or steady improvement), explain the likelihood of a subsequent relapse should they discontinue their care immediately upon symptoms subsiding. While pointing to the words "Decision Time" on the chart you might observe:

"You don't need to make your decision now, but when you've had enough, let us know. That way, together we can celebrate your success, close your case file properly and send you on your way.

"Whichever road you choose, our job is to provide the finest chiropractic care possible. Your job is to decide how much of it you want.

"Any questions?

"Great, then let's get started!"

You may notice the patient's body language noticeably relax. After all, most patients have heard that "once you go to a chiropractor you have to go for the rest of your life." So, they plot how they are going to beat the house. But they've just learned that you're different. They won't have to hatch an escape plan. They can just tell you when they've had enough and you're not going to swing into life insurance salesman mode.

Benefits of a Sharing Your Goodbye Procedure

Hopefully the value of explaining how patients can properly end their care in advance is self-evident. If it's not, here's a reminder of some ways you and your practice benefit:

1. Patients have no reason to think you're angry or disappointed in them. Because your relationship has closure, you avoid misunderstanding, guilt and shame.

2. You avoid awkward moments at the grocery store. Meeting an inactive patient in public won't generate apologies or embarrassing confessions. Or even worse, evasion tactics, fleeing fully laden shopping carts because they saw you before you saw them.

3. You increase the likelihood of reactivations. When their symptoms return, they are less likely to blame you or chiropractic. They're more likely to return to your practice because there won't be an "I told you so."

4. You improve new patient referrals. Your patients will be out in your community announcing that "you're not one of those chiropractors who keeps you coming back forever." That's appealing enough for patients to prompt many to drive past other practices to get to yours.

5. It frees up your support staff for more productive tasks. Your team can be doing something else instead of tracking down wayward patients. Incidentally, have these overtures ever converted patients who answer the phone to return for more than a guilt-ridden visit or two? By pressuring patients you can win the battle—but lose the war.

6. It demonstrates your willingness to put their needs first. While the hard sell is often justified as being in the patient's best interest, that's rarely how patients see it. Instead, help patients get what they want—even if it's merely a short-term patch—giving you the opportunity to explain what they need. Which may take several episodes.

7. You receive the praise and adoration. When patients have to sneak out of your practice, you rarely get to hear their appreciation and gratitude. Thus, you miss out on one of the emotional payoffs of being a chiropractor.

8. You slowly see an increase in once-a-monthers. The fact is, it usually takes multiple episodes of care to convince patients of the value of ongoing supportive care. With time you attract a tribe of practice members who see chiropractic as a valuable, ongoing lifestyle adjunct.

What does it mean when a patient drops out of care without a goodbye or thank you? It depends.

However, one thing chiropractic patient drop means is that you may not have instructed them about how to properly complete their care. It's an aspect of leadership and expectation management that is rarely discussed.

Bill Esteb has been a chiropractic patient and advocate since 1981. He is the creative director of Patient Media and the co-founder of Perfect Patients. He’s been a regular speaker at Parker Seminars and other chiropractic gatherings since 1985. He is the author of 12 books that explore the doctor/patient relationship from a patient’s point of view. His chiropractic blog, in-office consultations, patient focus groups and consulting calls have helped hundreds of chiropractors around the world. His Monday Morning Motivation is emailed to over 10,000 subscribers each week.