When Everyone Loses

When Patients Lose Their Patience, You Lose, Too!

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Dr. Edward Cartwright* has practiced medicine as a solo practitioner in a northern Boston suburb since 1980. The practice generated a comfortable income and after 25 years he was now caring for the children and grandchildren of his original patients. He was active in the community, well-liked among his peers, and still made house calls on occasion. His days were full and he was seeing 15 to 20 patients per day, four days a week. He used an off-site billing service and delegated all management, personnel, and front-of-the-house matters to his long-time office manager, rarely venturing into the front office area for more than a cup of coffee.

In July 2008, Dr. Cartwright noticed that his Fridays were much slower than usual. Chalking it up to summertime in New England, he didn’t really pay much attention. In March 2009, he was notified by the billing service that his insurance receipts for the past 60 days were down by almost 12%. In April, he learned that he had seen 28% fewer patients over the past 90 days compared with the previous year. In November, his billing service reported that they were having trouble collecting payments from self-pay patients who had previously always paid their bills on time. In December, his total number of patient visits was down by 29% compared with the previous year. When reviewing his tax return for the year, he made a mental note that the practice had employed five different medical receptionists during the year.

Situation Critical

Dr. Cartwright spent the weeks before Christmas 2009 desperately trying to work out why his practice was suddenly disintegrating. He couldn’t attribute it to any difference in how he cared for patients or to the office’s physical environment. They had recently installed a new handicapped ramp and updated their waiting room. Patients rarely had to wait more than 15 minutes once they checked in and their prescriptions were electronically submitted in a timely manner.

So what was wrong?

Cartwright’s ‘EUREKA! ’ moment came two days before Christmas. “I bumped into a long-time patient in the supermarket parking lot. I realized that I hadn’t seen her in many months and that she was long overdue for a visit. When I commented that I hadn’t seen her in a very long time, she looked down at the ground and mumbled something. I pleaded with her to tell me what was wrong. She looked me straight in the eye and said, “Your office made me cry.”

That statement was the clue he needed to resuscitate his practice. His first act was to come up with a list of five long-time patients who had not been in for more than nine months. He called each patient himself and asked why he or she had stopped coming for care. Each one alluded to an encounter with the office staff. One woman had been called by the office and told that if she didn’t change her appointment from Tuesday to Friday, “the doctor would never see me again.” While waiting for his appointment, an elderly gentleman was denied access to the restroom because “I’d be late to see the doctor.” Cartwright was appalled and asked patients why they hadn’t said anything, given the 20-plus-year length of their relationships. One by one he was told some version of “I thought you had made new rules and the staff was just doing what you wanted.”

Armed with this information, Dr. Cartwright decided to do some sleuthing. He began making random checks in the reception area, watching as patients were greeted and checked in. He also listened to the tone and content of telephone conversations.

This is what Cartwright witnessed over the course of a week: patients were turned away if they forgot their insurance cards; if they wanted to change an appointment, they were threatened with cancellation fees; the phone often went unanswered; people were yelled at in the waiting room; and numerous HIPAA violations occurred as patient information was shared among the staff in full view and earshot of patients in the reception area.

The Root of the Problem

It didn’t take long to identify several key administrative issues. “Once I actually began to pay attention, it became very clear that the source of the downward spiral was the bizarre behavior of my long-time office manager.”

The core of the problem lay with Joan*, the office manager, who had been with the practice for 16 years. In early 2008, and unbeknownst to Cartwright, Joan had opened her home to her daughter and three granddaughters, who were fleeing an abusive home situation. Many nights, Joan’s abusive son-in-law would try to enter the home, forcing a police confrontation. At other times, the son-in-law would call Cartwright’s office and demand to speak to Joan. Joan was stressed out, afraid, and sleep deprived.

Needing the income, she continued to come to work every day. But her multiple stresses and lack of sleep led to a cascade of abusive behaviors. First, she stopped answering the office telephone and instructed the receptionist to just “let voice mail pick it up. We’ll call them back.” If an employee questioned the wisdom of this or threatened to tell Cartwright, the employee was fired. Joan seemed particularly disdainful of older patients, showing no patience or empathy when they fumbled or required help with an insurance form.

Once Dr. Cartwright was able to identify the problem, he set out to address the issues very quickly. He offered Joan an open-ended leave of absence and put her in touch with a social worker from the hospital who helped her obtain the resources she needed to cope with her family situation. He promoted the medical receptionist—a warm and friendly young woman—to temporary office manager and went to work personally reaching out to patients who had been hurt or dissatisfied by the treatment they had received.

The Warning Signs

A variety of issues cause patients to electively change doctors. According to Bill Bristow, a partner with Doctors Management in Knoxville, Tennessee, the reasons rarely have to do with quality of care. “It’s more about the rude staff and the inability to reach the office or get on the schedule,” Bristow says. “If you start to see a pattern in why patients are leaving your practice, you have to look at it.”

Cartwright learned his lesson the hard way. He’s gradually rebuilding the goodwill of his patients with an outreach program that includes personal calls, letter correspondence, and newspaper advertisements featuring photos of his new warm and caring staff. He estimates it’s taken about two years to regain just about half of the patients who had left. But his real goal is to make sure nothing like this ever happens again. “Instead of staying in my ivory tower treating patients and recording my notes, I make time every day to visit with patients in the reception area, do a sweep of the front office, and make sure that the phone is answered professionally by the third ring.” He’s right to be concerned about the phone calls. In a 2010 survey of 2.7 million patients, patients continue to voice frustrations over the ease of scheduling appointments, the helpfulness of telephone staff and the promptness in return calls.[1]

In some ways, Dr. Cartwright was fortunate. A chance encounter with a long-time patient gave him enough information to fix his practice before it ran itself into the ground. Looking back, he realizes that there were plenty of early signs that something was wrong.

  1. Changes to a long-standing schedule. Cartwright’s Friday schedule during the summer was light. This was a departure from practice, and any ongoing change to a long-standing schedule should raise a red flag. To hide the fact that patients were leaving the practice, Joan packed the schedule early in the week, blaming the summer and the approaching weekend for the lighter Fridays.
  2. Changes in self-pay billing patterns. When patients don’t pay their bills, it’s sometimes a signal that they were not happy with their care. It’s surprising how often the reason that patients aren’t paying is because they are angry – angry about the way they were treated on the phone or something the receptionist said. For these patients, not paying the bill may be their last chance to express their displeasure.
  3. Decreasing patient census. You need to sit up and take note if the number of patients you see continues to decline over more than a 90-day period. In fact, you need to jolt up and ask a resounding, “why?”
  4. Excessive employee turnover. Five medical receptionists in one year? In this case, Joan was so intent on covering her tracks that she resorted to employee bullying and drove out five excellent motivated employees. This was corroborated by subsequent phone calls from Dr. Cartwright. “One former employee told me that she loved the patients and really enjoyed her job, but just couldn’t take Joan’s constant harassment and irrational behavior.”

Cartwright notes, “Intellectually, I know that some patients will never be happy, no matter how competent, efficient, and agreeable we are. And I recognize that those patients will probably leave, no matter we do. My goal now is to make sure I know when a patient leaves, and why. I can learn from our mistakes, but only if I’m aware of them.”


* Names have been changed.


Jill Shuman, MS, ELS
Published April 30, 2012



  1. Berry E. Is your telephone hurting your practice? Phone do’s and don’ts. American Medical News Website. http://www.ama-assn.org/amednews/2011/03/07/bisa0307.htm. Posted March 7, 2011. Accessed April 28, 2012.