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Setting Boundaries with Patients in DPC
One of the cornerstones of DPC is unprecedented physician access. The time DPC doctors have to devote to their patients and the access the patients have is what makes it what it is.
However, like anything good, too much of it can probably be bad.
One of the most frequently asked questions by doctors looking into transitioning their practice to DPC is some version of “But how can you be available to your patients by phone, e-mail, and text, and for urgent in-person needs, virtually 24/7 and still have a life?”
The answer is “It’s not as bad as it sounds.” It really isn’t. It helps that DPC docs have a limited patient panel size. That being said, every DPC doctor does have the occasional over-user. More on that later.
When it comes to setting boundaries with patients, generally we’re referring to what kinds of things patients can contact you for, when, how often, etc.,as well as how often they schedule appointments, how often they interact with your staff, etc. When deciding where to draw the line for these kinds of boundaries, most DPC docs will tell you that where you are in establishing your DPC practice will help define how strictly you set such boundaries.
Most DPC docs start out with fairly lax, --even very lax-- boundaries. We give our patients something amazing that they tell their friends about. There is tremendous value in a non-sustainable willingness to cheerfully answer a call about a lisinopril refill at 11:30 pm on a weeknight, or a text asking how many carbs are in a half cup of peanut butter on a Sunday afternoon. I know, I know, this sounds painful. And it is. But this pain is only temporary, for 3 reasons:
- When patients use you in this way, it’s what Dr. Jeff Davenport has called the “New toy at Christmas phenomenon”. The toy gets played with a LOT for a short time, and before long is collecting dust somewhere. DPC services are often used like that. When the patients know you’re available, the novelty wears off, and you’re there if they need them, and the usage/text frequency drops off dramatically.
- Often patients who are new to you come from inside the system, where they have had poor continuity, polypharmacy and basically, medical neglect. Once these patients are “tucked in” and their issues sorted out, the usage frequency drops off.
- As your patient panel fills up and you get to the point where your time is more limited, you can begin setting more strict boundaries with your patients. By this time, they have recognized the huge value of their membership, and they’ll back off with communications/usage that are unnecessary--if you ask them to.
OVER-USERS
So what happens when you have a full panel and 99% of your patients fall into the above-described categories, and recognize that you have 500 other patients and a life and therefore leave you alone for minutiae, but 1% of them drive you nuts? This is where we recommend more-strict boundary-setting. If you don’t set some boundaries, you’ll begin to resent the patient and the quality of care and the physician-patient relationship will be damaged. This is usually as simple as kindly asking them to call the office tomorrow and asking a staff member for assistance. Some docs will employ “therapeutic neglect” with over-users and won’t reply to frivolous messages quickly. There are numerous ways to kindly work with these patients to decrease over-use. In the rare circumstance where your boundary-setting offends a patient and they leave your practice, it’s probably for the best; they may not have been a good fit. And such patients are usually <1% of your panel, yet represent >95% of your text/e-mail interactions, so their leaving frees up a lot of time to use for other patients.
OVER-SETTING BOUNDARIES
Just as patients can over-use your services, doctors can over-set boundaries. Some DPC docs have lamented the lack of patient sign-ups and their having to moonlight to make ends meet due to the slow growth of their DPC practice. When auditing their business model, successful DPC docs have found that these physicians often have overly-strict boundaries. Perhaps the doctor doesn’t allow after-hours contact by phone, text or e-mail. Or perhaps the doctor doesn’t text with patients at all. This has the overall effect of lowering patients’ perceived value in the DPC membership. In essence, you have to give them something for their money, or they’ll take their money elsewhere.
Ultimately, every DPC doctor will find themself frequently moving around their boundaries as their circumstances evolve, to generate the perfect mixture of access/quality and work/life balance.
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Setting Boundaries with Patients in DPC
One of the cornerstones of DPC is unprecedented physician access. The time DPC doctors have to devote to their patients and the access the patients have is what makes it what it is.
However, like anything good, too much of it can probably be bad.
One of the most frequently asked questions by doctors looking into transitioning their practice to DPC is some version of “But how can you be available to your patients by phone, e-mail, and text, and for urgent in-person needs, virtually 24/7 and still have a life?”
The answer is “It’s not as bad as it sounds.” It really isn’t. It helps that DPC docs have a limited patient panel size. That being said, every DPC doctor does have the occasional over-user. More on that later.
When it comes to setting boundaries with patients, generally we’re referring to what kinds of things patients can contact you for, when, how often, etc.,as well as how often they schedule appointments, how often they interact with your staff, etc. When deciding where to draw the line for these kinds of boundaries, most DPC docs will tell you that where you are in establishing your DPC practice will help define how strictly you set such boundaries.
Most DPC docs start out with fairly lax, --even very lax-- boundaries. We give our patients something amazing that they tell their friends about. There is tremendous value in a non-sustainable willingness to cheerfully answer a call about a lisinopril refill at 11:30 pm on a weeknight, or a text asking how many carbs are in a half cup of peanut butter on a Sunday afternoon. I know, I know, this sounds painful. And it is. But this pain is only temporary, for 3 reasons:
- When patients use you in this way, it’s what Dr. Jeff Davenport has called the “New toy at Christmas phenomenon”. The toy gets played with a LOT for a short time, and before long is collecting dust somewhere. DPC services are often used like that. When the patients know you’re available, the novelty wears off, and you’re there if they need them, and the usage/text frequency drops off dramatically.
- Often patients who are new to you come from inside the system, where they have had poor continuity, polypharmacy and basically, medical neglect. Once these patients are “tucked in” and their issues sorted out, the usage frequency drops off.
- As your patient panel fills up and you get to the point where your time is more limited, you can begin setting more strict boundaries with your patients. By this time, they have recognized the huge value of their membership, and they’ll back off with communications/usage that are unnecessary--if you ask them to.
OVER-USERS
So what happens when you have a full panel and 99% of your patients fall into the above-described categories, and recognize that you have 500 other patients and a life and therefore leave you alone for minutiae, but 1% of them drive you nuts? This is where we recommend more-strict boundary-setting. If you don’t set some boundaries, you’ll begin to resent the patient and the quality of care and the physician-patient relationship will be damaged. This is usually as simple as kindly asking them to call the office tomorrow and asking a staff member for assistance. Some docs will employ “therapeutic neglect” with over-users and won’t reply to frivolous messages quickly. There are numerous ways to kindly work with these patients to decrease over-use. In the rare circumstance where your boundary-setting offends a patient and they leave your practice, it’s probably for the best; they may not have been a good fit. And such patients are usually <1% of your panel, yet represent >95% of your text/e-mail interactions, so their leaving frees up a lot of time to use for other patients.
OVER-SETTING BOUNDARIES
Just as patients can over-use your services, doctors can over-set boundaries. Some DPC docs have lamented the lack of patient sign-ups and their having to moonlight to make ends meet due to the slow growth of their DPC practice. When auditing their business model, successful DPC docs have found that these physicians often have overly-strict boundaries. Perhaps the doctor doesn’t allow after-hours contact by phone, text or e-mail. Or perhaps the doctor doesn’t text with patients at all. This has the overall effect of lowering patients’ perceived value in the DPC membership. In essence, you have to give them something for their money, or they’ll take their money elsewhere.
Ultimately, every DPC doctor will find themself frequently moving around their boundaries as their circumstances evolve, to generate the perfect mixture of access/quality and work/life balance.