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Pearls


Tips for telling your patients good-bye

Vol. 6, No. 11 / November 2007

Transferring to another psychiatrist can distress mental health patients and disrupt treatment, whether you part ways with them because of an insurance change or relocation. A smooth transfer helps maintain patients’ clinical progress and reduces the risk of losing them to follow-up. We suggest a timeline for saying good-bye (Table) and some strategies to ease the transition.

Table

Timeline for transferring your patient’s care

 

Issues to discuss/explore

6 months before departure

Determine which issues patient would like to address before transfer
Current or past medications

1 month before departure

Focus on closure
Avoid addressing new issues
Avoid changing medications or session time, day, or frequency
Go over transfer summary

Final session

Give 1 to 2 prescription refills
Encourage patient to follow up with new doctor
End session on positive note

Starting the conversation

Inform the patient of your approximate departure date as soon as possible. Most residents, for example, should have this conversation in January, allowing approximately 6 months to address issues your departure may bring up. Don’t be surprised if your patient does not recall this conversation, however, because he or she might unconsciously repress this information. You might have to discuss your departure several times before it becomes “real” for your patient.

Identify specific issues to address before transferring the patient’s care. For example, explore whether any medications need to be changed.

Tell your patient you would like to write the transfer summary together, and encourage him or her to think about what information to include. If another physician transferred the patient to you, inquire about that process. Did the earlier physician do or say something that was helpful?

Initiating transfer of care

Encourage your patient to talk about feelings related to the transfer by asking how he or she thinks the process will go. Don’t assume your patient is anxious or upset about the change, however. Some patients “bond” to the clinic rather than to a particular doctor.

Be alert for unconscious communication about your impending departure. For example, your patient might talk about others who have left in the past. Consider these statements as opportunities to discuss your departure against the backdrop of other losses and changes.

Patients might unconsciously act out in response to your upcoming departure. For example, a patient who has faithfully attended appointments might “accidentally” miss a visit or discontinue 1 or more medications.

Examine your feelings about the impending transfer of care. Guard against attributing your feelings about the process to your patient. If you find that these feelings lead to difficulty helping your patient find closure, consider consulting with a colleague or mentor.

1 month before the transfer

Your patient might initiate more intense work than in the past. Your impending departure might make it seem safer to share previously undiscussed information because there is little time to explore it.

Although you may be tempted to take advantage of your patient’s impulse, carefully assess this strategy. This is the time to work toward closure, rather than delving into new areas. Keep treatment structured; avoid increasing or decreasing the frequency of visits as you approach the last session.

Also avoid changing the patient’s medication regimen, if possible. If your patient is anxious about your departure, new medication side effects might exacerbate this anxiety.

Begin writing the transfer summary with your patient. Ask the patient what he or she feels the new physician should know. Discuss the information you are including on the transfer summary, such as a unique medication regimen. This information will help the new physician and could alleviate the patient’s anxiety.

If possible, personally introduce your patient to the new physician and discuss the transfer summary. Don’t say that the new doctor is “really good.” The qualities you like about this clinician might not appeal to the patient. Encourage the patient to “interview” the new physician.

Don’t discuss what you will be doing after you leave. If the patient asks, talk about your plans in general terms. Detailed or persistent questioning might have psychological meaning and could be discussed in psychotherapy.

The last session

Write 1 or 2 prescription refills. Many patients are concerned about a possible delay in starting treatment with the new physician, and adequate refills may allay fears about obtaining medication. Having refills also may act as a temporary “transitional object” until the patient feels comfortable with the new physician.

Tell your patient that many individuals don’t follow up with a new physician, but it is important to do so. Discussing this phenomenon may increase the probability that your patient will follow up because you can talk about his or her concerns about seeing a new physician or ending treatment with you.

Don’t agree to correspond with the patient after you transfer care. Further communication might interfere with the new therapeutic relationship. The patient might communicate clinical concerns to you, not to the new physician.

Don’t initiate a hug at the end of the session. If your patient initiates a hug or a handshake, you may accept it if you are comfortable with physical contact. End the session on a positive note, and express your best wishes for the patient’s continued growth and well-being.

Still having problems?

If the transition of your patient’s care is unusually difficult, do not hesitate to ask a supervisor or colleague for assistance.

Dr. Kay is instructor in psychiatry and Dr. Mago is assistant professor of psychiatry, Thomas Jefferson University, Philadelphia, PA.

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