Hi Rando,
I agree with you 99.99%. In fact, I probably dismiss patients less than anyone. Hell, you can No show 50 times in a row, and I will likely not discharge you. Just not worth my time to keep track and send letters, etc. (But that is another story).
I do remember early on in my career discussing/debating/arguing with a patient about the need for her child to have an U/S and VCUG after the first UTI. We generally just do an U/S after the first. We also do not think that UTIs and renal scarring necessarily lead to kidney failure.
If I saw that patient again, I would likely tell her it is a good think you didn't take my advice. We now do not recommend a VCUG. But, that is hindsight is 20 - 20 vision type thinking.
Whether or not I think I should dismiss a patient over not following my advice is a separate issue. If the patient says, I will think about your advice and come to my own conclusion, that's great. But, for them to say, "I will think about your advice and come to my own conclusion, especially since it is possible your advice may change after it is debunked ten years down the road," doesn't fly well with me. I can only give my best advice based on the science and the recommendations at that time. THAT is the advice they should heed or not heed. Not the advice that may be given ten years from now.
