The Right Way to Say Goodbye
Discharging a patient is never easy and
could lead to charges
of abandonment, but keeping certain problem patients is also
a liability.Know the law surrounding patient dismissal and the
steps to take to safeguard your practice.
of abandonment, but keeping certain problem patients is also
a liability.Know the law surrounding patient dismissal and the
steps to take to safeguard your practice.
Patients who refuse to pay their bills..
Patients who are rude and even abusive to staff... Patients who
refuse to follow treatment protocols... Patients who lie...
Patients who try to manipulate the physician into prescribing
medications the physician feels are inappropriate.
Every physician who
has been around for any length of time has his own top 10 list
of problem patients. If there were a way to purge the practice
of these headache-makers, life would be a lot easier for
everyone.
Of course, there is a
way to handle particularly troublesome patients. Fire them.
It’s a drastic measure some physicians are reluctant to
take, but handled correctly, firing patients from the practice
benefits not only the doctor and other medical staff, but other
patients and even the problem patient himself.
“The
professional relationship is based upon mutual trust,”
says Lee Spangler, JD, the assistant general counsel for the
Texas Medical Association. “If for some reason
there’s an obstacle to that trust, then that’s when
the physician should begin to think about this issue,” he
says.
Any number of things
can cause a breakdown of trust between doctor and patient.
Whether it’s a personality conflict, bizarre behavior on
the part of the patient, or a simple failure to communicate,
the end result is that the patient isn’t getting the care
he or she deserves and the doctor is dealing with frustration
he or she doesn’t need. It’s time for patient and
physician to part company.
Rather than issue a
Trump-like “You’re fired,” physicians can
sever the physician/patient relationship in various ways. A
physician who is unable to develop a good rapport with a
patient for whatever reason might solve the problem by
suggesting the patient see a colleague, either within the
practice or in another group.
This solution only
works, of course, if the patient agrees that seeking help
elsewhere is a good idea.
Some doctors handle
problem patients by trying to influence the patient to leave
the practice of her own accord. “For the most part, you
can as a physician manage to alienate a patient enough in the
course of a visit to get them to make the choice to
leave,” says Kathryn Stewart, MD, MPH, the medical
director for care management at Mt. Sinai Hospital in Chicago
and a family physician for more than 20 years.
 | ||
Patients who fire doctors
Discharging a patient isn’t always
necessary; sometimes patients stop coming in to the office
altogether, for whatever reason. “I’ve had a number
of people that just disappear from my practice,” says
Sanders. “You know, it’s easy to fire your doc. All
you have to do is not come back. It’s more difficult for
the physician to fire the patient.”
If this were any other
consumer/provider relationship, either party could sever the
relationship at will. A consumer can decide to take her
business elsewhere, and the service provider has the right to
refuse service for almost any reason, without advance notice.
But the law recognizes
that the relationship between doctor and patient is a special
case. While the patient can, indeed, decide not to see the
doctor again for any reason and without advance notice,
physicians have a fiduciary—or trust—responsibility
toward the patient. Physicians are expected to act only in the
best interest of their patients. Suddenly refusing to see a
patient again, even one with whom the physician has had serious
problems in the past, can be seen as patient abandonment and
could lead to legal liability.
Because of this legal
liability, physicians need to be careful in interpreting a
patient’s actions. “Just because a patient might
act against medical advice or leave a hospital against medical
advice, that does not necessarily mean the patient is
terminating the physician/patient relationship,” Spangler
says. “It may just mean that the patient is rejecting
that particular bit of medical advice. Termination of the
patient/physician relationship means that the patient has
communicated to the physician that they don’t want to
participate anymore in the relationship.”
Likewise, when a
problem patient ceases making appointments, physicians may feel
relief and think the relationship is over. At this point,
however, the patient has the option of returning to the
practice at any time. Spangler suggests that if the physician
is unsure of the patient’s intent, he should send a
letter confirming that the patient has, indeed, terminated the
relationship.
When to fire a patient
If a problem patient doesn’t leave
of his own accord and various attempts to solve the problem
don’t work, the physician may have little choice but to
discharge him. “If you have an abusive patient and the
behavior is not part of the underlying disease, I don’t
think I would give them any more than two chances,” says
Geoffrey Anders, JD, the president of The
Health Care Group, Inc., a
practice management company and law firm in Plymouth Meeting,
Pennsylvania. “If they’ve abused the staff and you
don’t do something about that, then potentially
you’re open to legal action by one of the staff
people.”
Also, noncompliant
patients or those who are repeatedly unwilling to follow a
prescribed treatment plan put themselves at risk and increase
the doctor’s risk of a malpractice claim. Such patients
also require a disproportionate amount of physician and staff
time, taking away from time that is available for other
patients.
While conceivably
it’s possible to fire a patient for almost any reason,
including something as basic as the fact that the doctor finds
the patient’s personality unpleasant and doesn’t
want to work with him anymore, the law does outline several
exceptions. A physician may not fire a patient on the basis of
gender, sexual orientation, race, religion, or disability.
Courts have, however,
ruled in favor of the physician in instances where providing
treatment to a patient ran counter to the physician’s own
religion. For instance, a Roman Catholic physician may not be
compelled to perform an abortion.
One reason physicians
sometimes dismiss patients is for non-payment of bills.
“If the individual has gone through your normal
collection procedure and is still delinquent, assuming that
they’re not in a continuing course of treatment, that
would be an appropriate time to discharge them, Anders says.
“With most physician practices, that collection process
lasts many months, so there typically have been numerous
attempts to communicate with the patient.”
Spangler points out
that the relationship between the physician and the patient is
based on mutual trust and respect. Failure to pay a bill can be
a sign of disrespect and can erode the physician’s trust
in the patient, so it is certainly a valid reason for
dismissal.
Some physicians feel
differently. Sanders says he has never discharged anyone for
not paying a bill. Instead, he makes every attempt to help
patients find funding through various state and federal
programs.
The right way to say goodbye
Dismissing a patient is rare for most
physicians—a course they choose only after all other
methods have been exhausted. Once the decision is made to
dismiss a patient from the practice, the physician should
follow a formal protocol in order to avoid leaving himself open
to charges of abandonment.
While the physician is
only required to give written notice of the decision to
terminate the relationship, most experts agree that the best
first step is to confront the patient about her behavior and
try to find a way to improve the relationship. “I believe
in honestly putting all your cards on the table with patients
about everything related to their care,” Stewart says.
“If they have a behavior that I think is problematic, I
would sit them down and have a talk with them.”
If a patient is not
following a treatment plan, what are her objections to the
plan? Are these valid concerns the physician can address? This
may be enough to solve the problem without resorting to firing
the patient. “For the most part just sitting down and
having a rational discussion with patients and being honest,
you can usually bring people around,” Stewart says.
If the patient appears
truly to want to resolve the problem, the physician might
consider drawing up a contract with her. The patient agrees to
do certain things, such as following the treatment plan,
keeping appointments, etc., and the physician agrees to
continuing treating her. Dr. Sanders reports that the pain
management practice to which he refers patients has used this
approach successfully.
If discussing the
problem doesn’t work, or if the situation has reached a
point where the doctor sees no way to continue in the
relationship, then he must also consider where the patient is
in the course of treatment. Attempting to dismiss of patient in
the middle of the course of treatment for an acute problem
could leave a practice open to a charge of abandonment. For
example, it wouldn’t be recommended to discharge a
patient during treatment for a fractured hip, where the outcome
of a normal course of treatment would be expected to bring the
patient back to full functioning. However, if a patient has a
chronic problem, such as diabetes or hypertension, the doctor
is not precluded from dismissing him.
In many cases by the
time the physician has made the decision to fire the patient,
the situation has deteriorated to the point where trust is
broken and the physician cannot provide effective care. In that
case, it’s important to put anger and ill feelings aside
and approach the patient with the idea that seeking care
elsewhere is to his benefit. “Usually, I think if the
patient believes that you have their best interests at heart,
they’ll accept that,” Sanders says.
The next step is to
write a letter to the patient, stating that as of a specific
date, usually 30 days from the date of the letter, you will no
longer treat him. Be as diplomatic as possible. It isn’t
necessary to detail the reasons for dismissing him, though
again, it’s a good idea to emphasize that this is for his
benefit, as you can no longer provide the care he needs. Offer
to transfer medical records to a new physician.
“Why is the
physician giving notice?” asks Spangler. “One,
because it’s ethically appropriate, but two, to prevent
charges of patient abandonment. If a lawsuit ever comes out of
the situation, the physician is going to want proof that he did
communicate his intent to terminate and did give the patient
notice.”
While the notice
period is 30 days, circumstances could lead to a longer notice
period. For instance, if a patient is in the late stages of
pregnancy, the physician might be reasonably expected to
continue to provide care through the end of the pregnancy.
Should you offer to
assist the patient in finding another physician? There is no
obligation to do so. One purpose of the notice period is to
allow the patient time to find another provider. However, the
physician may wish to refer the patient to the local medical
society or hospital help line as a source for finding a new
physician.
Sample letters are
available from many medical societies. The letter should be
sent to the patient via certified mail. A copy should go into
the patient’s chart, and another copy should go to the
patient’s insurance company. If the letter is returned,
this should be noted and the returned letter placed in the
patient’s file. A a second letter should be sent via
regular mail, with the date of mailing also noted in the
patient’s file.
