Earlier this year, I read an article about a doctor in Canada who literally “fired” 500 patients. After many years of practice, the doctor found himself with 2,100 patients and a 14-hour-a-day workload. Exhausted from trying to keep up with the demands of his practice, even with an assistant, the doctor held a lottery. The 500 names that were selected received a letter explaining that they would have to find medical care elsewhere.
That story prompted thoughts about why, when and how a physician might need to terminate a relationship with a patient. After all, a patient can leave a physician at any time for any or no reasons. A doctor, however, must follow ethical protocols in order to end a physician/patient relationship without incurring potential litigation.
Guidelines issued by the American Medical Association cite that a doctor is ethically obligated to provide for the patient’s continuity of care. According to those guidelines, a doctor my end the relationship if the patient, patient’s family or responsible parties are notified with enough advance notice for the patient to secure another doctor. A physician can also, under these guidelines, decline to treat a patient who requests a treatment protocol that is scientifically invalid or is incompatible with the personal, religious or moral beliefs of the physician.
Many physicians also believe that, no matter how frustrating it may be, a patient’s noncompliance with treatment may not be reason for terminating the relationship. Although when such noncompliance cannot be overcome and the doctor is unable to make any headway in bringing such patients around, it may be in the patient’s best interests to terminate the relationship.
Some reasons that doctors may need to fire a patient include:
1. Patients who are abusive to the doctor and staff.
2. Deadbeat patients who will not pay for their care.
3. Patients demanding unacceptable treatments.
4. Patients that create problems with other patients or staff.
5. Patients who chronically miss appointments.
6. Improper sexual advances by the patient.
Regardless of the specific reason or situation, experts advise that a doctor discuss the situation with a peer or clinical risk manager before taking any termination action. Such an objective outside view can often provide some balance. Sometimes the patient may not be at fault. It is possible that, for whatever the reason, the doctor has an adverse emotional reaction to a patient. That may be a valid reason to request the patient seek help elsewhere, but the doctor should understand the situation beforehand.
Expanding on the listed items, patients with poor hygiene (odoriferous and unkempt) can disrupt other patients in your waiting room. Patients with a history of drug and alcohol abuse may demand opiate medications that are not in their best interests. A patient may continually scream abusively at your receptionist, nurse or yourself.
Each case needs to be thoroughly reviewed individually. Have steps been taken to change the patient’s behavior or belief? Have they been successful? Have you sought out assistance from family, friends or other professionals for the patient (without violating HIPAA)? After a thorough review, the decision to terminate the relationship must be handled ethically and appropriately to avoid potential claims of abandonment. Therefore I would recommend that you seek advice on the termination action with your attorney or insurance representative.
Key factors in the termination process include:
1. Allowing the patient adequate time to locate another caregiver. Most experts feel that a month is a suitable time period, but that may vary due to the availability of medical care providers in your community.
2. Draft a letter advising the patient of your decision. Be specific as to the date you will terminate services and resources directing them to other physicians. The letter should also reference the fact that you will need their written authorization to transfer patient records to a new physician.
3. There is some debate as to including the specific reasons for termination in the letter. Some experts advise avoiding any reference to the reasons behind your decision. Other experts advise full disclosure, but recommend keeping the reasons brief and factual. Each physician should follow the recommendations of their attorney or other professional on this matter.
4. You are still required to treat the patient during the period prior to the termination date and in cases of emergency.
However you write the termination letter, it should be written in such a way that the patient who reads it will feel that the discharge is for the benefit of the patient, not the practice. The patient should feel that whatever happened has damaged the physician/patient relationship to the extent that it has become ineffective, which does not serve the best interests of the patient. Therefore the patient can seek a doctor with whom a good relationship can be created. Emotionally you may want to “fire and blame the patient”, but that could actually increase your potential exposure for claims of abandonment or unprofessional conduct.
And, as always, document, document, document every step of the termination process.
J. Michael Rosenthal, ARM is the President & CEO of California based RGI Insurance Services, specializing in insurance for physicians and medical groups. For more information, visit www.RGIinsurance.com or call 1-800-852-8872.
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