PRACTICE RECOMMENDATIONS
• Unless a single incident irreparably damaged your relationship with a patient, exhaust all efforts at resolution before deciding on dismissal. C
• Establish policies that help you set limits on problem behavior—eg, drug-seeking or angry outbursts—while continuing to care for the patient. C
• When dismissal is unavoidable, inform the patient in writing that you will be available to handle medical emergencies until he or she has found another physician. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Susan L, a 53-year-old who’d been a patient of Dr. O’s for the past 6 years, received a bill for a visit that had occurred nearly 2 years earlier. She called the office and told the receptionist that she had never been billed for this visit and didn’t think she should have to pay after such a lengthy delay. When she received a past due notice, Susan called and asked to speak to the physician—and to schedule an appointment. She was told that she could do neither until her account was current.
Eventually, the unpaid bill was sent to a collection agency, and Susan received a letter threatening legal action. In response, she sent a letter of her own—certified, return receipt requested—detailing her reason for not paying and threatening to sue Dr. O for abandonment.*
*Adapted from actual cases, with details changed to protect the privacy of the parties involved.
With the national unemployment rate hovering at a record high, unpaid medical bills may be your most pressing problem—and potential grounds for patient dismissal. Judging from a recent survey in which primary care physicians identified nearly one patient in 5 as “difficult,"1 it’s unlikely that nonpayment is the only patient conundrum you face.
Indeed, there are many ways a patient can be difficult, including exhibiting habitual hostility, chronic drug-seeking behavior, or consistent noncompliance; breaking appointments at the last minute; or being a no-show. You may wish you could “fire” the worst off enders but be concerned about professional and ethical responsibilities and the legal risk you might face. Ironically, though, struggling to maintain a chronically stressed physician-patient relationship is often riskier than a well-timed termination.2
The key here, however, is the persistent or extreme nature of the difficulty.3 When a dismissal is prompted by a one-time occurrence or lower-level offense, what constitutes a reasonable response is not always clear-cut.
Under what circumstances is it appropriate to end your relationship with a patient? When you do terminate the relationship, what steps can you take to safeguard the patient and avoid charges of abandonment? Here’s a look at these questions—and some answers.
Professional responsibility: How far does it go?
As a physician, you’ve pledged to “do no harm.” And you’ve likely been taught—as it states in the American College of Physicians (ACP) ethics manual—that you have “a moral duty to care for all patients.” 4 The American Medical Association’s code of ethics cites a similar standard: the obligation to place patients’ welfare above your own interests.5
According to the ACP, the physician-patient relationship should be discontinued only under “exceptional circumstances."6 But not everyone agrees, not only on what constitutes “exceptional,” but on whether that is the correct threshold for termination.
A health care attorney writing in American Medical News, for example, takes a more liberal view. It’s time to dismiss, he asserts, when the doctor-patient relationship doesn’t work.7 By that standard, virtually any ongoing problem could be construed as evidence of an “irreparable breakdown” of the physician-patient relationship (TABLE).
TABLE
Key reasons to "fire" a patient
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| Sources: Kodner C. FP Essentials. 2008.3 Harris S. Am Med News. 2008.7 |
We can work it out
Legally, a doctor can dismiss a patient for virtually any reason, or fail to give any explanation at all.2 Ethically, dismissal should be your last option, not your first choice.
In a home study course titled “Challenging physician-patient interactions,” the American Academy of Family Physicians (AAFP) advises doctors to be certain they have exhausted every reasonable effort to communicate, set achievable goals, and meet the patient’s needs.3 The steps you take to try to mend a damaged patient relationship, of course, will depend on what caused the rift in the first place. Here are some examples.
Nonpayment. You are not compelled (or expected) to indefinitely continue to treat a patient who’s unable—or unwilling—to pay you, of course. But if he or she is out of work and has fallen on hard times or has a single unpaid bill, discussing the problem and attempting to accommodate the patient’s financial limitations (and establish a realistic payment plan) is a reasonable approach.