On Letting Go, Part II: Severing ties With Difficult Patients
We know. It sounds strange when you think about it, and even a bit, well, wrong. We’ve covered the firing process on this blog before, the ins and outs of letting go of a difficult, unaccountable, or untrustworthy staff member. But telling a patient that your practice is no longer open to them, that they must seek quality care elsewhere? You chose a calling predicated on compassion, and service. You took an oath (an actual oath…). Is it appropriate to just “fire” a patient?
…Well, when you consider the fact that, despite the high ideals attached to it, medicine is a profession like any other, and that your practice is (here it comes again) a business, then yes, firing a patient can be appropriate given the right circumstances.
As unappealing and even shameful as it sounds, discontinuing the doctor-patient relationship is sometimes not only practical, but absolutely necessary. In a previous post, we discussed ways of dealing with many kinds of difficult patients: the habitually late, the verbally abusive, the never-payers, the chronically addicted, and the blatantly non-compliant. Assuming you’ve taken the necessary steps toward improving relations with these patients and their behaviors continue nonetheless, it’s time to part ways.
When enough is enough
Answer the following questions as honestly as possible:
- Do you currently treat any patients who consistently exhibit standoffish, or threatening behavior? This includes in the examination room, the waiting area, and over the phone (verbal abuse is still abuse). Remember, you must think about the safety and wellbeing of yourself, your staff, and the other patients waiting quietly in their seats. What does it say about you and your practice if you regularly turn a blind eye to this kind of behavior?
- Do you have any patients who abuse prescription drugs? This is tough accusation to toss out there, but if you have to wonder, then you already know. Are they battling you constantly for refills, and suspiciously fail to show for scheduled follow-ups? The writing is on the wall.
- Has a patient filed, or is preparing to file a lawsuit against you? (This one is pretty cut and dry.)
- Perhaps the most infuriating: does a patient constantly question, or outright fail to follow your prescribed medical treatment? On top of this, do they frequently miss their appointments on very short notice, or without any notice at all? Again, think of those other patients waiting out there whose health is your responsibility, and who do show up on time.
- We’ve discussed the virtue of dynamic, flexible payment plans for patients at length here. They do work, provided you’re willing to offer them, and your patient is willing to stick to them. Now, do you have a patient who fails to pay his bills despite his ability to do so? Does their lack of accountability fly in the face of your efforts to provide them with a suitable payment plan?
The toughest of cases
Sometimes, the patients you must part ways with are those with the greatest needs, and that can make it all the more difficult. It may seem downright cruel to discontinue a patient’s care in this situation, but hear us out first. It’s very possible that you aren’t the first physician to let them go. They may have been discharged by other doctors and specialists for any number of reasons. If you are a primary care physician, this puts you in a difficult position.
The best care is that which can be provided in a network. This is especially true of patients with numerous health issues. A team of doctors, specialists, and surgeons is needed to combat their many ailments in the long term. What if that “team” is just you? What if there is no internist, or endocrinologist to confer with about a diabetic patient? What if you are the one writing a certain prescription, and must take it on faith that this patient complies with taking it, and/or follows up with any corresponding treatments?
Remember that certain high-risk medications require very close monitoring, and regular lab work. If this patient cannot afford these crucial supplementary services, or simply refuses to show up for appointments, the liability falls on you as the primary caregiver. This is a risk you should not have to take. You are, in this scenario, unable to provide adequate care—at least to the extent this patient requires. There is no shame in admitting this. In continuing to see a patient in this way, you are putting both them and your practice at risk.
What actions to take
It is not desired nor is it easy. Thankfully, “firing” a patient is also not terribly complicated. Your practice should ideally have a policy for officially dismissing patients. If you do not, then it may be wise to consult an attorney to help you draft one. There is no singular legal standard for cutting ties with troublesome patients. However, there are “wrong ways” to this end, and each state has its own set of guidelines. For good measure, revisit your liability policy, or contact your carrier with any questions you may have.
(OK. We started this section by saying that the process for discharging a patient wasn’t terribly difficult. We stand by that. We also assume that as a physician, you met the widely accepted standards of medical practice. You conducted yourself with professionalism, patience, and candor, and provided only the best medical treatment.)
After properly documented the reasons for their dismissal, inform your staff of your decision. Then, draft an official letter that includes these reasons, along with a copy of their medical records, and a form allowing them to be sent to any other physician of their choosing. As a kind gesture, you can add a referral list for them, some guidance to help them find a new provider. Make sure the language and tone used in this letter are professional and courteous. Be sure to get confirmation of the delivery of this letter. As a contingency, make a copy to keep on file.
Still feeling uncertain? Well, there is a pretty sound formula to default to, a question of ratio. With a certain problem-patient in mind, ask yourself the following: How would I weigh this particular patient’s need for care when measured against their propensity for, and my policy towards things like appointment no-shows, habitual non-compliance, and unwarranted aggressiveness? Do, or do not? We think you know the answer. It’s true that dismissing a patient is unpleasant. It may dominate your thoughts for a few days, and even nights. But one thing that is equally as true is this: it’s not the patient you dismissed who will ultimately come back to haunt you, but the one you should have dismissed.
Have a great day!
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