The right and wrong ways to dismiss patients

May 10, 2017
Ed Finkel

While physicians should be circumspect about “firing” patients in most types of cases, they are well within their bounds to dismiss patients who are violent, verbally abusive or use their trusted doctor-patient relationship to feed drug addictions.

Gary LeRoy, MD, a primary care physician in Dayton, Ohio, recalls an incident at East Dayton Health Center when a patient with mental health issues became belligerent and tried to grab a front-desk employee through the window.

“That person was immediately given a verbal notification that he was being discharged from the office,” LeRoy says. “We had our office manager draw up the letter immediately.”

Although this kind of incident is the exception, not the norm, it does illustrate that sometimes, practices need to dismiss a patient. Most often, patients pose problems like non-adherence to treatment plans or failure to show up for appointments and need to be managed on a regular basis.

Terminating a patient relationship is “not a first-resort issue because the doctor-patient relationship is really paramount,” says Carrie Horwitch, MD, a Seattle-area internist and chairwoman of the American College of Physicians committee on ethics, professionalism and human rights.

“It’s very uncommon for doctors to summarily dismiss folks because they’re an annoyance,” LeRoy agrees. “It’s our responsibility to ferret out whether there is something there that can be fixed.”

 

Some Cases Merit Dismissal

While physicians should be circumspect about “firing” patients in most types of cases, they are well within their bounds to dismiss patients who are violent, verbally abusive or use their trusted doctor-patient relationship to feed drug addictions. 

When a patient becomes violent or physically threatening, Horwitch says, they need to be dismissed. “The cases I am familiar with, where a dismissal became necessary, was where a patient came in with a gun to a clinic and threatened somebody,” she says. “Then it’s a safety issue not only to clinicians and staff but to other patients.” LeRoy cites another type of situation that often warrants dismissal: when patients with drug addictions forge or alter a prescription, or “physician shop” to get prescriptions. 

“That violates our trusted relationship, where I cannot provide you medical care,” he says. “If they’re at the emergency room for an overdose of a controlled substance that I didn’t give them, [the next time I see them] I ask, ‘Where did you get this?’ That’s grounds for dismissal,” at least potentially, judged case by case.

 

If a patient isn’t clearly in violation of the law, LeRoy says, he will sit them down and remind them of the contract that he has ongoing users of opioids and controlled substances sign that says they will not abuse their medications. 

If they are not forthcoming about their actions, he informs them they have violated their contract and that he will no longer prescribe those medications. In some cases, the patient then elects to leave the practice to find another doctor. 

If the patient does appear to be in violation of the law, which LeRoy says is very rare in his experience, he is obligated to contact the local office of the Drug Enforcement Administration. 

Perhaps unsurprisingly, LeRoy says, patients never acknowledge doctor-shopping but will sometimes invent stories about a friend or family member who gave them the pill and pretend not to know its name. Mental health issues also can play into this scenario (see sidebar).

Whatever the cause, doctors and healthcare attorneys offer several legal guidelines as well as ethical advice regarding what to do-and what not to do-when physicians reach the point where a doctor-patient relationship simply cannot be saved.

Legal Guidelines & Ethical Advice

The Dos

Check state statutes/licensure rules 

Wakefield notes that each state has specific licensure rules, or at least case law that governs various aspects of how to properly end a doctor-patient relationship. 

Jodi Laurence, JD, a healthcare attorney with Greenspoon Marder in Fort Lauderdale, Florida, says most states require physicians to provide written notice of about 30 days along with some assistance in finding another physician, and some state statutes include language regarding forwarding of medical records. 

 

Notify the patient clearly and in writing

The patient should know why they are being turned away, and they should have been given opportunities in most cases to correct their behavior, says Joel Wakefield, JD, a healthcare attorney with the Nelson Law Group in Phoenix, Arizona.

He adds that he often finds himself advising clients not to terminate a patient based on a first-time problem. 

 

East Dayton provides very clear reasons for terminating a relationship, LeRoy says, adding that he also tries to explain to the patient face to face why the health center finds termination necessary. If that can’t happen, letters from the office manager or another staff member are sent out via certified mail, with a restricted delivery signature, “so we know the person has actually received it,” he says.

Medical practices should inform patients in writing what types of behavior could lead to their dismissal and then again in writing when they are dismissed, Horwitch says. And Lewis urges providers to try to reach patients who haven’t paid to find out why they’re having difficulty. “We are given the responsibility and faith of our patients,” she says. “On the other hand, if you’re running a business, you have to pay your staff and keep the lights on.”

 

Give adequate notice, going beyond legal standards when medically justified

The state might require 30 days, but “in some specialties, I will tell clients to give them more time,” Wakefield says. “If they can’t get in to see another endocrinologist because everybody is booked for 60 days, I can’t just cut them off.”

This timeframe can vary based on the specific standard of care, Laurence says. For example, an OB/GYN obviously would not want to end a relationship with a woman in the third trimester of her pregnancy. And in general, “If you’re treating a patient during an active episode of care, you would have to be very careful about how you transition,” she says.

 

Provide a referral

LeRoy describes this as a “critically important” aspect of the process. “You do have to provide them advance notice and provide them medical care until they’re established with another professional,” he says. “You need to help them as much as you can” in making the transition.

 

Provide medical records, if requested

“You want to make sure you facilitate getting the new doctor the medical record, so the patient is continuing to receive care appropriately and is not put at risk of harm,” Laurence says.

 

LeRoy warns against holding a patient’s medical records hostage because they haven’t paid their bills unless the medical practice is sure it’s on solid legal ground. He recalls one recent anecdote in which a father was laid off from his job, the family got behind on medical bills, their doctor dismissed them and then refused to forward their records. 

“Therefore the kids couldn’t start school because they didn’t have the medical records to verify immunizations,” he says. “If they are going to withhold medical records, they have to say so, and if it’s legal in your state, you should put that in your letter.”

 

Clearly explain to the patient his or her lingering medical problems upon departure

Mark Glassman, JD, of the law firm Glassman Lane in Plantation, Florida, says physicians need to make specific recommendations in the form of a treatment plan and ask patients to sign off on them. “Having the patient sign their chart is one of the best things you can do to protect yourself,” he says. “It sounds daunting, and it sounds very legal, but if you’re already in the process of parting ways with a patient … it protects the doctor.”

 

Communicate with staff

This is especially important for receptionists and other employees who might encounter a patient who doesn’t go away quietly, Wakefield says. 

“You owe it to those people to let them know what’s going on, without any malice or vitriol, and give them a script for how to deal with it,” he says.

Otherwise, patients can get their foot back in the door, LeRoy says. If a doctor dismisses a patient but does not inform a colleague, who then treats that patient, “inadvertently, if we’re in practice together, that reestablishes the patient-physician relationship,” he says. “That can get sticky, legally.”

The Don’ts

Don’t cut them loose without a lifeline

“The key is to avoid patient abandonment,” Laurence says. “It will be easy-if God forbid they say you abandoned them-if you have a policy that shows you didn’t.”

 

LeRoy suggests having an attorney look over the practice’s standard termination letter. “It’s very important for the patient being dismissed to understand the circumstances that led to that, and what their obligations are,” he says.

Horwitch says that if the physician hasn’t yet found a referral source, he or she is obligated under most circumstances, when a patient has an acute issue, to continue providing care. “There always needs to be respect for a patient’s best interests, and the overall health and well-being of that patient,” she says.

“You can’t leave patients high and dry,” Wakefield says. “That is the first thing I’m telling my clients.”

 

Don’t respond in kind to the patient’s behavior

Sometimes that’s tempting to do when doctors and staff are frustrated, but remaining professional lessens the chances of a patient sending a letter to a licensure board-or filing a lawsuit, Wakefield says. 

Doctors sometimes want to respond to a rude patient in similarly vitriolic language, but “I’m usually trying to talk them down off of that,” he says. 

More measured tones will soothe not only the patient but also family members and others “who will help the patient understand what happened, and [encourage them to] move on.” And if the patient contacts the licensure board, “I want [board members] to see a reasonable and helpful letter” and not an angry rant, he adds.

 

Don’t say or do anything discriminatory

“You don’t want to [terminate care] if it would be discriminatory, or violate any laws or rules around race, gender, disability, nationality, etc.,” Laurence says.

 

Don’t send them to usual referral sources

“This gets really tricky,” Wakefield says. “You don’t want to say, ‘Go see my good friend Jim,’ because then Jim won’t talk to you anymore.” 

He frequently counsels his clients to send the patient to a medical board or medical association website, which he says “is a bit of a cop out, but I always want to send them someplace.”  

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