When Is the Right Time to Cut the Cord with a Patient?

In today’s world of reality-based television programming, the words “You’re fired” have become synonymous with Donald Trump as he weeds through candidates to determine who will become his next apprentice. Seldom are those words associated with the physician-patient relationship. In reality, however, their meaning—if not the actual words themselves—is conveyed more often than you might imagine. “Doctors want to help out,” explains Laura Dixon, BS, JD, RN, CPHRM, director, Department of Patient Safety, Western Region, for The Doctors Company, a physician-owned medical malpractice company. “They don’t recognize that it’s okay to send a patient on. It happens more frequently than they think.”

In today’s world of reality-based television programming, the words “You’re fired” have become synonymous with Donald Trump as he weeds through candidates to determine who will become his next apprentice. Seldom are those words associated with the physician-patient relationship. In reality, however, their meaning—if not the actual words themselves—is conveyed more often than you might imagine.

“Doctors want to help out,” explains Laura Dixon, BS, JD, RN, CPHRM, director, Department of Patient Safety, Western Region, for The Doctors Company, a physician-owned medical malpractice company. “They don’t recognize that it’s okay to send a patient on. It happens more frequently than they think.”

Reasons vary

According to Dixon, there are three main reasons why physicians find themselves in a position to terminate a relationship with a patient: treatment or follow-up noncompliance; office disruption, which can include both verbal and physical abuse on the part of the patient; or simply the inability of the patient and physician to get along. But, adds Dixon, there are times when the reason for termination has nothing to do with the patient.

“Often, the doctor loves the patient, but it’s the family, or the well-meaning, well-intentioned friend, who can make life miserable for everybody,” Dixon explains. “Unfortunately, you have to deal with both of them.”

Coming to grips with patient termination, however, is not an easy thing for most physicians to do. They feel an ethical obligation. They started providing care, and they want to see it to the end. But Drew Stevens, PhD, a customer service expert and president of Stevens Consulting Group in Eureka, Missouri, says the reality is that when patients create more expense than profit, it’s time to let them go.

“Examine how many times a patient comes to the office,” Stevens suggests. “Are they spending too much time with the office management staff going over paperwork and requiring too much service from an administrative end? Do they constantly phone? Do they constantly complain? And more importantly, are they tying up the waiting room where the physician could be seeing other critically ill patients?”

A clear process

The number one issue physicians need to be aware of when it comes to terminating a patient is to avoid abandonment-of-care issues. For starters, says Dixon, you don’t want to terminate a patient when they’re in-patient. But the list doesn’t end there.

“When you’re dealing with a third trimester pregnancy, or a second trimester that is a high-risk pregnancy, you’ve already got a bad situation, and if you leave the patient without care, there’s an abandonment issue,” says Dixon. “We recommend that if the physician is in the middle of treatment, or if the patient is in an acute phase of a problem, don’t terminate them. Get them transferred to another provider so care can continue.”

Dixon also stresses the importance of putting the termination of service notice in writing. It’s okay to tell the patient verbally, but it should be supplemented with written notice that you are not going to be their physician anymore and that they should find another healthcare provider. Some states require the letter be sent to the patient via certified mail, and Dixon adds that it’s helpful to explain to the patient why you are ending the relationship.

“If the patient is not compliant, explain that to them,” says Dixon. “Tell them, ‘I’m not going to care for you anymore because you’re not following recommended care.’ We also tell physicians to explain to patients that they need ongoing care, and it’s their responsibility to find another physician.” Note the effective date of termination, which The Doctors Company says should be 10 to 30 working days, unless the patient is currently under the care of another healthcare provider, or unless you are a specialist. Under those circumstances, immediate termination may be allowable.

Look in the mirror

Before taking any steps to terminate a physician-patient relationship, it’s a good idea to step back and carefully examine the situation. To what extent, if any, are you or a member of your office staff part of the problem?

“We recommend the doctor consider why a patient is so upset,” says Dixon. “Sometimes there is a staff member who didn’t work well with them and set them off. Maybe something happened where the physicians needs to back up and say, ‘Okay, it was me.’” Does that happen often? “Not as much as the other way around,” Dixon admits. “We ask that physicians look at each case individually.”

And the next time you feel you’re at your wits end with a patient, contact The Doctors Company and get their advice. It might just be time to do your own impersonation of Donald Trump.

Ed Rabinowitz is a veteran healthcare reporter and writer. He welcomes comments at edwardr@ptd.net.