Dismissing patients always a last resort

Sooner or later, every primary care physician runs into patients who inspire thoughts of dismissal from the practice. Missed appointments, chronic lateness, drug-seeking behavior, belligerent attitudes and refusal of treatment can strain a physician-patient relationship to the breaking point. But although physicians retain the legal right to dismiss patients in most cases, if a dismissal is not carried out in accordance with state laws, they may find themselves facing charges of patient abandonment as well as disciplinary action from their state medical boards.

“Unilateral discontinuation of the patient-physician relationship by the physician should only be done in rare circumstances and only when other care is available and the patient's health is not going to be harmed,” said Lois Snyder Sulmasy, JD, director of the American College of Physicians' Center for Ethics and Professionalism. “Our position on this is in the ACP ethics manual. We see it as a last resort. Otherwise it can be seen as abandonment.”

Try to work it out

When physicians begin to think of dismissing a patient, they should take a step back and try to assess the situation from the patient's point of view, said Ms. Sulmasy.

“Apart from a patient being violent or a danger to others, we would hope that any issue that comes up would be something both the patient and the physician would be willing to try and work out,” she said. “People are not necessarily at their best when they are sick, and physicians more than anyone know that.”

Michael Green, MD, MS, FACP, professor in the departments of humanities and medicine at Penn State College of Medicine in Hershey, Pa., agreed.

“Generally, when patients are acting badly, it's a symptom of their suffering. It's not necessarily a symptom of their condition, but of underlying issues. They are afraid, frustrated, ill, or concerned, and some have better coping skills than others,” he said. “There are reasons for it. They may not be good reasons, but reasons. Look at it in a therapeutic context.”

Dr. Green suggests taking a “collaborative and curious approach” instead of engaging in confrontation.

“If a patient is angry and yelling, calling security may get the patient out of the office, but it will likely escalate the situation and harm the doctor-patient relationship.” he said. “It's better to acknowledge the anger and seek to understand what could be causing it.”

Regardless of the issue, an honest discussion can provide an opportunity for resolution, said John Davenport, MD, JD, partner and physician risk manager for a large Southern California medical group. “Sit down and talk, and give the patient a chance to hear the issues that are causing you to consider dismissal, so that they can understand your side.”

How long to give the patient to improve his or her behavior is up to the physician. However, there are several potential costs to a practice for not dismissing an abusive or belligerent patient, said Dr. Davenport. “Should the staff be stressed, this might lead to increased sick time, poor productivity, and, in severe cases, claims for worker's compensation for stress.”

Common reasons for dismissal

Data on patient dismissal are scanty, but a 2008 study of 526 primary care physicians published in the Journal of General Internal Medicine suggests that as many as 85% of primary care physicians have dismissed at least one patient. Among physicians in the study who dismissed patients, 71% had dismissed 10 or fewer patients, but 14% had dismissed 11 to 200 patients.

The most common reasons cited for dismissal were verbal abuse and drug-seeking behavior. Among physicians who dismissed patients, 40% cited verbal abuse and 40% cited drug-seeking behavior as reasons. In addition to reporting whether they had actually dismissed patients, physicians in the study were presented with 12 scenarios involving hypothetical patients and were asked whether they would dismiss them. Among all respondents, 97% said they would dismiss a patient for verbal abuse and 90% said they would dismiss a patient for drug-seeking behavior.

Dismissing a patient for verbal abuse is a matter of a physician's personal tolerance once efforts to resolve the issue have proved fruitless. But drug-seeking behavior can put a physician's license on the line.

“Heightened state laws and regulatory requirements are becoming increasingly common across the country,” said Gregory A. Hood, MD, FACP, Governor of ACP's Kentucky chapter and medical director at Quality Independent Physicians Accountable Care Organization in Lexington. “In our state there are clear regulatory requirements that spell out how dismissals [under these circumstances] are handled. There is a medical concern about abruptly stopping a medication. A 30-day supply is generally OK so the patient doesn't get into a life-threatening situation.”

Yet physicians cannot serve as narcotics dispensers, as that can also jeopardize licensure. One way they can protect themselves is to have the patient sign a contract regarding the prescribing and use of controlled substances.

In general, such contracts state that the physician will be the only one prescribing that drug for that patient and stipulate the patient's responsibilities for storing the drug, maintaining an adequate supply, using only one pharmacy to fill the prescription, and not sharing the prescription with anyone else.

“The contract should spell out that a violation of terms may be cause for termination from the practice, and the patient should sign it up front, before the prescription is written,” said Dr. Hood. He noted that a violation will usually result in patient dismissal, but not always.

“One option is to offer to keep the patient in the practice, but only for matters that do not involve prescribing controlled substances. Then you need to make a referral to an appropriate specialist, whether that's a psychiatrist or someone who specializes in pain management or addiction,” he said.

The sticky issue of nonadherence

As frustrating as it can be to see a patient disregard medical advice, nonadherence is a weak reason for dismissal, said Ms. Sulmasy.

“A lot of patients don't follow medical advice. Some would argue that it's the role of the physician to work with them,” she said, noting the challenges of weight loss and smoking cessation in particular. “It would be wrong to discriminate against obese patients or smokers. These are the very people who need help.”

Dr. Green emphasized the patient's right to self-determination. “It's not really our job to force people to do anything. It's our job to provide them with resources they can use for their health,” he said.

Dismissing patients for not following doctor's orders can be detrimental to the practice, said Dr. Hood. “Physicians who dismiss patients who don't exercise or lose weight will have a hard time paying their rent.”

He acknowledged that a patient may sometimes wish to pursue medical or surgical care entailing such extreme risk that a physician feels compelled to recuse himself or herself.

“But generally, we are about finding consensus or options,” he said. “In many cases, there are two or three possible choices. The physician may prefer one option over another but can at least see the patient's side of it and go with the patient's choice.”

Physicians should make sure that patients who refuse medical advice or treatment know the risks and possible consequences of doing so, said Dr. Davenport. “There should be informed refusal. They're entitled not to take your advice, but it's your duty to tell them what the risks and possible consequences are.”

He added that physicians should document such discussions in the patient's chart as proof that the patient was counseled on the possible outcomes, and then follow up in writing. “Write a letter explaining why you want [the procedure or treatment] done and what the risks are for not having it done, and send the letter by certified mail, return receipt,” he advised.

Documentation of this kind can protect physicians if the patient experiences a negative outcome that could be attributed to refusal of care. “In aberrant cases, if someone refuses obvious and significant care and then dies, the only ones left are the family, and they sometimes don't know that the patient refused treatment. In their world you were negligent, so you should have the documentation there to protect yourself,” said Dr. Davenport.

When dismissal is not an option

Even though physicians retain the legal right to dismiss patients in many situations, there are some circumstances when it's not only unadvisable but unethical and, depending on the state where it occurs, illegal and punishable both by law and by censure. The most notable situation is when the patient is in active treatment.

“A withdrawal from a physician-patient relationship should not be attempted when the patient is in need of medical attention,” said Humayun Chaudhry, DO, MS, MACP, president and chief executive officer of the Federation of State Medical Boards in Washington, D.C. “For example, this could be a situation of acute care, where someone is in the hospital for 30 days. That is the wrong time to talk about terminating the relationship.”

Likewise, physicians should not disrupt continuity of care, he added. “A physician should not terminate the relationship when he or she knows, or reasonably should know, that no other provider can provide the same services.”

Physicians in specialties or subspecialties often fall into this category, as do physicians in rural areas. “It's generally not reasonable to expect a patient to drive 300 miles to see another doctor,” said Dr. Chaudhry.

The last resort

When all attempts to resolve the issues between physician and patient have proven futile, a physician may feel there is no alternative to dismissal. If it comes to that, physicians must follow all state laws with respect to providing interim care and not abandoning the patient.

“The first thing they should do is check with legal counsel and their state board of medicine so the dismissal is done in a fashion that does not get them sued or into trouble,” said Dr. Chaudhry.

Physicians in large health systems or multigroup practices should also check to see if there are policies and procedures in place for patient dismissal, he added. Those in smaller practices may want to put such guidelines in place if they do not already exist.

“Just like when you have an employee handbook, it is prudent to have policies in place so you are consistent in the way you act,” Dr. Chaudhry said.

The process of dismissal begins with a frank conversation, one that takes the patient's point of view into consideration and couches the discussion in terms of the patient's best interests.

“One way to approach it is to say, ‘You've come to me for the best medical opinion, and in my best medical opinion, I'm not the doctor for you,’” said Dr. Hood. “That can be a humbling thing for a physician to admit, but in that situation you are not only stressing yourself, but holding the patient back from finding a physician who can help.”

From that point forward, it's a matter of documentation.

“Clearly note the reasons for dismissal and the discussions you have in the chart. Then send a brief letter noting that you will be unable to see the patient after 30 or more days,” said Dr. Davenport.

He continued, “State where the patient might find resources to obtain future care, and emergency care, and include an authorization to copy and release medical records for the patient to give to his or her next doctor,” stopping short of suggesting specific referrals to other individual physicians, who may or may not be able to take on the patient.

To avoid throwing gasoline on an already fiery situation, Dr. Davenport recommends not charging the patient for a copy of the chart to be sent to the next physician.

Maintaining the roster

Depending on the reasons patients have been dismissed, physicians may wish to keep the door open for reestablishing the relationship at a later date.

“It may be worth reopening the issue if the patient wants to try to have a productive relationship,” said Ms. Sulmasy.

Dr. Chaudhry noted that once a relationship is reestablished, dismissing the patient again will require starting from scratch. Therefore, he advises physicians to check with their attorneys first. A second opinion from a colleague in the practice couldn't hurt, either.

“A third party you can trust can help you make the right decision,” he said.

If there is no doubt that the dismissal is permanent, the next step is to take precautions against the patient getting back onto the roster. The dismissal should be noted in charts and electronic medical records, and staff should be informed that the patient has been dismissed. Dr. Hood suggests maintaining a master list of dismissed patients, as well.

“If our practice were to disband or merge into another, or if one of us leaves, we'd want to have a printout of names and unique identifiers,” he said, cautioning against using Social Security numbers, which could violate privacy laws.

If for some reason a physician encounters a patient after the patient is dismissed (i.e., the patient manages to get an appointment or the physician is on call and sees the patient in the emergency department), the physician should make it clear that the visit is a one-time event and note it in the chart, said Dr. Davenport.

“The patient should know that a professional relationship is not being offered or established,” he said.

Dismissing a patient should prompt physicians to think about their own role in the demise of their physician-patient relationships, said Dr. Green.

“It's a two-way street. Physicians should not only be aware of their patients' behavior, but also look within and see how their own attitudes and behaviors may be contributing to conflicts when they arise, and consider what they could do differently,” he said. “We should all be more self-reflective.”