‘3 Strikes ‘n’ yer out’: Dismissing no-show patients
Reducing no-shows: Evidence-based methods
Many medical and mental health articles describe evidence-based methods for lowering no-show rates. Studies document the value of assertive outreach, home visits, avoiding scheduling on religious holidays, scheduling appointments in the afternoon rather than the morning, providing assistance with transportation,8 sending reminder letters,16 or making telephone calls.17 Growing evidence suggests that text messages reduce missed appointments, even among patients with severe disorders (eg, schizophrenia) that compromise cognitive functioning.18
The measures I’ve described won’t prevent every patient from no-showing repeatedly. If you or your employer have tried some of these proven methods and they haven’t reduced a patient’s persistent no-shows, and if it makes sense from a clinical and financial standpoint, then it’s all right to dismiss the patient.
To understand why you are permitted to dismiss a patient from your practice, it helps to understand how the law views the doctor–patient relationship. A doctor has no legal duty to treat anyone—even someone who desperately needs care—unless the doctor has taken some action to establish a treatment relationship with that person. Having previously treated the patient establishes a treatment relationship, as could other actions such as giving specific advice or (in some cases) making an appointment for a person. Once you have a treatment relationship with someone, you usually must continue to provide necessary medical attention until either the treatment episode has concluded or you and the patient agree to end treatment.20
For many chronic mental illnesses, a treatment episode could last years. But this does not force you to continue caring for a patient indefinitely if your circumstances change or if the patient’s behavior causes you to want to withdraw from providing care.
To ethically end care of a patient while a treatment episode is ongoing, you must either transfer care to another competent physician, or give your patient adequate notice and opportunity to obtain appropriate treatment elsewhere.20 If you fail to do either, however, you are guilty of “abandonment” and potentially subject to discipline by state licensing authorities21 or, if harm results, a malpractice lawsuit.22
In many states, statutes or regulations describe what you must do to end a treatment relationship properly. Ohio’s rule is typical: You must send the patient a certified letter explaining that the treatment relationship is ending, that you will remain available to provide care for 30 days, and that you will send treatment records to another provider upon receiving the patient’s signed authorization.21
One note of caution, however: If you practice in hospitals or groups, or if you or the agency where you work has signed provider contracts, you may have agreed to terms of practice that make dismissing a patient more complicated.23 Whether you practice individually or in a large organization, it’s usually wise to get advice from an attorney and/or your malpractice carrier to make sure you’re handling a patient dismissal the right way.
