‘Firing’ a patient: May a psychiatrist unilaterally terminate care?
More discussion of the possible contents of termination letters appears in Table 3.7,12-14
Table 2
Common reasons to consider terminating a patient’s care
| Failing to pay bills |
| Repeatedly cancelling or missing appointments |
| Repeatedly failing to follow the agreed-upon treatment plan |
| Overly demanding, rude, disruptive, threatening, or violent behavior toward staff or other patients |
| Patient is very dissatisfied with care |
| Needing specialized services that the physician cannot provide |
| Filing a complaint or legal action against the physician |
| Dishonesty that compromises safety or legality of treatment |
| Physician feels treatment is ineffective |
| Conflict of interest (eg, physician’s religious beliefs preclude providing certain treatments that might be indicated) |
| Developing and acting upon an inappropriate personal interest in the physician |
| Inappropriate response by physician to feelings about the patient (eg, physician feels tempted to act upon an attraction) |
| Source: References 7,8 |
Table 3
Potential elements of termination letters
| Element | Comment | |
|---|---|---|
| Reason for termination | Giving a reason is not required. If an explanation seems necessary, offer a general statement (eg, ‘I have determined it would be best…’) | |
| Adequate time to seek care elsewhere | Typically, at least 30 days. Courts have described appropriate time frames in general terms, such as ‘ample,’ ‘sufficient,’ or ‘reasonable’ | |
| Interim care provisions | Offer interim care for urgent problems until the time limit stated above | |
| Continued care provisions |
| |
| Medical record copies | Offer to provide a summary of treatment or copy of the record to a new provider. Consider enclosing a ‘release of information’ authorization to be returned to the office with the patient’s signature | |
| Sending the letter | Regular and certified mail (return receipt requested). Place a copy of this letter in the patient’s medical record, along with the original certified mail receipt and, if received, the original return receipt | |
| Source: References 7,12-14 | ||
Deciding to ‘fire‘ a patient
Physicians in all specialties encounter patients whose actions generate intensely negative feelings—resentment, anger, even hate.15 But “firing” a patient should be a rare circumstance that’s not undertaken lightly. Many different circumstances can make it reasonable for a physician to consider terminating a patient’s care, so it’s difficult to provide general advice about when firing a patient really is the right thing to do. But 1 “prescription” seems clear: consult a respected colleague first. According to psychiatrist Robert Michels, “Any physician who is thinking of firing a patient should first speak to a colleague… This is an enormous decision and, while it might even be right at times, the physician is probably having a countertransference reaction to his patient and should really understand that before taking action.”1
Having an anonymous consultation with a colleague offers several potential benefits, such as:
- If you’re thinking about firing a patient, you’re probably very upset. A colleague who isn’t emotionally involved can help you assess the matter more dispassionately.
- You may be feeling guilty about disliking the patient. A colleague’s empathy (“Of course you’re angry!”) can help you avoid disowning your feelings, which may make it easier to figure out how to use those feelings to help the patient.15,16
- A colleague may think of solutions that you haven’t considered, which might help you feel less frustrated about how treatment is going.
- A colleague may help you see ways that you’re actually helping the patient, despite feeling that your work is futile.
- If a thoughtful colleague confirms your view that terminating care is appropriate, you’ll feel better about the decision. If you document the anonymous consultation in the patient’s chart, you’ll create a record of your reasonableness and prudence—which will be helpful if you have to defend your action in court.12
Revisiting the case patients
With these thoughts in mind, we return to Dr. C’s clinical dilemmas.
Ms. A. In retrospect, Dr. C might wish he had been clearer with Ms. A about how often she would need to see him for medication monitoring. At this point, however, Dr. C still has options besides firing Ms. A:
- Dr. C can call Ms. A to ask how she’s doing and to explain his medical responsibility to see and reassess her if he is to continue prescribing her medication. He can then follow up with a letter summarizing the conversation.
- Dr. C might ask whether some problem is preventing Ms. A from making an appointment. If, for example, Ms. A has lost her job and health insurance coverage for office visits, Dr. C might suggest options (such as seeing Ms. A once at no charge) or help Ms. A find other ways to obtain follow-up care.
