Clinical Review

How to divorce a difficult patient and live happily ever after

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An orderly dismissal does not discriminate, does not abandon the patient—and does help avert legal problems


 

References

You need not despair if you’re confronted with a patient who disrupts your practice. You have every right to discharge her. But once a physician-patient relationship is established, you must terminate the relationship officially, to end your obligation. An orderly dismissal does not abandon your patient, and minimizes potential for legal problems.

Although difficult patients may be uncommon in your practice, it is unwise to give no thought to the possibility, and to have no plan to handle the situation. Protect yourself and your practice by following a consistent path with difficult patients, and seek legal counsel when faced with an unusual situation.

Difficult patients aren’t the only ones you may need to dismiss. You may have to dismiss patients because you are retiring or discontinuing your participation with an insurance company.

It’s time to consider dismissal when patients…

…chronically skip key appointments

You know that Kimberly means well, but she has a history of failing to keep her appointments. Your last encounter was a consult at the hospital, where she left against medical advice, as reported to you by her admitting physician. A recent positive test result has you concerned, particularly because she did not show up for 3 visits you’ve scheduled to discuss her care.

…never pay

You’ve delivered 2 of Julie’s babies, and now she’s on the schedule for her preventive gynecological care this afternoon. While you’re grabbing a bite of lunch, your manager comes in to let you know that Julie has never paid you a dime—for three years’ running, despite dozens of statements, phone calls and requests for payments at the front office.

…verbally abuse your staff

Sally has verbally abused your staff on multiple occasions since she became your patient several years ago. She often brings her partner, whom you’ve observed to be ill-tempered with staff. Although they’re pleasant to you when you walk into the room, their behavior is such that your staff refuses to provide nursing assistance any longer.

First, call your liability insurance carrier

Using your professional liability insurance carrier as an adviser is critical. In sensitive situations, such as a patient who displays disruptive behavior, and whom you believe may be litigious, consult the risk management department before a dismissal. Your carrier knows your state’s laws on terminating the patient-physician relationship.

Check insurance contracts

Although most health insurance contracts do not state dismissal terms, they can stipulate anything. HMOs often require specific procedures. If you’ve signed such a contract, you’ll need to be aware of and follow the rules before a situation comes up. Examples: Some payers require a period of time (eg, 90 days) before dismissal, and some require notification first, so that they can counsel the beneficiary.

In future contracting, negotiate for terms that are friendly to your practice, not just to the insurance company.

Warning signs

Difficult patients tend to:

  • Fail to make payment arrangements according to normal practices
  • Fail to comply with a recommended plan of care, including subsequent appointments
  • Display disruptive or violent behavior in the practice (or the patient’s partner is disruptive or violent)
  • Leave the hospital against medical advice
  • Threaten lawsuits
  • Abuse drugs or controlled substances

Put your policy in writing and practice it consistently

Your dismissal policy—and the reasons and protocols your practice follows—must be in writing. Decide what constitutes a reason for dismissal and make sure you apply your own rules consistently.

Do not discriminate or appear to discriminate

As a physician, you have the right to terminate a difficult patient from your practice. Exceptions are dismissals based on ethnicity, gender, religion, or age. If you apply your dismissal policy inconsistently, your actions could be considered discriminatory. For example, do not terminate one patient for failure to pay her $500 debt while ignoring another patient’s past-due balance.

Document, document, document

Document in the patient’s medical record any verbal or written communication to and from the patient. This is especially important in the case of a noncompliant patient. Record every instance, for example, of a patient who fails to show up for her appointment. Record your attempts to contact her to reschedule, and notate the consequences of her failure to keep the appointment.

No-shows are dangerous

Although no-show abuse is rampant for many practices, be careful about continuing to treat these patients without taking some action. Let’s say, for example, you notify a patient of a positive Pap smear and recommend a colposcopy. The patient cancels her first colposcopy and fails to show for the rescheduled procedure. You document your multiple attempts to contact the patient.

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