How to divorce a difficult patient and live happily ever after
An orderly dismissal does not discriminate, does not abandon the patient—and does help avert legal problems
IN THIS ARTICLE
If the patient continues to schedule appointments and fails to show up for them, contact your malpractice carrier for advice. This patient will likely have a serious medical problem in the future, and you do not want to get tied up in a lawsuit claiming abandonment. Although it may be tedious, thorough documentation of your actions prior to dismissal will pay off in the long run. Include in the record when you communicated to the patient and what you told her regarding the consequences of her failure to present for her appointment.
Dismissal for nonpayment
In the case of nonpayment—the most common cause for dismissal—consider dismissal if the patient refuses to work out payment arrangements.
Consider offering the option of continued treatment on the basis of payment of past debts and future payment prior to service. It is standard practice to offer to allow the patient to return if she abides by this arrangement.
Threats and violence
Call local authorities immediately if a patient makes a threat or displays violent physical behavior. Stop short of broadcasting the situation to other area ObGyns, because that is the responsibility of the police.
When you have dealt with a violent or abusive patient, ask authorities to advise other physicians who may be affected.
You may immediately dismiss a patient when there is a threat or perceived threat of violence. Otherwise, follow the steps of a consistent process to terminate a patient.
Pre-dismissal strategy to avert allegations
The goal of the dismissal process is to terminate your patient-physician relationship while avoiding an allegation of abandonment or discrimination.
Consider alternatives
If the patient is in the course of treatment for a medical condition that requires physician supervision, such as an obstetrics patient or a postoperative gynecologic surgery patient, consider alternatives before dismissing her.
- Can you treat her during the course of the condition and dismiss her afterwards?
- Can you contact a community agency for assistance if, for example, the reason for her failure to show up for appointments is transportation or childcare challenges?
If you have no alternatives but still want to dismiss a patient during a specific course of treatment, seek counsel from your malpractice carrier.
Ask her about correcting the problem
Before dismissing a patient, attempt to communicate with her directly. Discuss your concerns. Document your conversation and her reactions. Proceed with the termination unless she assures you that she will alter her actions. This is optional, and certainly not recommended for a violent patient or one who has a violent partner. However, open communication is suggested because it can help avoid angering the patient. An angry patient may be more likely to sue, especially if she had been unaware of your intention or reasons to dismiss her.
If the cause for dismissal is noncompliance with your recommended treatment, document the recommendations and conversations in detail. Include the recommended treatment plan, her objections, and your statement of the consequences of her failure to comply. In the case of an adverse event, documentation may be crucial.
You may receive a transfer of medical records that includes a dismissal letter for a reason that causes you concern. You are not obligated to treat that patient if you have not yet established a relationship. The establishment normally occurs at the first appointment.
All the same, it’s wise to contact your malpractice carrier about any state laws that would impact the initiation of the patient-physician relationship and how you should handle refusing to treat a patient.
- The letter of dismissal (Sample letter) Outline in the letter the reason(s) for the dismissal. Be objective. Stating subjective reasons for dismissal may open the door for a case of abandonment on the basis of discrimination.
- How to handle the referral Include a copy of your medical records transfer request with your letter. When possible, include a referral source such as your medical society or hospital referral center. Do not refer her to a specific physician.
- How to handle the mailing Mail the letter with a return receipt requested. Patients may refuse a letter sent with receipt requested, so also send a copy by regular mail. Copy the letter and record the date and method by which the letters were sent. Keep the return receipt (or record of refusal) in the patient’s record.
- Consider 30-day continuance Most physicians allow 30 days to establish a relationship with another provider, and limit care during this time to acute needs only—but sensitivity to the patient’s situation is wise. Although 30 days typically suffice, check with your malpractice carrier if you are concerned about the patient’s condition or availability of other ObGyns.
- Specify termination of services In your written communication, outline what services you will provide until she locates another provider.
