Medicine is a business. And just like any other business, healthcare providers should be able to refuse service to anyone. Depending on your perspective, this may or may not be acceptable. But the reality is that doctors and PAs dismiss, fire, or terminate patients every day for a variety of reasons.
Why would a doctor fire a patient?
A doctor firing a patient is less common than the patient firing the doctor, but it happens regularly. Providers fire patients who present a danger to the practice or themselves. These folks might be difficult, non-compliant, or there may simply be no “therapeutic relationship”.
A therapeutic relationship is established between a clinician and her patient when there is mutual trust, respect, and shared goals. There must also be agreement on how these goals will be achieved.
Take vaccination, for example. Pediatricians may fire an entire family when there’s disagreement on when or how to vaccinate. Why? From the doctor’s perspective, that family could become a liability–they obviously trust their judgment over the doctors. They can also present a risk to sick children who are seen in the same office.
Disputes between doctors and patients don’t always center on controversial topics, however. There may be a disagreement on the role of prescription medication or natural remedies. Or perhaps the patient wants certain procedures or tests that the provider feels unnecessary.
Another reason a doctor might fire a patient is if that patient is abusing their medication. What constitutes medication abuse? Taking it in any way than originally prescribed. This is certainly a problem for controlled substances like opiates and benzodiazepines, but even run-of-the-mill meds like those for diabetes or high blood pressure can be dangerous if not taken as directed.
Patient termination policy
When a new patient shows up for their first appointment, there’s a stack of paperwork to complete. Among the health histories and financial agreements, there is usually a patient termination policy. This policy lays out the grounds for termination or dismissal from the practice.
Grounds for firing a patient
To prevent seemingly innocuous situations from developing into persistent problems or full-blown crises, the patient termination policy lays out grounds for dismissal from the practice. Often cited reasons for patient termination include:
- Physical aggression
- Verbal abuse/harrasement
- Sexual harassment
- Missed appointments
- Late cancellations
- Display of weapons
Dr. Ryan Creek, DMSc, PA-C noted that when he was working in pain management, most patient dismissals were for abusive behavior towards himself or his staff. We care for patients who are often at their best, and may actually be at their very worst but even pain doesn’t excuse verbal abuse and aggression.
Physical aggression is an obvious no-no. In some US states, it’s a felony. But not all abuses are so obvious. Missing too many appointments can be the first sign that there’s trouble brewing. In order to prevent a bad situation from becoming worse, the doctor-patient relationship comes to an end.
Doctors don’t appreciate being harassed or abused. But it’s more common than you might think. According to the World Health Organization, up to 38% of healthcare workers will be victims of physical violence at some point in their careers. Verbal abuse likely affects close to 100% of healthcare workers.
How many is too many missed appointments?
2-3 missed appointments are typically enough to constitute termination for most practices. Canceling an appointment with less than 24 hours notice may be considered a missed appointment. Things come up, we get busy or forget to write down the appointment information but a repeated pattern of behavior shows a lack of respect and can cost the office real money.
The legality of firing a patient
A physician-patient relationship typically begins when services are rendered. Severing that relationship without notice to the patient constitutes abandonment. But there are also implied relationships. Courts have upheld the notion of an implied physician-patient relationship without any actual care being provided (as in Pizzo-Juliano vs. Southside Hospital, 2015, where an on-call surgeon was found to have a duty to a patient whom he never actually treated).
There’s no set rules for a doctor kicking a patient out of the practice, but abandonment is always a potential liability. Abandonment occurs when a doctor or PA abruptly decides to discontinue care without providing adequate notice. 30 days is often sufficient notice to avoid allegations of abandonment.
Intentional abandonment is straightforward–the doctor or PA refuses to see a patient without notice. Inadvertent abandonment can occur when there’s poor communication or confusion among on-call providers.
Rural healthcare providers or those in an underserved specialty should take caution–even 30 days’ notice may not be enough time for a patient to secure alternative medical care. 90 days may be more appropriate in these circumstances.
“You should have a protocol in place to notify the patient of the dismissal and cause and allow for the transfer of care. Remember that you have a duty to treat once you have established a relationship, so this could lead to a medical malpractice lawsuit if not handled appropriately, “ says Dr. Harrison Lewis, DMSc, MS, PA-C.
A specific reason for termination does not have to be given.
Refilling medications for the fired patient
There aren’t many medications that can be stopped without some sort of repercussion. Make sure to refill all medications or provide medically appropriate tapers. Long-acting opiates, for example, may not be amenable to reducing more than 10% a week.
Termination does not mean discrimination
No one should be discriminated against because of something they cannot change about themselves. Developed nations protect their citizens from discrimination based on age, race, and sex among other things.
How should notice of patient termination be delivered?
Sending a certified letter is a common way to inform a patient that they are being dismissed from the practice but it shouldn’t be the only way. If an electronic health record is utilized, a notation should be added to the patient’s chart and all interactions should be documented. Many electronic records have a patient message system, or portal, that could also be used to deliver the notice. Be sure to keep a copy of the termination letter.
Salvaging a damaged doctor-patient relationship
We all want to be heard. What appears to be a souring relationship might just be a misunderstanding. Rather than jumping to dismissal, try kindness. As it says in Proverbs, “A soft word turns away wrath, but a harsh word stirs up anger.”
Face-to-face meetings can be helpful but it can also lead to confrontation. If something has happened, allow some time for the dust to settle. Give the patient a call and let them know you’ve been thinking about them. Give them an opportunity to share their feelings without interruption or judgment.
Discuss boundaries. As another old saying goes, “good fences make good neighbors.” Explain why you’re concerned about a certain event or behavior. This gives the patient an opportunity to see that you are genuinely concerned about their welfare and not just their pocketbook.
How do you politely dismiss a patient?
Firing a patient is never pleasant. But can be necessary to keep the clinic running smoothly or even to protect the patient from themselves. When it comes time to ask someone to seek care elsewhere, do it politely. It may help to avoid a lawsuit.
Dr. Benito Lopez, DMSc, PA-C has some experience with this. He says, “We usually talk to patients, notifying them they are noncompliant with our practice standards, and also let them know that it’s not that we want to dismiss them but if we can not help them prevent further complications, they need to find someone they can trust for a better, healthier lifestyle.”
Ending the physician-patient relationship successfully
Sometimes you just have to let a patient go. It’s not easy, but you can make the dismissal as painless and professional as possible.
Though essential for a successful society, healthcare cannot be considered a right. Just because we need doctors, nurses, and PAs doesn’t mean that we get to control them. Being able to make decisions regarding your future is essential to success and happiness and we should allow healthcare providers the same opportunity.
Sample Patient Termination Letter
It has been a privilege to care for you as your physician/physician associate. Practicing medicine requires mutual trust and respect between doctor and patient. We feel that that relationship has been irreversibly damaged.
Our office policy states that a patient may be dismissed from our practice in the event of missed appointments/non-payment/verbal or physical abuse/lack of a therapeutic relationship.
We will continue to provide emergency medical care for the next 30 days or until ________. We urge you to find alternative care as soon as possible. You may contact your insurance provider for offices in your network.
All of your non-controlled medications will be refilled for 30 days. Controlled substance refills are subject to best practices and may be given as a tapering dose.
We will gladly forward all medical records to your new healthcare provider free of charge.
This decision has been made irrespective of age, race, gender, religion, disability, or sexual orientation.
Tell us how you go about dismissing a patient from your practice!