Take care in terminating relationship with patients
Ending relationship sometimes best for patient
Patients who are noncompliant, unpleasant, or troublesome give physicians frequent opportunities to consider terminating their physician-patient relationships.
But before "firing" those patients, experts recommend physicians take some specific steps to protect the patients and themselves.
"The thing to always keep in mind is that you terminate a physician-patient relationship for the sake of the patient — not for yourself," says James W. Saxton, JD, chairman of health care litigation for Stevens & Lee in Lancaster, PA.
Know when termination is appropriate
Patients often frustrate their doctors, or take up too much of their doctors’ time. But those aren’t reasons for termination, he advises.
"That’s simply a part of the practice of medicine," says Saxton. "However, when situations arise that cause the doctor to feel the patient is literally putting himself or herself at risk, then [the physician] has to think seriously about terminating the relationship."
Carol Santalucia, MBA, manager of program development of the Ombudsman Department at The Cleveland Clinic Foundation, offers some examples of behaviors that warrant serious consideration of terminating a relationship:
- The patient is threatening to the physician, staff, or other patients.
- The patient is verbally abusive to the physician or staff.
- The patient is extremely noncompliant and refuses to adhere to any kind of treatment plan.
- The patient refuses to pay or even attempt to pay his or her bills.
- The patient attempts to steal or defraud the physician out of drugs.
- The patient consistently fails to keep appointments.
"It’s important to strengthen the physician-patient relationship, but when there’s no trust and actually deterioration, then it’s time to look at terminating," says Santalucia.
Noncompliance is a situation that can clearly be shown to be a threat to the patient’s health, and not just a nuisance to the physician, Saxton says.
"Sometimes patients and physicians just don’t click, just like in any other relationship," he says.
Preventive steps to take
Before a physician-patient relationship reaches the point where termination is considered, there are steps that the physician can take early on to let patients know what is expected of them.
Just as patients have rights, they also have responsibilities to maintain a good relationship with their physicians, Saxton explains.
"There’s a trend toward telling patients what’s expected, as far as their involvement and accountability," he says. "And there are data that show that the more involved patients are, the better they do, as far as their health goes, and it helps bring their expectations in line with reality, which has the benefit of offering the physician protection from liability."
A medical practice should set forth the expectations for patients that the patient is expected to come to his or her appointments, pay for services rendered, and act responsibly when it comes to treatment and instructions from their provider, Saxton says.
Once the decision is made to terminate a physician-patient relationship, the doctor should be sure he or she understands the rules set out in state law.
States permit physicians to terminate relationships with patients, but to avoid patient abandonment they specify that advance notice must be given and require that patients be seen in emergencies.
Some physicians, faced with a deteriorating relationship with a patient, will send an "at risk" letter, notifying the patient in writing that his or her noncompliance, behavior, or missed appointments could jeopardize his or her continuing to be a patient of that physician.
"Before it reaches the point of termination, I advise physicians to talk with their patient," Santalucia says. "The patients should never be surprised when they get a letter saying the relationship is being terminated — it should just be the final step in a plan."
The American College of Physicians’ ethics code says termination "should be undertaken only after genuine attempts are made to understand and resolve differences."
Once the groundwork is laid, state and health plan requirements are met, and the physician has decided on termination, the decision should be absolute and final, Santalucia and Saxton agree. When the termination letter goes out (by certified mail, Santalucia suggests), the physician should not consider it merely another threat and must expect — and resist — attempts by the patient to persuade him or her to keep the patient on.
"What we tell our doctors is to not confuse the termination process and letter with the kind of letter practices send out to noncompliant patients threatening them with termination," Saxton says. "Once the physician makes the decision to terminate, he or she has to do to it."
While some patients will try to persuade or threaten the physician into keeping them under care, the physician needs to be ready to say "no."
"Again, it needs to be explained in terms of how the relationship is not working for either the physician or patient, and that the patient needs to develop a relationship with other providers," says Saxton.
A typical letter explains the basis for the termination, specifies an exact time (10-30 days from the date of the notice, typically) after which the relationship is ended, and offers the name and number of local medical societies or referral agencies that can put the patient in touch with new providers.
The letter should also assure the patient that, in accordance with state laws, he or she will continue to be seen in emergencies until a new physician is located.
The clearer it is to the patient, Santalucia says, the less likely it is that there will be a problem resulting from the termination.
"Sometimes the patient just doesn’t like what [is being said about the causes for termination] and, even if it has been explained, there might still be some repercussions," she points out. "That’s when [the patient] might call and complain, or will call my [ombudsman] office, and we’ll talk with them about it. But we don’t change the decision."
While the physician needs to be sure the patient’s needs are met and a charge of abandonment can be avoided, the physician is not responsible for finding the patient a new physician. He or she should, and may be required to in some states, provide referrals to physician locator services that can help the patient find a new provider.
"If trust has broken down to the point of termination, I don’t think the physician should probably be referring the patient to another physician, anyway," says Santalucia.
If the terminating entity is a facility such as a hospital, and the terminated patient returns to the facility through its emergency department, he or she must be accepted and examined under the guidelines set forth by the Emergency Medical Treatment and Labor Act. If the patient’s condition requires treatment and admission to the facility, the medical relationship is resumed, and must be terminated again later on if the relationship has not improved to the physician’s or facility’s satisfaction.
Sources
- Carol Santalucia, MBA, Manager, Program Development, Ombudsman Department, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195. Phone: (216) 444-2544. E-mail: [email protected].
- James W. Saxton, JD, Chair, Health Care Litigation, Stevens & Lee, 25 N. Queen St., Suite 602, Lancaster, PA 17608. Phone: (717) 291-1031. E-mail: [email protected].
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content