Jarrod Shapiro, DPM PRESENT Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

When Do You Say
Enough Is Enough?

Several months ago, I was confronted by my office manager with a difficult patient issue: he wanted to terminate our office relationship with a patient.  In the waiting room, this patient was belligerent and difficult (not so bad – this I can handle with relative ease), but when this gentleman was brought to the back office, he made blatantly sexual comments to the office staff including the use of expletives.  When I found out what had transpired (unfortunately, after I had examined him) we politely confronted him and requested that he find another physician.  He agreed, a certified letter was sent to his home address, and we never saw him again.  This particular patient issue was relatively concrete and easy to justify.  But what happens in less clear cases?  How much nonsense should a physician handle before he or she says enough is enough and terminates the doctor-patient relationship?  And how does one go about doing so?

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When To End It

At what point do you call it quits?  When do you take the steps to dissolve this relationship?  Here are some legitimate reasons for the physician to terminate the doctor-patient relationship:

1. The patient requires referral to another specialist.
2. The patient is uncooperative and does not follow medical advice.
3. The patient repeatedly does not keep appointments.
4. The patient does not pay their bills.
5. The patient is disruptive and/or rude to staff.

Now these reasons need to be tempered with some reality.  You cannot reasonably discharge a patient simply because you don’t like him.  Unfortunately, we don’t get to pick and choose our patients.  Additionally, if your patient is rude but apologizes when confronted, there is no need to discharge her (assuming this is not a regular occurrence).  Failing to follow your medical advice should be significant enough that you have concerns for their overall well-being and successful resolution of the particular complaint.  For example, if I have a patient who failed to take the Motrin I prescribed for his plantar fasciitis, I am not going to discharge him from my care.  On the other hand, if I have a diabetic wound patient who continually walks around without a dressing, removing the offweighting device despite my warnings against it, they may be considered for discharge from the practice.  So, I would temper the above points with the term "history."  There should be a documented history of failure to comply in spite of multiple attempts by the physician to resolve the issue.

Go Our Separate Ways

When it’s time to end that relationship, how do we do it?  I’ve listed below a few suggestions.  I think a general philosophy to keep in mind would be to discharge the patient only after multiple attempts to rectify a particular problem that has become a risk to patient or doctor, and this will be done with open communication, respect, and patient safety in mind.

1. Maintain an open communication policy with all patients.
2. Make every attempt to resolve the particular problem with the patient.  For example, try to determine why the patient is noncompliant with treatment of their foot ulcer.  Perhaps they do not understand your instructions.  Perhaps they’re suffering from depression.  I have a noncompliant diabetic who was diagnosed with Wernike’s dementia during treatment for his foot ulcer after going missing multiple times.  I was about to discharge him from my practice, when the possibility of dementia came up.  We made some adjustments, engaged the family, and the patient is now healing well.
3. Consider referral for a second opinion evaluation and management.  This is often a diplomatic way to end the relationship.  It may turn out the patient simply responds better to a different physician.  Be sure to warn your colleague beforehand!
4. When you decide to end the relationship have a firm conversation with the patient providing clear reasons why you are discharging them from your practice.
5. Document document document.  Be sure to provide not only documentation of your discharge discussion, but the previous chart notes should indicate recurrence of the issue and your attempts to resolve it.  If it was noncompliance, you should be able to review your charts, showing a history of the noncompliance.
6. Send a follow-up letter via certified mail that reviews your conversation and again documents the reasons you are dissolving the doctor-patient relationship.  Provide names and phone numbers of 3 other doctors from which the patient can obtain further care.  Consider adding a statement that says you will continue to care for them for 30 days in the case of emergencies. 
7. Make every attempt to prevent the patient feeling they were abandoned by you.

Sometimes enough really is enough.  When it’s time to end the relationship, remember to be consistent, concise, clear, and compassionate.  A preplanned algorithm for this patient interaction will pay dividends in the long run.  Good luck with your next patient interaction.

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Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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