Have you ever wanted to dismiss a patient from your practice?

In my 26 years of practice, I have never terminated a patient. Certainly, patients will self-terminate (that’s happened to me) due to relocation, displeasure with our services or having been sent to collections, but the decision to a patient relationship is a serious decision.

Patient abandonment is defined as “the unreasonable discontinuation of health-care treatment without the patient’s knowledge;” and is a tort that exposes the physician to civil liability. The AMA states in Opinion 8.115 of the Code of Medical Ethics that “Physicians [must] support continuity of care for their patients. While physicians have the option of withdrawing from a case, they cannot do so without giving notice to the patient, the relatives, or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured”.

Once a doctor/patient relationship has been established, the doctor has an obligation to continue treatment until one of these four criteria are met:

1. The relationship is terminated by mutual consent
2. The patient decides to seek care elsewhere
3. The doctor properly dismisses the patient
4. The clinical services are no longer needed.

If just one of these criteria are fulfilled, we may sever the relationship. Once severed, there is no obligation to re-engage.

We spend time and resources to attract and retain patients, and it is difficult when we lose them for any reason. Interestingly, primary care physicians commonly discharge patients from their practices. It is part of the cost of the way they define doing business. Not so much in subspecialties such as ophthalmology.

SOME REASONS TO LET GO

These include:

• Chronic noncompliance or no-shows
• Rude, unacceptable behavior
• Repeated nonpayment of bills
• Verbally threatening lawsuit
• Theft
• Altering a written prescription
• You are retiring or moving from the area

REASONS YOU CAN’T DO IT

In the following situations, we cannot terminate the physician-patient relationship:

• As an act of discrimination of any kind. The Americans with Disabilities Act protects those with diagnoses of a communicable disease such as HIV/AIDS. The act also forbids discrimination based on religion, race, sexual orientation or gender.
• When no other physician or specialist is available in the region who can care for the patient’s diagnosis.

OUR RESPONSIBILITIES

Here’s what you need to do:

• Explain, preferably in person, why you are discharging the patient from the practice. Try to have a witness present for the discussion. Document the discussion carefully in the patient records. Such documentation must never include disparaging remarks about the patient.
• It is unethical to stop treating a patient while he/she is in medical crisis.
• Follow up with a written letter to the patient, including a description of his or her medical problem(s), then mail it certified with receipt notification. If the patient refuses to sign for it, resend in regular mail. If that fails, as do phone, text, or e-mail, place the letter in the patient’s chart and document the contact efforts .
• If the discharged patient is seeing you on call while you cover for another physician, explain and document you are seeing the patient on behalf of the other doctor and not re-establishing a relationship.
• You should care for the discharged patient for at least 30 days (clearly discussed with the patient), unless the physician/staff/patients are faced with danger or violence, and offer, at no charge, to send the patient’s new physician a copy of the patient’s records.
• Recommend other specialists who are able to care for the patient’s specific issues, and emphasize the importance of establishing the new relationship as soon as possible.
• Ask the patient to sign an authorization to release medical records.
• Consider alerting your malpractice insurance carrier if the patient is threatening suit.
• If the patient is a member of a managed care network, you should discuss your intention with a plan representative as special considerations may apply. In addition, they can often recommend other providers in the patient’s network.
• Inform your staff about the decision to discharge the patient from the practice, and remind them not to schedule for, or remind the patient of an appointment, as either could be construed as re-establishing the relationship.
• If you are in a group practice, decide if this patient is discharged only from your care, or the entire group.
• Notify the patient that prescription refills will only be provided up to the date of termination.

FINAL THOUGHTS

As stated by Susan Keane Baker, a patient relations and risk management consultant, “It’s not the patient who is terminated that keeps the doctor up at night. It’s the one who should have been terminated but wasn’t.”

We all have patient relationships that do not “work”. We may be doing the patient a favor by recommending another practitioner with whom he or she may better fit. Many state and federal sources offer help; one resource is The Doctor’s Company’s.

Do not let your emotions get the best of you. Patient dismissal should be your last option, not your first choice. OM

Steven M. Silverstein, MD, FACS, is a cornea-trained comprehensive ophthalmologist in practice at Silverstein Eye Centers in Kansas City, Mo. He invites comments. His e-mail is ssilverstein@silversteineyecenters.com.