Terminating the Relationship Requires Care
Practice Management Feature – May 2012
Tex Med. 2012;108(5):37-40.
By Crystal Conde
Associate Editor
Trust and mutual respect lie at the foundation of the professional bond between a physician and a patient. The connection takes time to form but can be broken in an instant. When a patient lies to a physician, tampers with a prescription, forges a medical note, is only seeking drugs, refuses to follow recommended treatment plans, berates staff, or stops showing up for appointments, those actions can irreparably damage the relationship.
Austin health attorney Amanda Hill, JD, advises physicians facing repeated patient noncompliance or difficult behavior to try to correct the problem while documenting all communication with the patient.
"If a patient with severe diabetes and hypertension repeatedly cancels appointments, for example, I'd encourage the physician to write a detailed letter that explains the health risks of missing appointments and that stresses the patient come in to be seen. The physician should keep a copy of the letter and any other communication in the patient's chart," she said.
If the noncompliant or difficult patient continues to misbehave, it may be time for the physician to consider "firing" him or her from the practice.
Ms. Hill worked as Austin Regional Clinic's (ARC's) general counsel for four-and-a-half years and recognizes that some patient relationships cannot be salvaged. During her time at ARC, she says, terminating patients from the practice was rare and was "a last resort" decision.
Seth Kaplan, MD, who owns TLC Pediatrics of Frisco, says he has asked about 10 patients to discontinue seeing him in the past 12 years. In the few instances he had to formally terminate a patient from his practice, Dr. Kaplan says, the reason generally was not complying with treatment plans for chronic conditions or with the immunization schedule recommended by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.
"My office staff is good about screening parents early on. When they call for a first appointment, we refer them to the immunization policy on our website, which states we can't accept responsibility for the care of patients who refuse to vaccinate. Usually, if parents have hesitations about vaccination, I'll have a discussion with them and discover they're willing to follow the schedule," he said.
Dr. Kaplan says his office is taking steps to improve patient compliance with chronic illness treatment plans.
"Many times, noncompliance is unintentional on the patient's or parent's part and requires me and my staff to examine how we're communicating and following up with patients," he said. "We're working to improve when and how often we follow up with patients, see them in the office, and track whether they're filling their prescriptions. We're implementing a new electronic health record this summer that should help us transform our process."
Ms. Hill hopes to give physicians effective skills they can use to thwart difficult behavior and reduce patient noncompliance in their practices. She will conduct a presentation on dealing with difficult patients at TexMed 2012 in Dallas this month.
In addition to offering effective techniques to handle difficult or noncompliant patients, she will advise physicians on how to terminate the professional relationship with the patient. The Texas Medical Association will offer a webinar titled "Dealing with Difficult Patients," based on Ms. Hill's TexMed presentation. The webinar will be open for registration in June on TMA's Education Center site.
Difficult Behavior Tools
Ms. Hill says one encounter with a difficult patient can ruin a physician's day and potentially break down the physician's rapport with the patient. Physicians can learn techniques to help diffuse tense situations and calm cross patients.
Ms. Hill says one encounter with a difficult patient can ruin a physician's day and potentially break down the physician's rapport with the patient. Physicians can learn techniques to help diffuse tense situations and calm cross patients.
"It helps if physicians put themselves in patients' shoes to figure out what's driving the difficult nature. When I've shadowed physicians in the past, I've seen patients come in the exam room frustrated and angry and leave the appointment thanking and even hugging the physician," Ms. Hill said.
Lack of communication or failure to understand the patient's perspective often is the root of difficult behavior. For instance, a patient may have unrealistic expectations of the physician or staff, demanding calls be returned within an unrealistic time frame.
"In this case, it helps for physicians or staff members to explain the practice's call-back policy to the patient or to explain how busy the physician's schedule is. A glimpse into the world of a doctor can go a long way. That way, the patient's expectations aren't constantly unmet," Ms. Hill said.
She says difficult patient behavior commonly surfaces when physicians run behind schedule.
"Patients often become angry when they're on time for an appointment and end up having to wait 45 minutes to an hour to see the doctor. That anger can be diffused instantly if the physician takes a moment to genuinely explain why he or she is running behind. Provide a legitimate reason for the delay, and express empathy," she said.
These types of communication techniques can go a long way with patients; they feel the physician respects their needs and values their time, Ms. Hill says.
Keller pediatrician Jason Terk, MD, chair of TMA's Council on Science and Public Health, follows a procedure when patient behavior problems may result in terminating a patient from his practice.
"We try to first understand if there are factors on the physician or practice side of the relationship that might need to be addressed. The physician or the practice manager may find that respectfully asking about what is troubling the person may provide insight. If some deficiency is revealed, then acknowledging that information and expressing a willingness to address it will strengthen the relationship with the patient or parent in question," he said.
He adds that the patient and/or parent should understand that future interactions with the staff must be mutually respectful or the relationship may be terminated.
To help medical practices implement and enforce their own policies and procedures, TMA offers Policies & Procedures: A Guide for Medical Practices.
The guide provides sample practice policies for addressing patient complaints, conflicts between staff members and patients, noncompliant patients, and termination of the patient-physician relationship. For instance, the patient complaints policy outlined in the guide suggests staff members manage patients' complaints by:
- Listening to the patient without arguing or interrupting,
- Suggesting solutions or advising the patient that management will respond to the complaint quickly, and
- Following through by thanking the patient for taking time to inform the practice of the complaint and documenting the incident by having the patient fill out a patient complaint form.
A hard copy of the guide with customizable CD is $295 for members and $395 for nonmembers. The customizable CD alone is $255 for members and $355 for nonmembers. To order the guide, telephone the TMA Knowledge Center at (800) 880-7955 or email TMA Knowledge Center.
Patient Noncompliance
Dr. Terk's policy on patient noncompliance with recommended immunization schedules garnered statewide attention. Late last year, he wrote on TMA's MeAndMyDoctor blog about children contracting vaccine-preventable diseases because their parents didn't have them immunized.
The media took notice when TMA shared Dr. Terk's blog post on Twitter. KRLD radio and CBS Channel 11 in Dallas/Fort Worth ran stories about physicians turning away unvaccinated patients to protect their more vulnerable patients, complete with a commentary from Dr. Terk. He said that because some children in his office are too young to be fully vaccinated or have weakened immune systems, he has a responsibility to keep them safe and to prevent their exposure to unvaccinated children.
"The failure of parents to adhere to the recommended vaccine schedule is an increasingly frequent reason that pediatric patients may be discharged from a practice. But, compliance issues certainly can occur in any medical specialty that involves direct patient care," he said.
Fortunately, Dr. Terk hasn't discharged many patients from his practice.
"In the past 10 years, I think I have discharged no more than five families for various reasons," he said.
In addition to noncompliance with treatment, Dr. Terk cites inappropriate or abusive behavior, failure to make arrangements to pay a bill, and children getting older as the most common reasons for terminating a patient from his practice.
Dr. Terk explains that his practice sees the patient for 30 days after the termination date for medically necessary reasons to give his or her parents time to find another doctor. He also provides contact information for the local medical society as a resource to assist the patient or family in the task.
"If barriers to compliance are identified and can be addressed, then the relationship can potentially be continued. If compliance issues continue, then neither the interests of the patient nor those of the physician are served by continuing the patient-physician relationship," he said.
Terminating Patients From a Practice
Physicians need to be careful when dismissing patients from their care. Ms. Hill says the only legal requirement physicians must meet when terminating a relationship with a patient is that they avoid abandonment, which may result in civil liability for the physician.
Physicians need to be careful when dismissing patients from their care. Ms. Hill says the only legal requirement physicians must meet when terminating a relationship with a patient is that they avoid abandonment, which may result in civil liability for the physician.
According to TMA's white paper "Termination of the Physician-Patient Relationship," prepared by the TMA Office of the General Counsel, abandonment is usually defined as "the unilateral severance of the professional relationship without reasonable notice at a time when there is still the necessity of continuing medical attention."
The white paper says abandonment involves physician failure to provide "an adequate medical attendant" and failure to give adequate notice. Additionally, it recommends physicians orally advise the patient, document notice of termination in the chart, send a letter to the patient with return receipt requested, and keep a copy of the letter and the receipt.
To request a copy of the white paper, contact the TMA Knowledge Center at (800) 880-7955 or e-mail TMA Knowledge Center.
Texas Medical Board (TMB) rules say "termination of patient care without providing reasonable notice to the patient" violates the Texas Medical Practice Act. TMB spokesperson Leigh Hopper says board rules do not define reasonable notice, but it generally should be given to patients in writing and should allow them anywhere from two weeks to 30 days to find another physician. She adds that the board doesn't have statistics on abandonment complaints or orders.
Ms. Hopper says physicians whom the board determines abandoned a patient face potential penalties ranging from a remedial plan with a $500 fine to sanctions that could include continuing medical education requirements and an administrative penalty. She says in some cases of patient abandonment, depending on the facts, the board could revoke a physician's medical license.
Texas Medical Liability Trust Senior Risk Management Specialist Michele Luckie says she frequently fields calls from physicians who have questions about terminating a patient from their practices. She encourages physicians to discuss the problem with the patient before pulling the trigger on termination.
She says having and adhering to sound policies and procedures can help physicians avoid difficult behavior and noncompliance in their practices. For example, some offices have a policy that if a patient fails to show up for an appointment three times, the practice discharges the patient. These expectations should be set during the first visit either through printed materials or discussion with the office staff, Ms. Luckie adds.
She also cautions physicians to be careful not to terminate patients who are in their third trimester of pregnancy or in the midst of a course of treatment.
"In those instances, it might be difficult for the patient to resume care with another physician. I would advise the doctor to carefully document any issues of noncompliance and communication with the patient and then move forward with discharging the patient once treatment is completed," Ms. Luckie said.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.
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