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Firing patients: When it's time to say farewell

Nearly every doctor has a problem patient and likely a fantasy about ditching him. But there are times when you have to dismiss a patient, and there are ways to do it gracefully.

By Damon Adams, amednews staff. April 14, 2003.

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When John Sattenspiel, MD, was a student at the University of Arizona College of Medicine in Tucson, some professors preached that doctors should continue to treat troublesome patients -- no matter how difficult they are.

That advice was easier to hear in the classroom than it is to follow in the working world.

In 20 years as a family physician, Dr. Sattenspiel has dismissed patients for abusive behavior to his staff and for nonpayment. One irate patient rattled staff members with his screaming and cursing so much that they asked building security to escort them to their cars when the office closed.

"I actually called [the patient] and said, 'This behavior is unacceptable. We're going to have you see another physician,' " recalled the Salem, Ore., physician.

Dr. Sattenspiel rarely dismisses a patient; it happens every few years. But he and other physicians said doctors need to know how to handle difficult patients and how to properly cut them loose if all else fails. "It is a two-way relationship. It requires that both parties work with each other. But there are some cases where that type of physician-patient connection doesn't happen," said Dr. Sattenspiel, a board member of the American Academy of Family Physicians.

At some point in their careers, most doctors will face the tough decision of keeping or firing a problematic patient, medical ethics experts said. They must weigh the impact on their practice and the well-being of the patient.

Often, a peaceful split occurs. Other times, physicians and patients work out their differences and agree to try again. And occasionally, the friction sparks a lawsuit.

The threatening patient

John Bower, MD, knows what it's like to be sued for firing a patient.

In 1987, the nephrologist was treating a man for severe kidney problems at the University of Mississippi Medical Center in Jackson, Miss. But the patient often skipped dialysis treatments. He verbally lashed out at nurses.

He threatened Dr. Bower's life.

"His sister told me he had a gun and was doing target practice in the back yard," Dr. Bower said.

So, he dismissed the patient, citing threats and noncompliance.

The patient sued.

The Fifth Circuit Court of Appeals in New Orleans ruled in Dr. Bower's favor, saying that forcing a physician to treat a patient would violate the 13th Amendment, which forbids involuntary servitude. The court ruling proved a victory by giving doctors a legal foundation for dismissal, Dr. Bower said.

As it turned out, however, Dr. Bower continued to treat the man, for whom -- despite everything -- he held no animosity. "He still needed a doctor, and there wasn't anyone else at the medical center," said Dr. Bower, who retired from the university but still practices in Jackson.

The decision to dismiss a patient is rarely as simple as liking or not liking the person in question. The reasons vary: Patients don't pay their bills. They don't follow the doctor's treatment plan. They are abusive to the doctor and staff. They try to deceive the physician to get drugs.

In some cases, the exam room seems more like a battlefield than a place for healing, and the parties go their separate ways.

"It's like a divorce. Sometimes, divorces are ugly and bad. Sometimes, they're OK, and you just have to move on," said Richard Collins, MD, a cardiologist in Omaha, Neb.

Dr. Collins had a patient who was angry and confrontational to fellow patients in a heart therapy group.

The doctor fired him.

"Sometimes, you can work around other people's problems, but when they start affecting other patients, you have to say goodbye," Dr. Collins said.

No pay, no show

Continual nonpayment has long been a key reason for firing a patient. But managed care has made the process more complex, with some health plans wanting details about why a patient is being discharged, doctors and attorneys said.

"In the era of managed care, physicians are contracted to treat more patients. There's not as much freedom of choice to treat patients. And there's not as much wiggle room to fire a patient," said Yarnell Beatty, general counsel for the Tennessee Medical Assn.

Missing office visits is another common reason physicians get rid of patients.

Marc Grobman, DO, an internist, discharged four patients in one month for repeatedly missing office visits.

A notice about missing appointments is posted in his Wilmington, Del., office. "It's basically three strikes and you're out," he said.

Dr. Grobman's patients have offered several reasons for not showing. "They overslept. Their alarm clock didn't go off. They forgot. Or we didn't call them."

Like Dr. Grobman, most doctors give patients two or three missed visits before they dismiss someone. They are decidedly less understanding of patients who threaten them or their staff or deceive them over prescription drugs.

Dr. Grobman said he once found out that a patient went to another doctor for the same drugs he was prescribing. To discourage such "drug shoppers," he asks patients to sign an agreement that they won't give drugs to other people. If they do, they face dismissal.

Ed Ryter, MD, took issue when a patient changed a prescription. But perhaps the biggest problem occurred with another patient, when Dr. Ryter told him he was required by law to notify the state that he was treating someone with hepatitis C.

"He just went off the wall and said, 'Those people are after me,' " said Dr. Ryter, an internist in Ludlow, Mass. "I felt this guy was threatening and I wasn't going to feel threatened in my own exam room."

Legal experts and medical organizations said physicians have a right to terminate a patient, but they must not leave the patient without adequate care. They must also make it clear to the patient that the doctor-patient relationship is being terminated. If the dismissal is not done right, doctors could face state and federal laws for discrimination or abandonment.

These days, many doctors are more attuned to the dismissal dilemma because of rising medical liability premiums, which have increased concerns about litigation.

"Doctors are going to sever ties with more risky patients than they would have before," said David Fleming, MD, director of the Center for Health Ethics at the University of Missouri in Columbia, Mo. Some medical societies recommend that doctors provide any emergency care until the patient finds a new doctor.

We can work it out (or not)

The American Assn. of Health Plans said some health plans may try to mediate when a patient-physician conflict arises. Depending on the health plan, doctors could violate a contract if they dismiss a patient without following the plan's policy.

The American College of Physicians' ethics code says termination is a serious event and "should be undertaken only after genuine attempts are made to understand and resolve differences." The AMA says doctors may dismiss patients, but not without advance notice to the patient, relatives and responsible friends that allows the patient time to find another doctor.

"The patient has to be informed, notified in writing. Usually you give a patient a 30-day notice in a letter," said Leonard Morse, MD, chair of the AMA's Council on Ethical and Judicial Affairs.

But when dealing with troublesome patients, doctors should remind themselves that the patient's care comes first, experts said.

Firing a patient should only be a last resort.

"You've got to be willing to accept the behavior of certain patients and work within their boundaries," said Dr. Bower, the nephrologist in Mississippi. "Our career is one of service. We are here to serve them."

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