Take care when firing a patient
■ A column examining the ins and outs of contract issues
The ethics of the medical profession define the physician-patient relationship as one in which the doctor accepts ongoing responsibility for the patient's medical care. Unfortunately, there will be some physician-patient relationships that, for whatever reason, simply do not work.
Therefore, it is in the best interests of not only the physician, but also the patient, to terminate the relationship. A physician may legally and ethically decide not to continue treating a patient as long as the patient is not in need of immediate care and has been given a reasonable opportunity to find another doctor, which is consistent with the recommendations of the American Medical Association Council on Ethical and Judicial Affairs.
But the patient-physician relationship, while not a written contract, should be treated as one by the physician in order to avoid legal trouble upon its termination.
So it is advisable that a physician handle the dissolution as he or she might any other contractual relationship -- by drafting a letter, reviewed (or written) by an attorney, to the patient, explaining that their "contract" has been terminated, and why.
Reasons for termination
There are several legally justifiable reasons for terminating a patient. Common reasons include:
- The patient fails to pay his or her bills.
- The patient continually cancels or misses appointments.
- The patient is rude, disruptive, uses improper language, exhibits violent behavior or threatens the safety of the office staff or other patients.
- The office staff is uncomfortable working with or communicating with the patient.
- The patient is dissatisfied with the care he or she received from the physician.
- The patient requires more highly specialized services than the physician can provide.
- There is a conflict of interest between the patient and the physician, such as the physician's religious beliefs preclude him or her from providing certain treatment options, or the physician has a personal or financial interest in the treatment option.
- The patient is habitually uncooperative and refuses to comply with the treatment plan.
- The patient fails to complete a series of treatments.
- The patient is unreasonably demanding.
- The patient did not provide an honest medical history or was misleading in the information he or she provided, thereby compromising the efficacy of treatment.
- The patient develops a personal interest in the physician. Examples include excessive contact with the physician, demanding the physician's time in the absence of a legitimate or urgent medical need, and becoming angry or unreasonable when the physician is unavailable.
- The physician develops a personal interest in the patient. Examples include consultations that involved discussion of information not relevant to the patient's treatment, such as details about the physician's personal life; the physician becomes attracted to the patient; or the physician acts in a manner that would be deemed inappropriate by his or her colleagues.
- The patient files a complaint or initiates a legal proceeding against the physician.
One of the most difficult problems for a physician is finding a satisfactory way to terminate the physician-patient relationship.
The responsibility for ending the relationship rests with the physician and should not be delegated to an office staff member.
The decision should be communicated verbally to the patient, and with a letter outlining the reasons why this dissolution is occurring.
Below are several steps for a physician to follow when terminating the relationship with a patient:
- Clearly communicate your decision and reasons for terminating the relationship as compassionately and supportively as possible.
- Provide the patient with reasonable time to find another physician. What is "reasonable" will vary, depending on the patient's circumstances and the level of care required.
- Offer to provide the patient with assistance in finding a new physician.
- Offer to provide the patient or the patient's new physician with a copy or a summary of the patient's medical record.
- If the patient is in need of medical care during the transition period, it is advisable that you continue to provide that care so the patient is not abandoned while he or she finds a new physician.
- If the patient will require ongoing medical care, make sure that fact is clearly conveyed to the patient.
- If the patient has been habitually noncompliant with the treatment plan, ensure that the patient has an accurate understanding of the possible consequences.
- Inform your office staff about the termination so it may handle any contacts with the patient appropriately.
- Notify the patient's other physicians and health care professionals of the transfer to the new physician.
- Document the termination process and maintain detailed records of discussions with the patient.
- Send the patient a letter drafted by an experienced lawyer confirming the termination and the reasons for this decision. Be sure to send the letter by certified mail with a return receipt requested.
- Put a copy of the letter and the postal receipt in the patient's medical record and write a final record entry.
Either party has the right to terminate the relationship. But it is important for the physician to be fully cognizant of the patient's situation.
The physician must always act in a manner that best represents the interests of the patient first and foremost.
To avoid possible legal issues, it is advisable that the physician consult his or her lawyer before terminating the doctor-patient relationship. That way, the physician can be advised on the best possible approach to ending the relationship ethically and legally and to minimizing the risks that are posed by each particular situation.