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When it's OK to say: No new patients

Are there ethical limits to a physician's right to refuse accepting new patients?

By — Posted Oct. 6, 2008.

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There are times when a doctor has to say "no" to new patients. Given the shortage of primary care physicians, deciding to close a practice to new patients takes on ethical import.

Response:

"I'm sorry, Dr. Roberts is not taking any new patients." This all-too-common statement in primary care practices across the country means different things to different stakeholders.

If you are a prospective patient hearing those words, you may feel a little panicky. Your best friend uses Dr. Roberts, and your current doctor just announced that she is leaving primary care.

Now what? Finding an internist -- and sometimes even a pediatrician -- can be a challenge.

The physician who has closed his panel may have mixed feelings.

The first may be relief. Most primary care physicians already have too many patients. On the other hand, Dr. Roberts might feel just a tad guilty for putting up a "No room at the inn" sign. After all, didn't the doctors of yore take care of all comers?

A third feeling might be self-satisfaction-- maybe even a little pride. There is nothing like barring the door to make you feel more wanted. It would be easy to mistake the clamor for your services as a measure of your wisdom and competency rather than the fallout from a dearth of primary care doctors. Unless you are the Angelina Jolie of primary care, it could be simple supply and demand at work.

When is it OK for an internist to say "no" to new patients?

Obviously, when there are retirement or departure plans, even if far in the future, the ethical decision is to close the practice to new patients unless demand and need necessitates taking them on.

Full disclosure about future plans, if known, should be given.

Short of retirement or departure, ideal panel size depends on how hard the doctor wants to work, how much income he or she wants, how many work sessions are devoted to clinical care and how high productivity standards of the practice are.

More and more primary care doctors are electing to work part time to avoid burnout, pursue other interests and maintain quality of life.

Most physicians do not have access to their panel size. The number of patients a doctor cares for turns out to be somewhat elusive and fluctuating. Unless a physician works in a closed system, he or she needs to rely on various HMO lists sent periodically. These are notoriously inaccurate and often out of date; plus, the doctor may see patients from all sorts of insurers -- many not HMOs.

Given the lack of data, how does a physician decide to close his or her panel?

It is sort of like Justice Potter Stewart's well-known definition of pornography, only in this case, you know it when you feel it.

There are many signs: too many phone calls, no free time, irritability, depression, the "sprint to the finish approach" to each day, and the most notable -- a feeling that one is sacrificing quality for quantity.

When every patient request feels like an imposition, it may be time to restrict your practice. Some have accomplished this by switching to a concierge form of practice. High-maintenance, demanding patients? Fine, but they will pay for it.

What are the ethical constraints, if any, to closing one's practice to new patients?

My view is that these decisions are entirely personal. There are no commandments or laws proclaiming that physicians must continue to take all comers regardless of the personal or professional consequences.

Even the Hippocratic oath does not infringe on a doctor's right to make a living, have a reasonable quality of life, or have a manageable workload. Nor is it written that physicians must put up with abusive, demanding patients.

That said, I believe that physicians contemplating limiting their practices must satisfy themselves on two ethical points, both related to intent.

First, is the practice really being closed, or is the doctor cherry-picking patients?

We all probably felt a little uncomfortable reading the recent story in The New York Times about dermatologists who run two offices. One is for the insurance-bearing patients who come with rashes, warts and moles, and who often have long waits for appointments and get second-class service. The other is for the cash-bearing seekers of cosmetic medicine, who have no trouble getting appointments along with a cheerful office staff and a plush office setting.

Internal medicine has its own cherry-picking strategies: no new Medicare patients, no drug seekers, no difficult patients, no doctor shoppers, etc. How do they manage that? It's simple. Close the practice to new patients and then agree only to take friends, friends of friends, families of existing patients, colleagues and their families, VIPs and so on, "just this once as a special favor."

This strategy eliminates the so-called "high maintenance" and nonpaying patients.

The second unethical intent behind taking no more new patients is the same strategy that nightclubs and restaurants and even retailers employ. There is nothing like telling humans that they cannot have something to create insatiable demand and cachet.

Physicians who can assure themselves that, in all honesty, their motives are ethical, should endeavor to maintain a practice size that assures quality care for all patients.

Victoria R. McEvoy, MD, chief of pediatrics and medical director, Mass General West Medical Group, Boston; assistant professor, Harvard Medical School

Response:

There seems to be little debate that the United States is on the verge of a national physician shortage.

With a population that is both growing and aging, the demand for health care access and services is anticipated to escalate substantially over the next several years. Furthermore, most U.S. physicians distribute themselves disproportionately around population centers. The only exceptions are family physicians, who tend to distribute themselves geographically in the same proportions as the U.S. population.

Despite that, more than one-fourth of our nation's counties (780 out of 3,082) are designated by the federal government as shortage areas for primary care health professionals. In other words, lots of Americans have significant difficulty gaining access to health care -- and that situation is likely to worsen in the near future.

The generalist physicians of America provide the bulk of health care access points; primary care doctors account for more than half of all physician visits. As the doctor shortage worsens, however, more primary care physicians will have to decide whether to close their practices to new patients. They will have to decide how many patients they are able to care for at any given time.

What an ethical dilemma. Do you continue to take new patients until your workload exceeds your capacity, or do you decide at some point that you have as many patients as you can care for properly?

The question seems inescapable, but is it ethical to deny care to anyone who would otherwise be unable to receive it in your area? Except in the case of a true emergency, is it ethical to require people from your community to seek health care far from home -- sometimes more than a hundred miles away?

Many physicians will soon be faced with answering those questions.

What are some of the points physicians should consider in making responsible decisions about their practice workload?

The first, I think, must be the quality and safety of health care that he or she can deliver to the patients in a practice. Physicians bear a responsibility to continue to provide (or arrange) for the care of patients with whom they have already established a professional relationship. If a physician is too busy to give due attention to each patient's needs and make judicious and responsible decisions, an ethical boundary clearly has been crossed. At that point, a limit must be put on the physician's workload so that he or she can provide safe and effective care to all those in need. The primary value of "first do no harm" must be preserved.

Other considerations should include physicians' inherent obligations to their communities, their families and even to themselves.

The responsibility physicians bear to their communities is to operate responsibly, contribute to the community and address the stewardship of their businesses to support their employees, associates and financial obligations. Not to do so is irresponsible.

Their personal obligations include being spouses, parents, adult children of aging parents, neighbors and citizens. Ignoring those obligations would be considered by most to be a violation of ethical principles.

And certainly, physicians bear a basic responsibility to themselves to do what's necessary to maintain their own physical, emotional and spiritual health. All of these considerations affect doctors' decisions regarding when obligations to their patients compromise their obligations to society and their own health.

Evidence presented at the 2008 meeting of the Assn. for Medical Education in Europe suggests that duty-hour limitations have generated a "shift mentality" among residents. Moreover, the current emphasis on team-based health care delivery may be creating a reduced sense of personal responsibility to patients among young physicians in training today. This threat may be real, but it should not deter dedicated physicians from maintaining practices that they can manage effectively.

Doctors who refuse to put any limits on the size and demands of their practices and work themselves to the point of medically dangerous practice, irresponsible social behavior or an early grave do no one any benefit.

Perry A. Pugno, MD, MPH, clinical professor, family and community medicine, University of California, Davis, School of Medicine; University of Kansas School of Medicine

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