Every year, NORCAL companies risk management specialists receive numerous telephone calls about terminating patient relationships. This case study describes a typical scenario.
The patient had been seeing his family physician (FP) for over six years. He weighed 320 pounds and had high blood pressure, left ventricular hypertrophy and renal insufficiency. Although the FP had consistently counseled the patient about weight loss, the patient rejected advice to diet and/or exercise and had steadily gained weight over the years. Additionally, the patient’s medication compliance was inconsistent, and he arrived late or not at all to monthly follow-up appointments. The FP wanted guidance with respect to dismissing this patient in order to focus his time and energy on other, more compliant patients.
Discussion
The physician in this case had a couple of options for dealing with the patient. He could send a termination letter and hope for the best — there was no apparent reason why this patient could not be dismissed, as long as he was given adequate time to find a new provider and was appropriately treated during the notice period. Alternatively, he could give the patient a final chance at compliance. This patient may not have realized his behavior was going to get him “fired.” Once informed of the problem, how to remedy it, and the consequences of failing to remedy it, the patient’s problematic behavior might stop.
Every difficult patient brings unique challenges to the termination decision process. For many patients, being presented with an option of adherence to practice expectations versus termination can diminish the practitioner’s liability and facilitate a later termination, if necessary.
Risk Management Recommendations
Giving Patients a Second Chance
If you choose to attempt to rehabilitate the patient, it should be done pursuant to an office policy and protocol. Intervention should occur early, before problems escalate. Rehabilitation should start with a patient meeting to explain your expectations. Issues discussed in the meeting can include:
- Clear identification of the patient’s inappropriate behavior, actions or inaction
- Explanation of why the identified behavior is not acceptable according to office policy
- Potential dismissals for financial reasons should be approached cautiously. Consider offering payment options as part of the rehabilitation plan.
- Description of your expectations for future interactions with the patient and the consequences of the patient’s failure to meet expectations
- Creation of a “patient contract” or “medical treatment plan” that memorializes the expectations and patient agreement
- The contract/plan should identify the consequences for breaching the contract, such as termination of care.
- The patient should sign and date the patient contract and be provided with a copy.
It is important to listen carefully to the patient’s point-of-view. You may discover practice management issues that could be resolved in a way that improves patient satisfaction and compliance. The details of the encounter should be entered into the patient’s record, including whether the patient has accepted or rejected the rehabilitation plan. The plan and expectations should also be communicated to staff, along with clear directions about how non-compliant behavior should be handled and documented. Ideally, if the rehabilitation attempt fails and the decision to dismiss the patient moves forward, his or her record will contain clearly documented grounds for the dismissal.
Withdrawal from Care Letter
Regardless of whether a rehabilitation plan was put in place or the patient dismissal occurred in person, a withdrawal from care letter should be sent to the patient. (A sample Withdrawal from Care Letter is available to NORCAL policyholders by contacting a NORCAL Risk Management Specialist.)
Consider the following recommendations:
- Use a professional tone that is neither accusatory, nor adversarial.
- If a patient’s failure to obtain ongoing care or treatment has the potential for negative consequences or a bad outcome, include this information in the termination letter.
- If appropriate, refer to the patient’s failure to comply with a patient contract/medical treatment plan.
- Include a referral source (e.g., the county medical society, state medical association, local hospital or the patient’s health plan).
- Offer to provide copies of the patient’s medical records to a subsequent physician, upon receipt of the patient’s signed authorization for release of medical information — a release form can be included with the letter.
- Give the patient adequate notice to enable him or her to find another physician. Thirty days will be adequate for most patients; however, some state statutes or guidelines may require a longer notice period, and some patients will need a longer notice period to find a new physician (e.g., indigent patients, rural dwellers, individuals with rare conditions or combinations of conditions).
- If the patient has a condition that requires continued medical care, specific instruction may be necessary to ensure he or she understands continued treatment is necessary, not optional.
- During the notice period, continue to treat the patient as you would treat any other patient.
- Do not limit your treatment of the patient during this period to “urgent or emergency conditions only.”
- Send the termination letter by certified mail, return receipt requested. If the letter is returned undelivered because the patient refused to sign for it, send another copy of the letter by regular mail.
- Maintain a copy of the termination letter and the signed, return receipt acknowledgment in the patient’s medical record.
The patient’s physician is responsible for ending the relationship, and he or she should not delegate termination decisions, discussions or letter signing to an office staff member.* Physicians are encouraged to consult their personal attorney or medical professional liability carrier, who can provide guidance when termination of treatment is contemplated.
Perhaps unfairly, considering the termination steps a physician must take, a patient may end a physician-patient relationship at any time for any reason or for no reason at all. For example, if a patient gets a new job, he or she might want to transfer to a physician whose office is more convenient to work. The patient may (or may not) advise you of this choice and request that copies of medical records be forwarded to the new practice. If the patient clearly conveys a decision to transfer care and end the relationship, then consider formalizing the termination of care with a letter.
Reference
* Harris S. Take care when firing a patient. American Medical News. 2008 Feb 4.
