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Patient Dismissal: The When, Why, and How

Patient Dismissal: The When, Why, and How

The prescription abuser, the never-payer, the no-shower, the surly swearer, the stubborn self-diagnoser — when these problem patients show up at your practice, they grate on your nerves, bring out the worst in you, and ruin your day.

What can you do? Patient dismissal is a drastic step that most doctors are loath to take. But some patients go beyond "difficult," to abusive; some physician-patient relationships fray beyond repair; some patients just will not follow their treatment plan; and some patients do not pay their bills.

Internist Toni Brayer, the regional chief medical officer at Sutter Health, a large network of physicians and hospitals in Northern California, says that while dealing with tough patient problems is part of being a good doctor, there are some things that physicians and practices should not tolerate. One physician Brayer knows, for instance, recently discharged a patient who repeatedly demanded a specific treatment for his thyroid condition. Not only did the physician disagree with the treatment requested, the patient failed to take his prescribed medication, neglected to follow up with testing, and repeatedly missed appointments. "It creates a really unsafe environment for the patient and frankly, great [legal] risk for the physician," Brayer says. "The doctor cannot in good conscience go against good medical practice."

Yet instead of discharging patients like this, many physicians suffer through unpleasant encounter after unpleasant encounter without taking any action, often to no one's benefit. If you're one of them, consider this: Not only will failing to discharge the patient cause you stress and potentially endanger the patient, it could also cause some serious legal issues for you down the road. "I can hardly think of a time where a [malpractice] case went to trial and the physician did not say to me, 'I knew that this patient was bad news,' or 'I hoped that she would go away on her own,' or 'I didn't take the time to figure out how I could terminate the patient,'" says Susan Keane Baker, a consultant in risk management and patient relations based in New Canaan, Conn. "It's not the patient who's terminated that keeps the doctor up at night. It's the one who should have been terminated but wasn't."

Before you dismiss a patient, you should take all reasonable steps to make the relationship work. But if those good-faith efforts fail, don't be afraid to take action to discharge the patient. Just be sure you do it in the right way.

Before you discharge

Some of the key scenarios in which discharging the patient may be necessary are when a patient:

• Is dangerous, threatening, or abusive;

• Fraudulently uses controlled substances;

• Files a lawsuit against you;

• Refuses to follow recommended medical treatment;

• Frequently misses appointments without notice;

• Repeatedly fails to pay bills despite his ability to pay and/or your efforts to provide him with a suitable payment plan.

But there is no universal legal standard for determining the appropriateness of patient dismissal in different scenarios, says Steven Kabler, attorney at Denver-based Jones & Keller. "From a malpractice and medical board standpoint, a physician can basically discharge a patient for any reason he wants, as long as it is nondiscriminatory and doesn't violate [the Emergency Medical Treatment and Labor Act] or other laws, or puts the patient's health, safety, and welfare at risk," says Kabler.

But those are big qualifiers, requiring a working understanding of different areas of the law. It's best to have a patient-dismissal policy in place that your attorney has reviewed.

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