Rodney K. Adams, JD

When’s the last time a patient told you how to practice medicine? Odds are it has happened in the past week. With increasing frequency, patients arrive at their physicians’ office demanding a specific test or treatment.

You shouldn’t always honor your patients’ wishes, but you do need to know how to respond to common situations in a respectful but firm way that emphasizes what’s best for patients.  Here are four principal drivers of patient-driven healthcare:

1)    The internet - There seem to be no limitations to the medical advice patients digest on the internet.

2)    The media - Reports of a medical study or a celebrity’s novel cure will generate a sudden spike in patient interest.

3)    Direct-to-consumer advertising – Big pharma hopes to have patients tell you what medication to prescribe.

4)    Alternative healthcare – In many markets, providers of alternative healthcare are referring patients to primary care physicians for specific tests or therapies.

When in these situations, you must determine whether the requested test or therapy is indicated by the standard of care for a reasonable physician. In other words, would a reasonable physician prescribe the course of care sought by the patient? If the answer is no, then you should not acquiesce to the patient’s demands. Many states’ Boards of Medicine have been clear that physicians cannot abdicate their role in deference to a patient’s request. Physicians must be more than an enabler for a patient’s desires, even at the risk of a damning Healthgrades review.

If a patient requests a test that is not clinically necessary, you should review the risks, benefits and alternatives with the patient. The patient should be advised that her insurance company may not cover the test. And if the test has no therapeutic or diagnostic benefit in your estimation, do not order it. That is better medicine than padding your documentation in an effort to obtain insurance coverage.

If you are not familiar with a test, the indications for it or how to interpret and treat the results, then you should not order it. A physician who orders a study is responsible for interpreting the results and providing appropriate care, even if it was done as a favor to another provider.

If a patient requests a specific form of treatment, such as a particular name brand medication, you are obligated to inform the patient of your best medical judgment. If you routinely prescribe the drug and it is the best clinical choice, then there should be no problem. If you do not routinely prescribe the drug or it is not the appropriate clinical choice, then you should advise the patient. Again, the determination for how to proceed hinges on what a reasonable physician would prescribe under the circumstances.

The prudent course is for you to stay within your usual practice. You should not undertake managing an unfamiliar treatment if you have no training or experience in doing so. Just as importantly, you should not let a patient’s insistence overcome good clinical judgment, especially when the potential for harm is high. This advice should still be followed by pediatricians and family physicians who daily face parents expecting an antibiotic prescription for a child’s viral infection. In these instances, insurance coverage may be a prime deterrent for patients.

Documentation is always important, including in instances where you go against your patients’ requests. Document what was discussed and why you declined the request. The same goes for when you recommend alternatives and patients decline.

You are the doctor. It is your responsibility - your protected responsibility - to provide your patients care to the best of your abilities. Acquiesce only when you believe what your patients want is actually in their best interest.

recently turned to academia after a career representing physicians in medical malpractice matters. He has a joint appointment at the University of Richmond Law School and Virginia Commonwealth University, Dept. of Health Administration. Mr. Adams also teaches a medical trial practicum and undergraduate study abroad programs on global medical ethics at the College of William & Mary. He may be reached at 

 is administrator of Gastrointestinal Specialists, Inc., a 27-provider practice in Central Virginia. He may be reached at 

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You’ve spent years studying and even more practicing medicine. Don’t let your patients forget your expertise, and authority, as their physician.

When the patient wants to be the doctor

Discharging patients is not fun, but it is often prudent and necessary. Because of the legal and ethical implications in patient dismissal, it is helpful to possess practical guidance on just how to correctly terminate a patient.

I find that most patient terminations fall into one of four buckets:

• Patients who are verbally abusive or threatening to providers or staff;

• Patients who are noncompliant with their care - missing appointments and/or recommended testing;

• Patients who "doctor shop" and often are most interested in obtaining medications; and

• Patients who do not pay for the care you provide.

Regardless of why the patient is being terminated, the letter itself is straightforward and contains four elements:

4. An offer to provide a copy of the records to the physician assuming the patient's care

Begin with a straightforward sentence stating the patient is being discharged from the practice. The letter should include an effective date that is at least thirty (30) days beyond the date the letter is mailed. Healthcare attorney, Rodney K. Adams recommends that this period be extended 45 days to 60 days if you practice in a specialty or geographic area where it may take patients longer to find another physician, or if you are providing current care for an ongoing condition.

During the period between your letter and the patient termination date, offer to provide 

 Our practice refills necessary prescriptions but otherwise avoids the provision of non-acute care during this period. 

 to suggest alternative providers in your letter, nor do I recommend doing so. I do not like it when other groups refer their "problem" patients to us, so I do not advise our problem patients to contact specific physicians or groups. Our discharge letters simply say we are providing ample time for the patient to find another provider.

I think it is appropriate to provide a reason for the patient's discharge. Even if the patient does not like the reason, they have a right to know why they are being discharged.

More patients are being discharged because they are unable to pay their bills. It's unfortunate, but it is a reality. There is nothing illegal about doing so, notes Adams. Just as patients who do not show up for appointments are breaching the physician-patient relationship, so too are patients who receive care but do not pay for it.

Finally, patients have a right to a copy of their medical records. Your letter should offer to make a copy of these records available to the patient or their new physician. You 

 need to provide a copy of your medical records with the termination letter.

• You should document the patient's termination in your practice management system to alert your staff not to make appointments going forward.

• It is not necessary to send a discharge letter via certified mail, notes Adams. Many patients will not accept or open certified mail.

• A small subset of payers require that you notify them when discharging a patient. I have never found this to be an issue, but you might review your payer agreements for such language.

is a healthcare attorney with LeClairRyan in Richmond, Va. He is the author of "Virginia Medical Law" and other publications and may be reached at 

 is administrator of Gastrointestinal Specialists, Inc., a 23-provider practice in Central Virginia. For the past 20 years, he has worked in and consulted with physician practices in areas such as compliance, physician compensation, negotiations, strategic planning, and billing/collections. He may be reached at 

Click the following links to download sample patient discharge letters. 

Discharging a patient from your practice can be a difficult decision. However, if done the right way, your practice will be better for it. 

Author | Rodney K. Adams, JD

Articles

When the patient wants to be the doctor

Discharging Problem Patients the Right Way