Why it’s Hard to Fire a Patient

Lately, I’ve been conflicted about patients I’ve terminated from my practice or who have been terminated from a specialist’s practice, thereby making me the de facto owner of the medical problem.  I am bothered by a decision made to refuse to provide care, while recognizing the practicality and necessity of this decision.

I don’t “fire” patients easily or routinely. The most common reasons are habitual no-shows or not following through on treatment plans so often that I no longer feel I can provide effective care. However, I struggle to do this because often these patients have the greatest needs and barriers. Adding one more burden to their already overflowing plates seems like the exact opposite of therapeutic. However, my decision to allow them to continue to consider me their primary-care doctor means that they can call and schedule (and then not show up) for an unlimited number of appointments or compel me to manage serious medical issues without the appropriate monitoring or treatment.

I wonder how the great physicians of all time would feel about “firing” a patient. Would Hippocrates or Osler even understand the concept that you could refuse to provide care to another human being? Probably not. When medicine is seen as a calling, the concepts of self-sacrifice, the greater good, and addressing a need are paramount. However, when medicine is seen as a business or even a profession, practical aspects creep in - there are only so many appointments in my day, so I’d rather save those for patients who will actually show up.

I also feel quite vulnerable when I prescribe high-risk medications to patients who do not keep appointments or obtain the recommended lab work. In our current society, doctors can be and will be held liable for prescribing medications without the proper monitoring,  even if we are recommending and ordering it. We are held liable for patient non-compliance and therefore physicians have hard choices to make at times.

As a primary-care physician, I feel like the end of the line for some patients. When they have been fired by a specialist or can no longer afford the medications or office visits, the management of medical problems defaults to me. Often, these patients are the most complicated, in part because of non-adherence, which puts me in a particularly difficult position. I want to help but feel less than qualified. I’ve made choices in the past I regret in order to “help” a patient who could not or would not obtain the appropriate and recommended care.

So, I face the question of balance again: Whether the patient’s need for care outweighs the practical considerations of no-shows and the very real risk of habitual non-adherence. My conclusion is to reserve this option for the most extreme cases, while trying to do my best to care for patients where they are at.