Dismissing A Patient

One of this column's regular themes is how few important business and organizational concepts are included in the average physician's training. Focusing upon science alone means physicians are often backpedaling, catching up to try to give our patients the best service available in a complex mileau outside the examination room or hospital that we are not trained to manage. This lack reduces our effectiveness and costs patients and doctors alike a lot of money. One of the (many) areas that I had to confront the hard way was the sometimes sudden realization that all patients are not nice, compliant, honest, or even able to be helped. What do you do?

If you are in a large group, one of the unexpected benefits is that this problem has already been thought through and protocols established. All the incoming physician has to do is to familiarize and understand what and when action is required. Another big benefit is that there is usually someone else to take over the problem, usually a civilian with the requisite experience.

But, all physicians can benefit from reviewing the necessary and unpleasant need in medical practice to occasionally remove the obstructive patient. I say need because these relatively, and thankfully, few patients can be disproportionately disruptive and expensive. Staff morale, our community reputation, and even our bottom line can be at play here, not just our tender feelings.

So, what are the indications for dismissing a patient from your practice? In general, these patients include the repetitively rude and/or abusive, chronic no-show, continually non-compliant and, the largest number, those who won't or can't pay their bills, which, in turn, means that you can't pay your bills. And, if the word gets out that you are not organized about collecting what is due, you will be caught in a rapid downward spiral, and that certainly includes co-pays.

It is in everyone's best interest—patient, staff, and physician—to have a pre-established protocol to get everyone on the same page as to how the practice can best function to its purpose. Put a friendly, edited version in your brochure and on your Web site. And, make sure that all on your staff understands, approves, and enforces what it contains. Don't we set great store by prevention? In addtion, dismissing a patient from your practice should only be the last, "nuclear" option. Quietly working with a problem patient about their behavior or about their bill is always best for all concerned.

If you have come to the point of no return with a patient, for whatever reason, when that mutual trust that is at the heart of the doctor-patient relationship is broken, then you must decisively act for your staff's benefit, your benefit, and paradoxically for your patient's benefit. You can get step-by-step guidance online or from your medical society and many other places.

An important part of this process, as if we haven't had this drummed into our heads enough already, is to document, document, document—in the chart and in a copy of the certified letter that you send. You want to ease the process, but also be in a position to defend a charge of abandonment. In the handful of times that I have had to go through this necessary business, there was usually no backfire because the manner in which it was done made it clear that there was a due process and that the patient understood, like it or not.

This also brings up the fact that there is not symmetry in the doctor-patient relationship. They can fire us any time without notice. They just don't come back. Or, they can return, if they wish, anytime later, unless we have specifically acted to prevent it. If they do communicate their leaving, it still behooves us to send a follow-up letter acknowledging the dissolution of the relationship with a copy in the chart, of course. And, they have no on-going responsibility to us, only to themselves. We understand the great responsibility that we take on our part, and so the elaborate planning and execution that is required by us.

There are potential problems if a patient switches to another physician in your group in an awkward on-call scenario, and it has to be decided if this is agreeable to all concerned. Also, there is the awkward situation that occurs when the patient sues a physician. Oddly, that fact does not end the doctor-patient relationship, and the physician's responsibility to the patient remains unless the formal process of severance occurs.

Two last points are important. First, don't lose your cool. You will be sorely tried, but emotions only, and always, stir the pot. What did George Costanza's fiery father on Seinfeld always say when pushed, "Serenity Now!" Oh, and the second point, if you fire a patient, be sure to remember to tell your staff! Innocently fielding calls and making appointments will inadvertently re-establish the doctor-patient relationship and here we go again!