The TMLT risk management department frequently receives calls from physicians who are seeking advice about how to handle difficult patients. Often, these physicians are "at the end of their rope."
They describe patients who are rude or disruptive; who fail to keep appointments; who refuse to adhere to practice policies; or who simply will not follow the treatment plan. These patients can leave physicians with no other viable alternative than to terminate the physician-patient relationship. This article will discuss the physician-patient relationship, provide guidelines for ending the relationship, and will describe the process for dismissing a patient.
ENDING THE PHYSICIAN-PATIENT RELATIONSHIP
"The physician-patient relationship is the result of a contract, express or implied, between a physician and patient that is voluntary and arises when a patient requests and is supplied medical information/treatment." (1)
While both the physician and patient have the right to terminate the relationship, the requirements for ending the relationship are more complicated for physicians. Physicians need to follow a process of proper documentation and adequate notice to avoid allegations of patient abandonment.
According to Texas Medical Jurisprudence, a patient may have a cause of action for abandonment when "without reasonable notice to the patient, a physician unilaterally discontinues treatment at a time when continued medical treatment is necessary." (1)
"A physician's obligation of continuing medical attention can be terminated only by: (a) cessation of the medical necessity which gave rise to the physician-patient relationship; (b) discharge of the physician by the patient, or when a patient voluntarily chooses not to return to his physician; or (c) withdrawal from the case by the physician after giving the patient reasonable notice, so as to enable the patient to secure other medical attention." (1)
Patient noncompliance is a main reason physicians give for wanting to dismiss patients. Other reasons include failure to keep appointments, rude behavior, or failure to pay an outstanding balance. When deciding whether or not to dismiss a patient the physician must consider the patient's medical status and needs.
According to Jane Holeman, vice president of risk management at TMLT, there are situations in which a physician cannot dissolve the physician-patient relationship. These may include when the physician is on call in the emergency department, when the physician is treating a hospitalized patient, or when a surgeon is treating a patient postoperatively.
"The physician must care for the patient until he or she is stabilized or until another physician is found to assume that person's care. Surgeons (or those covering for them) have an obligation to see patients after surgery until postoperative care is no longer required, the patient is stable, and can be discharged from their care," says Holeman.
A common question received in the risk management department involves when an on-call specialist can dismiss a patient. "For example, the orthopedic surgeon who is on-call in the ED and sees a patient with a broken leg must care for the patient through that acute episode. In general, the physician must see the patient for follow up until he or she is stabilized from that event," says Holeman.
In this example, the orthopedic surgeon is only obligated to treat the patient for the broken leg and generally would not have to treat the patient for any unrelated condition. Physicians are encouraged to review the terms of their on-call contracts with the hospital to determine specific responsibilities for follow up.
For obstetricians, it is not advisable to dismiss a patient who is beyond the 28th week of the pregnancy. The patient needs to continue prenatal care and other obstetricians may not accept the patient this late in the pregnancy. "After the 28th week, you will likely need to care for the patient through the six-week postpartum visit," says Holeman. "Additionally, if the patient was dismissed early in the pregnancy and you are on call when the patient shows up in labor and delivery, you must see the patient."
It can also be difficult for a member of a physician group to dismiss a patient. If the patient needs care and the dismissing physician is on call for the group, that physician will have to see the patient. "To avoid this, the patient should be formally dismissed from the group and not just from the individual physician's care," says Holeman.
Physicians who practice in rural areas may not have the option of dismissing patients. "Many rural physicians do not discharge patients because they are the only physician in town," says Holeman. "In this situation, if the patient is noncompliant or fails to show for appointments, the physician should thoroughly document any counseling or patient instructions. The burden is on the physician to document the interactions and medical management of that patient."
Another frequently asked question involves the obligation of the physician to the patient after the patient has filed a lawsuit or a complaint with the Texas Medical Board against the physician. According to Holeman, litigation or a complaint filed by a patient does not automatically terminate the physician-patient relationship.
"The physician is still obligated to see the patient until the relationship has been properly terminated. Even though the patient is suing, the physician would still need to go through the dismissal process," says Holeman.
Physicians should also be aware that some provider contracts — Medicare, Medicaid, and private health insurance plans — may stipulate that the physician must accept certain patients and specify the steps the physician must follow in order to dismiss a patient.
"These organizations may require you to contact them before you discharge the patient so they can be sure that you are not discharging the patient because they have certain insurance coverage. Though this is probably not a common stipulation, physicians should be familiar with the terms of their provider contracts before starting the dismissal process," says Holeman.
Additionally, because physicians' offices are subject to state and federal civil rights laws, a patient cannot be dismissed because he or she has been diagnosed with HIV/AIDS or because of "race, color, religion, national origin, sexual orientation, gender identity, or any other basis that would constitute invidious discrimination." (2-3)
"This does not mean that patients belonging to these classifications cannot be dismissed, but only that they cannot be dismissed because of their classification," says Holeman. "If a physician is considering dismissing a patient who is in a protected class or is disabled, he or she may want to consult an attorney to assess the liability risk."
Risk managers recommend that physicians develop a standardized process for dismissing patients. "As a first step in this process, we advise that physicians go through a counseling process with the patient, particularly if the patient is noncompliant. In addition to explaining the potential health consequences of continued noncompliance, tell the patient you may have to terminate the relationship if the patient does not comply. Have this conversation with the patient more than once and document it in the medical record," says Holeman. In certain circumstances, the physician may want to have a witness, such as a nurse, present.
Physicians who are tempted to forego the counseling process may be missing an opportunity to understand the cause of the patient's noncompliance. "Taking time to sit down with the patient with the goal of better understanding the underlying expectations or needs that are driving his or her behavior can be valuable. Some patients have unreasonable expectations, but for others, understanding the point they're trying to make can go a long way in repairing the relationship. Learning about the root cause of their dissatisfaction can help us improve the delivery of care to all our patients." (4)
A similar counseling process should be employed for patients who miss appointments or who exhibit rude behavior. "Direct statements such as, 'If you do this again, we will no longer care for you,' and 'You will have to go to another practice,' can be quite eye-opening for some patients." (4) Again, document these discussions in the record.
If the counseling process is not effective and the physician decides to dismiss the patient, the next step is to send a dismissal letter to the patient. The letter should be printed on office letterhead and sent by first-class mail and by certified mail with a return receipt requested. The dismissal letter should include the following elements. (Please see sample letters).
Keep a copy of the dismissal letter and the return receipt in the patient's medical record. Once the time period specified in the letter has passed, the physician is no longer required to treat the patient.
A similar process should be followed if the patient dismisses the physician. "If a patient tells the physician that he is never going to return to the office, the physician should send a letter to confirm that the patient has terminated the relationship," says Holeman. (Please see sample letters).
Another problematic situation can arise after the patient has been dismissed — the patient comes to the ED and the dismissing physician is on call. "When this happens, the physician has to treat the patient, but we recommend that he or she send a follow-up letter to the patient saying that though the patient was treated in an emergency situation, the relationship remains terminated," says Holeman.
A final step in the termination process that can be overlooked — inform office staff, especially the appointment scheduler, about the dismissal. Advise staff not to schedule the patient after the effective termination date.
DISMISSAL FOR NONPAYMENT
Patients can be dismissed from a practice for nonpayment of fees, but this situation must be handled very carefully. "The physician should closely evaluate the need for continuity of care, and it is strongly recommended that dismissal for this reason only be used as a last resort," says Holeman.
"As a corollary, a physician should not deny an established patient an appointment or cancel an appointment because of an unpaid balance. So long as the physician-patient relationship is established and not definitively terminated, a physician owes the patient the same duty of care, otherwise there is a danger of abandonment . . . a person is a patient for all purposes regardless of their pay status until the relationship is terminated." (5)
The first step in dismissing a patient for nonpayment involves a counseling process with the patient. "We recommend that the patient be given reasonable opportunity or time to take care of the outstanding balance before the patient is dismissed," says Holeman. This discussion with the patient should be documented, but it should not be included in the patient care portion of the medical record. Maintain this documentation with the billing information.
If the patient still does not comply after being given a reasonable opportunity to do so and the physician has determined that the continuity of care will not be compromised, send the patient a letter stating that the physician-patient relationship will be terminated if the patient does not respond. (Please see sample letters).
If the patient does not contact the office in response to the first letter, send a second letter stating that the physician-patient relationship has been terminated. (Please see sample letters). Both letters should be printed on office letterhead and sent by first-class mail and by certified mail with a return receipt requested. Place copies of these letters in the patient's medical records.
If the patient does contact the office and requests copies of the medical records, be aware that the patient's record cannot be withheld from another physician or from the patient because of an overdue account.
"Following this process will help physicians counsel patients to change their behavior, provide fair warning to patients and allow them time to find another physician, and will help ensure that the physician is not abandoning the patient," says Holeman.
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