Two of TMLT’s risk management experts discuss how to dismiss a patient safely and effectively, including typical scenarios that can make the process more difficult.
Tony Passalacqua: Hello and welcome to this edition of TMLT’s podcast, TrendsMD. I am your host, Tony Passalacqua. Today I have a special guest Robin Desrocher, she is a Director of TMLT’s Risk Management department. This podcast will address terminating the patient-physician relationship. Hello Robin. Can you tell me a little bit about yourself?
Robin Desrocher, 0:29: Hi, Tony. Thank you for having me. I’ve been working in TMLT’s Risk Management department for 16 years and have more than 30 years’ experience in the health care industry, including clinical operations in hospital and outpatient settings, health care administration, and continuing education planning and development for physicians and other allied health care professionals.
Tony Passalacqua, 0:51: Terminating the patient-physician relationship is not an easy thing to do for a number of reasons – both professional and personal. Robin, what would you say are some of the challenges of this often-necessary task?
Robin Desrocher, 1:04: Knowing when and how to terminate the patient-physician relationship is a challenge physicians face and often they do not know how to go about it. TMLT’s risk management department receives a lot of inquiries about dismissing patients. Termination questions typically fall into our top 10 call trends. While both the physician and the patient have the right to terminate their relationship, the physician must follow a series of steps to ensure the termination process has been handled properly.
Tony Passalacqua, 1:31: Should physicians just terminate the relationship if the relationship is not working out?
Robin Desrocher, 1:36: It’s really important for physicians to examine the relationship specifics before terminating, to avoid allegations of abandonment. I think it’s also important to mention here that not all negative patient encounters or situations must result in termination. Whether to terminate a patient-physician relationship is a difficult decision for physicians. When a relationship is no longer therapeutic, it is certainly within a physician’s right to end that relationship.
Tony Passalacqua, 2:03: Does a physician have to deal directly with or have physical contact with a patient to create a patient-physician relationship?
Robin Desrocher, 2:10: No, a relationship can be established as a result of a contract – expressed or implied – that the doctor will treat the patient. However, physicians who offer their services to the public may not decline to accept patients because of race, color, religion, national origin, sexual orientation, gender identity, or any other basis that would constitute discrimination.
Tony Passalacqua, 2:35: Robin, what are some of the common reasons for terminating the patient-physician relationship?
Robin Desrocher, 2:40: Patient non-compliance with recommended treatment is one of the most common reasons for dismissing patients. Additional reasons my include:
- failure to keep appointments;
- abusive, inappropriate, or rude behavior, such as threats, physical violence, or sexual advances;
- non-adherence to practice policies;
- prescription fraud or drug seeking behavior;
- filing a lawsuit or complaint with the state medical board; or
- failure to pay an outstanding balance.
Since the pandemic, we’re seeing more calls come in about terminating relationships because of disruptive behavior.
Tony Passalacqua, 3:17: That is a trend that we are seeing more and more of. For any of our listeners, we have another podcast in our series called, “How to de-escalate disruptive patients safely and effectively” with attorney Stacey Simmons and Dr. Brian Sayers. I would highly recommend listening to that podcast if you have not. We have included a link at the bottom of this web page.
Tony Passalacqua, 3:37: Are there specific situations that may make termination more complex?
Robin Desrocher, 3:42: Yes, that’s a great question, Tony. We advise our physicians to carefully review each situation before dismissing a patient. Termination would generally not be recommended in the following situations unless there are mitigating factors, such as highly disruptive or abusive behavior, criminal activity, or if the physician is not able to facilitate the transfer of care. Some tricky situations may include:
- when a patient is in acute episode of care;
- when a physician recently diagnoses a patient with a new condition and starts a new treatment plan;
- when patients have undergone surgery and they are in the early stages of recovery; or
- when surgery was several months ago but the physician is managing an active post-op complication.
Tony Passalacqua, 4:28: What if the situation includes a diagnostic test?
Robin Desrocher, 4:32: If a diagnostic test was ordered and results are pending, we recommend waiting until the results are in and communicated to the patient and the patient’s condition is stable.
Tony Passalacqua, 4:41: How should this be handled if the patient has an upcoming appointment?
Robin Desrocher, 4:45: If a patient has an upcoming appointment, it is best to see the patient and begin the termination process at the appointment, assuming no new active problems have been identified.
Tony Passalacqua, 4:55: Are there any specific considerations for an Ob-gyn patient?
Robin Desrocher, 5:00: For an ob-gyn physician it may be problematic to terminate a patient in the last trimester of a pregnancy or when there are known pregnancy-related complications. The patient may not be able to find another physician to care for them. If transfer of care cannot be arranged, it is likely that the physician will need to continue treating the patient through the post-partum period.
Again, there are always exceptions to these recommendations depending on the specific situation with the patient.
Tony Passalacqua, 5:27: Is there a phone number our policyholders can call to discuss some of these specific situations?
Robin Desrocher, 5:32: Yes! They can call us at 1-800-580-8658. We can listen to the physician’s circumstances and experiences with the patient and offer general guidance on steps to take if they decide to terminate a patient. But, at TMLT, our risk management team does not advise on whether or not to terminate patients. That decision is ultimately up to the physician.
Tony Passalacqua, 5:56: If transfer of care is arranged, what are some things the physician should do?
Robin Desrocher, 6:01: They should document the name of the new physician; the date and method the records were sent to the new physician; and the date of the patient’s first scheduled appointment with their new physician.
Tony Passalacqua, 6:11: Is there another situation that could make termination problematic for the physician?
Robin Desrocher, 6:16: Yes. Generally, an on-call specialist in the emergency department must see a patient through the emergency until the patient is stable, including providing follow-up care or arranging follow-up care for the patient. The specifics may depend on facility bylaws or call agreements. However, the specialist is not obligated to treat the patient for conditions unrelated to the emergency. Hospitals do not normally allow on-call physicians to refuse care to a patient, even if the patient has been previously dismissed.
Tony Passalacqua, 6:47: If a previously dismissed patient is provided care or admitted, do you have any recommendations for how the physician should manage that situation?
Robin Desrocher, 6:55: Inform the patient, and document the discussion, that once they are discharged from the hospital, the relationship is still terminated. If you feel a stronger message is needed, you may choose to give the patient written notification that the relationship is still terminated. We advise physicians to review their on-call contracts for any specific guidelines on patients who have been previously dismissed. Requirements may vary and we want to be sure the physician is meeting their obligations.
Tony Passalacqua, 7:20: Do you have any recommendations for terminating pediatric patients?
Robin Desrocher, 7:25: Dismissing pediatric patients can be challenging because reasons for termination, such as non-compliance or non-payment, are often not the fault or responsibility of the minor patient but is more likely due to their parents or caregivers. Working closely with the parents or caregivers to resolve any issue is recommended. Documenting all instances of non-compliance or difficulties is imperative. If a parent’s non-compliance threatens the patient’s safety, consider contacting Child Protective Services instead of terminating the relationship.
Tony Passalacqua, 7:56: If a patient threatens or files a lawsuit, should the physician assume the relationship has been terminated?
Robin Desrocher, 8:02: No. Ending the relationship still requires formal termination with a letter and appropriate notice.
Tony Passalacqua, 8:09: If a physician hasn’t seen a patient for a few years and they request an appointment, can they decline giving them an appointment if they recall them being non-compliant with treatment recommendations?
Robin Desrocher, 8:21: If no formal termination of the patient-physician relationship occurred, then the patient may have a reasonable expectation of continued care.
Tony Passalacqua, 8:28: Have you ever spoken to a physician who has been in a practice for many years who has never terminated a patient-physician relationship?
Robin Desrocher, 8:35: Yes! I have visited and spoken with some physicians who have never terminated a patient. These physicians maintain detailed records of the issues they encounter with their patients. They document detailed informed consent and refusal discussions.
Tony Passalacqua, 8:49: If a patient requests that records be sent to another physician in the same specialty, can physicians assume that THE patient relationship is ending and care is being transferred?
Robin Desrocher, 8:59: No. Unless the release of records request explicitly states the patient is transferring care to this physician, one should not assume the relationship is terminated. Patients may just be seeking a second opinion.
Tony Passalacqua, 9:13: We also have a podcast on second opinions. So, feel free to go ahead and look through our podcast selection and look for “The art of the second opinion.” Are there steps physicians should take before formally dismissing patients?
Robin Desrocher, 9:29: We recommend that the physician has open and honest conversations with the patient. Counsel the patient to improve non-compliance or disruptive behavior. It’s important to get a clear picture of the patient’s circumstances or reasons behind their behavior. For instance, a patient’s non-compliance may be about not having reliable transportation, financial stressors, or not fully understanding the treatment plan. Document your conversations and efforts to help in the patient’s medical record. If you establish a payment plan to assist with an unpaid balance, document this information in the billing portion of the record. If this doesn’t work, send a letter explaining that failure to pay may result in termination.
Tony Passalacqua, 10:10: Once it has been established that a patient-physician relationship exists, and termination is taking place, what must a physician do?
Robin Desrocher, 10:18: Many states have specific rules outlining the required steps to follow when terminating the patient-physician relationship. In this podcast, we’ll address the Texas requirements. If you’re working in a different state, check your state Medical Board and your professional medical society for rules and resources on termination. Also, research the patient’s insurance provider contract. Some providers may stipulate that the physician must accept certain patients and that specific steps must be followed to dismiss a patient.
Tony Passalacqua, 10:49: For our Texas physicians, where can they find information on terminating the patient physician relationship?
Robin Desrocher, 10:55: For our Texas physicians, the Texas Administrative Code (TAC) Chapter 190.8 states that “termination of patient care without providing reasonable notice to the patient” is a violation of the medical practice act. Termination of the relationship between patient and physician should be done carefully and thoroughly documented.
Tony Passalacqua, 11:15: Do physicians need to provide a reason for terminating the patient-physician relationship?
Robin Desrocher, 11:19: No, there is no requirement that physicians give a reason. In some circumstances, providing details about why you are terminating the relationship may be perceived by the patient as being inflammatory and escalate the situation. If you choose to include a reason, language should be straightforward and factual.
Tony Passalacqua, 11:37: May a physician terminate their relationship with a patient for any reason?
Robin Desrocher, 11:41: No. Physicians may not terminate a patient relationship based on the patient’s membership in a protected class, like race, gender, or disability. Under the Americans with Disabilities Act (ADA), “disability” is defined as a physical or mental impairment that substantially limits one or more of the major life activities, a record of such an impairment, or being regarded as having such an impairment. All patients must be treated equally. A patient may not be terminated because they have a disability that requires special accommodations.
Tony Passalacqua, 12:13: What type of notice must be given to the patient?
Robin Desrocher, 12:16: Documentation of proper and sufficient notice should afford the physician protection from possible civil liability or medical board action. Hence, in addition to orally advising the patient and documenting that advice in the chart, the physician should send a letter to the patient by first class mail and certified mail with return receipt requested to ensure the patient is aware of the physician’s decision. A copy of the letter and the return receipt should be retained in the patient’s medical record.
Tony Passalacqua, 12:44: It can often be very upsetting for a patient to receive this kind of notice. Is there any way to “soften the blow?”
Robin Desrocher, 12:51: It’s hard and upsetting for everyone involved. Therefore, we recommend looking closely at each situation before deciding to formally terminate the relationship. Receiving a formal termination notice may upset a patient, particularly if they are angry with a physician, provider, or the practice. That said, once the decision has been made that the physician is no longer willing to care for the patient, we recommend these steps be taken.
Tony Passalacqua, 13:15: How much notice is required?
Robin Desrocher, 13:18: Reasonable notice is required. In a lawsuit alleging abandonment, one issue may be whether the notice period was “reasonable” under existing circumstances. Many factors may affect this “reasonableness” determination.
Tony Passalacqua, 13:32: We see the term “reasonable” quite a bit. Can it have a different meaning depending on the physician’s circumstances?
Robin Desrocher, 13:39: The time necessary for a patient to locate another physician in a large urban area may be less than that which would be considered reasonable in more isolated rural areas where fewer physicians practice. Also, the nature and severity of the patient’s condition may affect the time required to find another physician. For example, an obstetric patient in her eighth month may not be able to locate another physician willing to assume responsibility for care. In this example, the physician who seeks to terminate the relationship may be delayed in doing so until after providing delivery and postpartum care.
Tony Passalacqua, 14:17: What information should be included in the termination notice to the patient?
Robin Desrocher, 14:21: The effective date of termination should be stated explicitly in the notification letter. In the notice, recommend that the patient find a new physician to assume their medical care before that effective date. Set the time frame based on state requirements, your specialty, size of your community and availability of other physicians. Give the patient a reasonable amount of time to find a new physician, based on these circumstances. Be factual and don’t include anything in the letter that could be seen as inflammatory by the patient, state medical board, an attorney, or a jury. Be available to the patient until this period ends. Don’t recommend a specific physician, clinic, or group. Instead, describe in general terms how the patient may find a new physician. This could include referring a patient to their health insurance company’s list of providers or to the county medical society. While it is not necessary to state reasons for the decision to terminate in the notice, the notice should make it clear the patient-physician relationship no longer exists starting on the effective date. The notification letter should remind patients that establishing follow-up and continued medical care are now their responsibility, and that they should pursue both. Additionally, the notification letter may include a statement explaining that medications will only be provided up to the effective date of termination.
Tony Passalacqua, 15:47: What is recommended when dismissal occurs in a group practice?
Robin Desrocher, 15:52: If you’re in a group, consider formally terminating the patient from the entire group. Clearly state in the letter that the relationship with both the physician and the group is ending. Call coverage can get tricky if the patient requires care when the physician who ended their patient-physician relationship is covering for the group.
Tony Passalacqua, 16:10: Should we include any other documents when sending the termination notice?
Robin Desrocher, 16:14: The physician should include an authorization for the release of the patient’s medical records to a new provider with the termination notice. Ask the patient to designate the new physician, sign the form, and send it back to you as soon as possible. Copy and forward the record promptly. We do recommend not charging patients for copies of their medical records when ending the relationship. These steps will help facilitate the transfer process.
Tony Passalacqua, 16:40: Should physicians involve any other staff members when a patient is being dismissed?
Robin Desrocher, 16:45: Have a process in place to notify your office staff, especially your schedulers about the dismissal and effective termination date. If using an electronic health record, alerts may help prevent accidental scheduling after the termination date.
Tony Passalacqua, 16:59: Do you have any guidance for physicians when a patient chooses to end the patient-physician relationship?
Robin Desrocher, 17:05: Our recommendation is to follow-up with written confirmation that the patient has ended the relationship. Include details like whether the relationship is ending immediately or does the patient need 30 days to find another physician. Documenting all conversations and actions is important.
Tony Passalacqua, 17:21: What is the one item you would want our listeners to leave with?
Robin Desrocher, 17:25: Tony, the management of challenging patients varies from physician to physician. Following state rules and regulations and contractual requirements is their best defense against allegations of abandonment. For more information on this topic, please visit our Resource Hub on our TMLT website at hub.tmlt.org.
Tony Passalacqua, 17:45: Thank you, Robin. Thank you for listening to our podcast. If you are a policyholder, please feel free to contact us with any question by calling 1-800-580-8658 or check out our resources at TMLT.org and clicking on our Resource Hub. For access to several of the resources we have please see the link at the bottom of this webpage. Thank you, Robin!
Robin Desrocher, 18:04: Thank you, Tony!
- Resource Hub: Patient relationships
- Podcast: How to de-escalate disruptive patients safely and effectively
- Podcast: The art of the second opinion
- CME: Terminating the patient-physician relationship
- Sample patient dismissal letters