Updated March 17, 2021
See related article Sample patient dismissal letters.
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
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."
"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)
The reasons physicians give for wanting to dismiss patients include patient noncompliance, failure to keep appointments, or rude behavior. When deciding whether to dismiss a patient the physician must consider the patient’s medical status and needs.
According to the TMLT Risk Management Department, 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.
In general, 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.
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.
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, the physician will likely need to care for the patient through the six-week postpartum visit.
Additionally, if the patient was dismissed early in the pregnancy and you are on call when the patient shows up in labor and delivery, the physician 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.
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.
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.
During a lawsuit or board complaint
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 the risk management department, 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.
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 to dismiss a patient.
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, disability, sexual orientation, or gender identity.(2)
This does not mean that patients belonging to these classifications cannot be dismissed, but only that they cannot be dismissed because of their classification, according to the TMLT Risk Management Department.
Risk managers recommend that physicians develop a standardized process for dismissing patients. As a first step, go through a counseling process with the patient, particularly if the patient is noncompliant. Explain the health consequences of continued noncompliance and 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.
Physicians who are tempted to forego the counseling process may be missing an opportunity to understand the cause of the patient's noncompliance.
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." Again, document these discussions in the record.
If the counseling process is not effective, 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. (See sample letters.)
- A statement that the physician-patient relationship will terminate in a specified time period and a recommendation that the patient find another physician. The time limit given in the letter will depend on several factors such as physician specialty, size of community, and availability of other physicians. The patient should be given a reasonable amount of time to find a new physician. The current physician should remain available for care until the specified time period elapses.
- The physician is not required to state a reason for the termination. In general, risk managers advise against including a reason unless it can be stated in a brief, clear, and objective way.
- Describe in general terms how the patient can locate a new physician. It is not advisable to name a specific physician, clinic, or group. Refer the patient to his or her health insurance company's list of providers, county medical society, or a physician-referral service.
- Include an authorization for the release of the medical record. Advise the patient to designate the new physician, sign the form, and send it to your office. Indicate in the letter that the record will be copied and forwarded to the physician as soon as possible.
- 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. (See sample letter.) 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.
Another problematic situation can arise after the patient has been dismissed — the patient comes to the ED and the dismissing physician is on call. In this case, 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.
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 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.
The first step in dismissing a patient for nonpayment involves a counseling process. Risk managers recommend that the patient be given reasonable opportunity or time to take care of the outstanding balance before the patient is dismissed. This discussion 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 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. (See sample letters.)
If the patient does not contact the office after the first letter, send a second letter stating that the physician-patient relationship has been terminated. 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.
- Fullbright and Jaworski. Texas Medical Jurisprudence. 22nd Edition. 2018
- U.S. Department of Health and Human Services. Office of Civil Rights. Laws and regulations enforced by the OCR. Available at https://www.hhs.gov/civil-rights/for-providers/laws-regulations-guidance/laws/index.html?language=en . Accessed March 18, 2021.
- Texas Medical Association. Termination of the physician-patient relationship. October 17, 2017. Available at https://www.texmed.org/Template.aspx?id=1897&terms=terminating%20the%20physician%20patient%20relationship. (Log on required.) Accessed March 18, 2021