Doctor to patient: You're fired!

Article Outline

 

Although held to a higher standard, doctors have the right to “fire” patients who are particularly difficult, abusive, and confrontational.

A recent article in the “science” section of The New York Times focused on a subject that virtually all medical professionals confront during their careers—extremely difficult, disagreeable, even obnoxious patients—and raised the question of whether it is within the physician's rights to no longer treat them.

In other words, can doctors “fire” their patients?

It poses an interesting dilemma. On one hand, it is no different than the business decision made by, say, the owner of a hair salon or an auto body shop who comes to the conclusion that “life is too short” to continue to work with an unpleasant client. This may be an individual who is a bully, who is abusive to staff, who continually complains, and who, in general, makes life miserable for everyone.

However, physicians cannot very well abandon patients who are in need of care, in pain, or in a compromised medical condition. Doctors, after all, must be held to a higher standard.

According to the Times' article, the ethical and legal issues involving the dismissal of patients are not clear cut. The article contends that from a legal perspective, the concept of patient “abandonment” can be open to some interpretation (although in many states there are laws specifying exactly what constitutes abandonment, which all practitioners in those states should be aware of). Patients cannot and should not be cut adrift without the opportunity to obtain proper care elsewhere. Yet, regardless of how high in esteem a practice may hold itself, it is extremely unlikely that a patient would be unable to find comparable optometric care elsewhere. From an ethical standpoint, however, it seems that each case needs to be examined by its own merits.

Take the example of an elderly woman who is being managed by her eye care practitioner for a potentially vision-threatening condition. She is a longstanding patient, one whose relationship with the office has deteriorated over the years. Understandably anxious and afraid for her future, she frequently lashes out at staff and loudly questions and fails to comply with the doctor's professional judgment. She is the type of patient who causes the entire office to roll their collective eyes and take a deep breath when they see she is on the day's schedule. Yet, although her actions may not be commendable, they are certainly understandable. Dismissing her as a patient, at least without first discussing the situation with her and explaining other options, would be unfortunate. She deserves the benefit of the doubt.

It should be noted that there are many optometric practices that emphasize geriatric care or low vision rehabilitation. In such practices, it is understood that patients often will be anxious and emotional. For the practitioners and staff in such practices, reassuring and counseling patients becomes as integral a part of care as treating or correcting the eye condition. Referring the previously described patient to a geriatric care or low vision practice rehabilitation practice, where practitioner and staff may have experience in handling emotionally distraught patients, can be highly beneficial for all involved.

However, compare that case with this patient situation: a man who has been bringing his young son for several years to a local eye care practitioner for his annual checkup and new eyeglasses. In addition to a history of failing to show up regularly for appointments, the man continually upbraids staff for perceived slights, loudly questions the competence of the doctor in front of other patients, and constantly complains about the cost of exams. Now, when his son shows an interest in wearing contact lenses, and the doctor recommends a certain type of lens, the man insults the doctor by implying that he must be in cahoots with the particular lens manufacturer.

At this point, the doctor has heard enough, as the patient has gone from difficult to being truly offensive. Does the doctor have grounds to “fire” the patient? There are no hard and fast rules, but holding on to a disagreeable, obnoxious patient like this seems self-destructive. Only a doctor who has little self-respect or is desperate to maintain patients, regardless of their actions, would be expected to put up with this type of behavior.

In the event a practitioner decides to terminate a patient, it is critically important for the optometrist to protect the practice legally. The American Optometric Association Office of Counsel outlined a 3-step process for the termination of a patient in the Practice Strategies section of the March 2003 edition of Optometry: Journal of the American Optometric Association. The article notes that there are 3 keys to terminating an optometrist/patient relationship in a manner that will not constitute improper abandonment of the patient—timing, communication, and record keeping. It is essential that the optometrist–patient relationship be terminated at a normal stopping point and not in the middle of any treatment. The patient should be notified of the termination of the relationship in writing in the form of a registered letter. The letter should then be retained in the patient record. In the case described here, the registered letter would inform the patient that his actions are not compatible with the philosophy of the practice and that he will need to find another eye care practitioner for his son. The letter would then go on to tell the patient that the boy's patient records will be sent to his new doctor.

Once the decision to terminate a patient is reached, it must be considered final. There can be no second chances. The letter is not intended as a threat, but as a fait accompli. The doctor may offer recommendations for other doctors in this letter, but then this is only likely to make the doctor unpopular with colleagues.