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Breaking Up is Hard to Do – Terminating the Physician-Patient Relationship
Physicians and other health care practitioners will have experienced a situation where a patient is being difficult, perhaps on more than one occasion or involving more than one patient. Often a decision is made to terminate the physician-patient relationship; sometimes there may be doubt that there is enough cause in a situation to terminate that relationship or ending the relationship is something that physicians and office staff never feel good about. Two frequently asked questions are:
- When is it okay to end the relationship? and
- What can a physician or office staff can do to lessen the odds of a break up?
Typically, once the physician and patient relationship is established that relationship is expected to flourish. However, as we all know there are peaks and valleys in any relationship. Whether it be a new or a long-standing patient, a physician practice may find themselves at a crossroad deciding whether to keep going on a bumpy stretch in that relationship or to end the relationship completely. Although it is always best to attempt to work through differences or relationship difficulties, the primary goal here for the physician is to avoid a claim of “patient abandonment” while ensuring safe discharge or departure from the physician and patient relationship. Although not limited to the list below, knowing the various reasons why ending the physician-patient relationship may be considered, is a starting point.
- Treatment non-compliance: The patient does not or will not follow the treatment plan or pain management contract.
- Follow-up noncompliance: The patient repeatedly cancels follow-up visits or is a “no-show”.
- Office policy noncompliance: The patient refuses to abide by the office rules and procedures.
- Abusive behaviors: The patient is rude or uses threatening, offensive, demeaning or hostile language, exhibits violent or aggressive behavior, makes threats of physical harm, or uses anger to jeopardize the safety and well-being of staff, other patients or visitors with threats of violence or other aggressive acts.
- Chronic abuse or misuse of medications or controlled substances: The patient, despite repeated recommendations refuses to seek treatment for substance abuse or refuses to abide by a therapeutic contract; drug-seeking behavior or obtaining controlled substances concurrently from multiple physicians; fraudulently obtaining any medication, including altering or adulterated a prescription.
- Property: The patient is believed to have committed theft or destruction of the practice’s property or equipment.
- Failure to honor agreements: The patient repeatedly fails to make a good faith obligation to meet financial obligations.
- Demands: A patient who makes unreasonable demands on the physician’s time or asks for care/treatment that is beyond the scope of the specialty or plan of care.
- Legal action/Board complaints: A patient or family has filed legal action against the physician or has made a Board complaint. Each case should be individually considered. If there is any concern that the physician, team or patient will be unable to carry out the duties of the relationship after the complaint was filed, termination should be considered.
- Business changes: Relocation of the medical practice, retirement or discontinuation with a specific health plan.
- Inappropriate contact: The patient has made unwelcome sexual advances or stalking behavior towards a physician or staff member.
Here are a few examples where terminating the relationship may become problematic:
- Any patient in an acute phase of care or under follow-up care post-hospitalization or surgery.
- Any termination based on a patient’s race, creed, color, national origin, marital status, sex or sexual orientation.
- Any time when the physician is the sole available physician specialty or sub-specialty for the patient’s condition within a reasonable geographical distance such as a rural setting.
What can you do to lessen the chance of having to terminate the physician-patient relationship?
- Set the standard for behavior during the patient’s first visit. When introducing your practice to a new patient, outline for them how they can address their complaints, and what to do if they feel they have not been heard.
- Consider providing a handout to the patient or placing a posting in the exam room area highlighting the best way to problem solve a situation before the patient leaves the office.
- To reduce the possibility of receiving a surprise complaint from the patient, Board of Medicine, or health insurance company, consider adding a confirming statement at discharge, such as, “Have we answered all your questions to your satisfaction today?” or “Is there anything more we could have done today to help make your appointment go more smoothly?”
- Plan for problem patient encounters. A part of life and a part of the business of caring for people is working through conflict. If you are not comfortable with your or your team’s skillset for dealing with conflict, reach out to MICA for more information on presentations and educational resources on communication.
- Recognize that the issues that caused the patient to become a challenge may have been brought on by internal policies or complex rules your practice has set in place. The patient may also be upset with issues such as challenging staff personalities or a long history of struggling for help with their health insurance company. Service and communication mishaps occur every day. Try to help the patient (and staff) work through any outstanding issues with the patient’s positive experience in mind.
- When problems arise, use a team approach for problem solving. Seek out resources to avoid termination if you can – such as a team conference, social work interaction; psychiatric referral, a different practitioner in your office, etc.
The termination process must be led/guided by the patient’s physician. The office team members will provide input but it remains up to the discretion of the physician whether to pursue termination or to revoke a proposed termination.