Want to 'fire' your patient? Examine your motives, proceed cautiously

Philosophical differences need not mean end of the relationship

A patient deciding to change doctors is not an unusual occurrence; sometimes, the physician doesn't even learn the reason for the change. It's a much more highly charged situation when a physician decides he or she must end a professional relationship with a patient.

As patients and their families become more educated consumers, and the physician-patient relationship moves away from its paternalistic history, conflicts in the relationship arise more often. But with only a few basic guidelines to go by, physicians are forced to rely on careful, stepwise actions to make sure discharging patients from their care goes smoothly.

"Patients are not our customers; the relationship is much deeper than that," says Neil Farber, MD, clinical medical director and professor of medicine at University of California, San Diego, and member of the American College of Physicians Ethics, Professionalism, and Human Rights Committee. "We have an obligation to do good on the part of the patient, and that makes it a special relationship, so it's less likely we'd want to — or should — terminate that relationship."

That said, Farber concedes, "there are times when something intervenes."

Evaluate reasons for ending relationship

If something is interfering with a physician's ability to do what's in the patient's best interest, that's one reason to consider recommending that the patient find another provider. Conversely, if the patient is presenting an imminent harm to the physician, that is grounds for termination.

Other not-uncommon reasons for ending a doctor-patient relationship include noncompliance with medical advice, a misfit between patient expectations and what medicine can do, nonpayment of medical bills, verbal or physical threats or abuse against staff, harassment or stalking the physician, repeated missing of appointments, and theft of prescription pads.

"If the interaction is such that the patient and physician are not talking effectively to one another, that would be grounds, but those should be extreme times," adds Farber, who is preparing to publish research on patient-physician conflicts.

Philosophical differences, however, should not be assumed to pose an insurmountable barrier to patient care, according to Gene Rudd, MD, an obstetrician/gynecologist who is senior vice president of the Bristol, TN-based Christian Medical and Dental Associations.

"People from different philosophical persuasions care for each other routinely, to the satisfaction of all," says Rudd. "When unusual situations arise, you want to positively interact with the patient."

That's not to say that the physician must abandon his or her beliefs or ethics when a patient's beliefs or ethics are at odds with the doctor's.

"If a patient asks me to do something that is morally objectionable, that's when I have a right not to do it," Rudd explains.

"I had a patient who came to my office, someone I had cared for for some time, and wanted an abortion," he recounts. "My dilemma was that in that particular town, there were two abortion clinics. Abortion clinic A was a butcher shop. Abortion clinic B did a technical job, and I knew she would be physically safe. My job was to let my patient know that.

"So I told her that I could not care for her in doing this, that she would have psychological trauma and spiritual trauma, but I didn't want her to have physical trauma as well. So I told her that while [her seeking] this procedure grieved me, and I could not do it, I would be here to care for her afterward if she needed me to."

Informing a physician on where his or her ethical boundaries are, when it comes to conflicts with patients, is not something that can be taught in medical school, Rudd contends.

"Ethical training doesn't make you ethical, anymore than sitting in your garage makes you a car," he says. "Your ethics are part of your character."

Practice 'preventive communication'

While some relationship-ending problems can't be foreseen, some can be — and therefore, can be avoided.

"Foremost, work on communication before it gets to be a problem," says Farber. "We train residents on communication techniques, and how to approach patients from a relationship-centered approach. When you're having a discussion with a patient, it's important to start from their perspective, and it's important for the patient to understand the physician's perspective."

Communication is one tool, Rudd says, but must be predicated by "respect, sensitivity, and permission."

"[Doctors] are trained to do that — we do that with every procedure," Rudd says. "Other qualities are competence, care, and compassion. Also, trust — the patient chooses to come to you, so there's implied trust already."

Further, the patient must provide accurate information and ask good questions, participate in decision-making, demonstrate willingness to comply with an agreed-upon plan; Rudd says when all these aspects of the physician-patient dynamic are satisfied, then communication can take place.

Just as patients provide their care providers with critical information by providing complete and accurate answers to a medical history, physicians can ward off problems by "letting patients know who you are and what you're about," Rudd continues.

"You can advertise, if you want to use that term, that you are an obstetrician, and that tells people that you deliver babies and you don't do heart surgery. But you can also train your staff to handle questions patients might ask before scheduling their first appointment — for example, you're an obstetrician who doesn't prescribe the abortion pill [RU-486], and you don't perform abortions. Or you are a general practitioner, and if someone asks if you'll put their elderly mother out of her misery, that you don't do physician-assisted suicide."

Though most patients don't, Rudd says it would be useful for patients to ask about a physician's position on ethical questions that are important to the patient before scheduling a first visit.

"If you're a patient, you shouldn't wait and see; you should ring up things important to you early, and if you're not in agreement, talk with the physician about how it might affect your care," Rudd adds.

What to do when the end has to come

While a patient who wants to end a relationship with a health care provider is not obligated to offer a reason — in fact, he or she can merely request their records be sent to a new provider with no cause given — a physician must guard against claims of ethical lapses and abandonment. Patients in medical crisis, those under acute care or who are in advanced stages of pregnancy or at high risk, are particularly tricky patients to discharge from care, and most physician insurers advise their clients against ending the relationship with those patients until their conditions are stable or their pregnancies or crises end.

But when the end must come, at least in the physician's view, there are some steps that are either required by law or are at least deemed appropriate:

• Talk to the patient. Don't send a letter or e-mail or leave a phone message unless you've spoken with the patient, either by phone or, preferably, in person. Farber suggests doing so in a non-threatening way, starting with asking the patient to gauge his or her understanding of the relationship; then, the physician should present his or her evaluation of the relationship, why it's not working, and suggest the patient seek care elsewhere. (An in-person conversation is not advisable if there is a threat of abuse to the physician or staff.)

• Follow up verbal conversation with a letter — preferably certified — summing up the decision to discharge. The letter should let the patient know he or she has 30 days to find another physician, and that during that time, the discharging physician will continue to care for the patient and will provide all medical records to the new physician.

"In terms of severing the relationship, all the patient has to do is not schedule another appointment; but legally, it's much more difficult and provocative for the physician," says Rudd. "It can create hard feelings, throw your past care into question, and incite gossip. But if you have a patient whose expectations you can't comply with, you have to recommend that they find another provider, and then give them time to do it."

Rudd blames the rise in patient-physician conflicts in part on the change inflicted by managed care.

"It used to be a covenant relationship, but the contractual elements of health care have changed it to a business relationship," he concludes.

Sources

For more information, contact:

  • Neil Farber, MD, clinical medical director, professor of medicine, University of California, San Diego; member, American College of Physicians Ethics, Professionalism, and Human Rights Committee. E-mail: nfarber@ucsd.edu.
  • Gene Rudd, MD, senior vice president, Christian Medical and Dental Associations, Bristol, TN. Phone: (423) 844-1000.