In the course of practicing medicine, many providers have to deal with patients who do not comply with instructions or who become upset because they can't have requested testing or treatment on demand. Although these patients may be frustrating to deal with at times, the best approach is always to focus on improved communication and education. These patients usually come to an understanding about the proposed recommendations or seek opinions elsewhere.
Occasionally a patient is verbally abusive to both staff and clinicians. This may be a one-time occurrence or recurrent problem despite requests for better behavior. Not only can this scenario be uncomfortable for all concerned, it can also create a disruptive atmosphere in the office setting. Staff and physicians may feel physically threatened. This patient should be discharged from your practice. Although we, as physicians, have an obligation to care for patients, we also have an obligation to provide a safe workplace.
Physicians who practice in a large institution with a compliance or regulatory department should first reach out to that department for advice. Physicians who practice in a smaller setting should contact the attorney for the practice or local medical society for advice. States may have different regulations with respect to claims of patient abandonment.
A patient who is receiving active care (for example, postoperative care or treatment for infection) should not be discharged. In this situation, the provider has an obligation to complete the care, unless another provider agrees to take over care.
The patient should be sent a certified letter stating that care from the current provider will continue for 30 days from the date of the letter; after that period, the patient will need to seek medical care elsewhere. The letter should include the reason for discharge, such as threatening remarks made by the patient to staff or a perceived loss of faith in the physician as evidenced by continual noncompliance.
Most states require that the physician provide the patient with a list of alternative places of care in reasonable vicinity of the patient's home. However, the physician does not need to contact those care providers.
If the physician practices in a large institution, is part of a multispecialty group, or has multiple office locations, the letter should specify whether the discharge is from just the single provider, or from the specialty, location, or entire institution. The patient may be receiving care from another provider in a different specialty and have no relationship issues.
A copy of the letter should be filed in the chart. This can help ensure the patient is not referred back to the provider. Appointment schedulers should be notified when a patient has been sent a withdrawal from care letter, so that they do not offer to make another appointment for the patient after the transition period. In addition, if the office location has security personnel, they should receive a photograph of the discharged patient and be asked to stop the patient from entering the facility.
If an abusive patient physically threatens the physician or other staff, the patient can be discharged immediately, without a 30-day grace period. If a patient makes physical contact (such as pushing or spitting) with staff or the physician, the local police should be contacted.
Discharging an abusive patient from your practice should be a rare event. Each practice should familiarize itself with the local regulations on this matter.
Gail S. Chorney, MD, is a member of the AAOS Practice Management Committee. She can be reached at email@example.com
Editor's note: This article is provided for informational purposes only; it should not be considered as legal advice. For legal advice, consult a qualified professional.
- Blotter RH: Tips for Dealing with the Difficult Patient. AAOS Now, November 2009.
- American Medical Association Legal Resources: Termination of the Physician-Patient Relationship.
- Capozzi JD, Rhodes R, Gantsoudes G: Ethics in practice: Terminating the physician-patient relationship. J Bone Joint Surg Am 2008;90(1):208–210.