Ethics Question: If you were a doctor what would you do in this situation?

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Here is the scenario, tell me what is the ethically correct thing to do.


A doctor saw a patient via consult in the hospital for a serious but treatable condition. Patient then sees this doctor for the next few years for treatment and monitoring of this condition. The patient does not heed all of doctors advice. Doctor says to have something drastic like surgery but patient decides to wait on surgery and prolong treatment as much as they can. The patient has insurance but owes the doctor whatever the insurance did not reimburse. Patient has an outstanding balance due to the office.

The patient hasn't seen this particular doctor in a year and the patient ends up in the ER unexpectedly. The patient is not gravely ill but needs to be treated and admitted. ER doc asks the patient who their doctor is and patient says doctor so and so. ER doc calls up this doctor that has been treating the patient and informs him of the situation and the doctor says he will not see the patient.

If you were this patient's doctor, how would you approach this situation?

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As a doctor you have the right to "fire" any patient for any reason. However it is your responsibility to ensure continuity of care. In this case, the physician should treat the patient during the hospitalization and then say he will no longer be his doctor after the patient is discharged. He should refer the patient to another physician and transfer all related medical records.
 
Here is the scenario, tell me what is the ethically correct thing to do.


A doctor saw a patient via consult in the hospital for a serious but treatable condition. Patient then sees this doctor for the next few years for treatment and monitoring of this condition. The patient does not heed all of doctors advice. Doctor says to have something drastic like surgery but patient decides to wait on surgery and prolong treatment as much as they can. The patient has insurance but owes the doctor whatever the insurance did not reimburse. Patient has an outstanding balance due to the office.

The patient hasn't seen this particular doctor in a year and the patient ends up in the ER unexpectedly. The patient is not gravely ill but needs to be treated and admitted. ER doc asks the patient who their doctor is and patient says doctor so and so. ER doc calls up this doctor that has been treating the patient and informs him of the situation and the doctor says he will not see the patient.

If you were this patient's doctor, how would you approach this situation?

You lost me somewhere here. Which doc says he will not see the patient? The ER Doc? And which patient's doctor are we supposed to be? The ER doc? If not the ER doc to either of these, didn't your scenario already choose for us that we would not see the patient? Or are you asking us if we would make the same choice?

Either way, I would probably see the patient if the patient is not gravely ill. Yeah, I probably wouldn't get paid and they probably wouldn't listen, but I'll keep doing my part and hope they'll eventually care enough to do theirs. It's not like I really have to sacrifice that much to do this provided there aren't expensive procedures being done.
 
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You lost me somewhere here. Which doc says he will not see the patient? The ER Doc? And which patient's doctor are we supposed to be? The ER doc? If not the ER doc to either of these, didn't your scenario already choose for us that we would not see the patient? Or are you asking us if we would make the same choice?

Either way, I would probably see the patient if the patient is not gravely ill. Yeah, I probably wouldn't get paid and they probably wouldn't listen, but I'll keep doing my part and hope they'll eventually care enough to do theirs. It's not like I really have to sacrifice that much to do this provided there aren't expensive procedures being done.

Sorry for the confusion. I'm asking what you would do if you were the doctor who has been treating the patient for the last few years and now he won't see this patient when he is in the ER because the patient has an outstanding balance and the patient won't agree to aggressive treatments. We will call him "Doctor A."

The ER doc is just the middle man. He is trying to make sure patient is well taken care of. We can call the ER doc "Doctor B."

I found this story odd because I thought that, as a doctor, "Doctor A" has a responsibility to this patient in some way despite the outstanding issues.
 
Sounds like your question is more along the lines of "Should Doctor A have treated the patient?"
 
Is the patient in the ER for the condition the physician was origionally treating him for?

Yes, the patient was in the ER because the condition he was being treated for returned. Instead of seeing him in the ER, "Doctor A" said he was not interested in seeing him period.

The ER doc then had to arrange for another specialist to treat him.

By doing this, the new specialist will have no experience with this patient and as a a result, I think the patient's health might have been compromised in some way.

I thought that the right thing to do would be for "Doctor A" to see the patient despite the other outstanding issues and then once the patient was better, he should have told him that he was severing the relationship.

Instead of this, "Doctor A" just appeared to leave the patient hanging.

I wanted to know if this is ethically correct.
 
I would. If he was in the ER, there is a chance he wasn't going to get money the patient anyways. I would try and treat and let him on his way and what he decides to do from then on is up to the patient.
 
Yes, the patient was in the ER because the condition he was being treated for returned. Instead of seeing him in the ER, "Doctor A" said he was not interested in seeing him period.

The ER doc then had to arrange for another specialist to treat him.

By doing this, the new specialist will have no experience with this patient and as a a result, I think the patient's health might have been compromised in some way.

I thought that the right thing to do would be for "Doctor A" to see the patient despite the other outstanding issues and then once the patient was better, he should have told him that he was severing the relationship.

Instead of this, "Doctor A" just appeared to leave the patient hanging.

I wanted to know if this is ethically correct.

It's hard to say with no details provided. As a previous poster said, though, the doc is responsible for establishing continuity of care when he fires a patient. Some questions in mind:

1) Was the patient aware he was fired before he got to the ER? Had the physcian formally informed him that their relationship was over?

2). How acute was his condition and how complicated was it? An oncologist firing a patient in the middle of a complicated chemo regimine might be different than an FP firing a typical presentation of hypertension.
 
This is a 76 year old widow who was hospitalized three years ago. The primary care provider consulted with a cardiologist who took over the care of the patient who was diagnosed with a heart condition which might best be managed with surgery. The patient wants to avoid surgery and so is treated by the cardiologist for several years with medication and lifestyle changes although the patient admits to not following the prescribed plan of care as directed. Furthermore, the patient has not been paying the required co-pays and owes a few hundred dollars for office visits. We don't know if the physician has sent this bill to collections or has any written policy shared with patients on unpaid balances.

Now the patient comes into the ER with shortness of breath and swelling of the ankles. A short inpatient hospital stay and medical management of the acute condition will be a quick fix although surgery is still recommended for long term management. The ER calls the cardiologist who declines to see/admit the patient.

Has the cardiologist done anything unethical?
 
It's hard to say with no details provided. As a previous poster said, though, the doc is responsible for establishing continuity of care when he fires a patient. Some questions in mind:

1) Was the patient aware he was fired before he got to the ER? Had the physcian formally informed him that their relationship was over?

2). How acute was his condition and how complicated was it? An oncologist firing a patient in the middle of a complicated chemo regimine might be different than an FP firing a typical presentation of hypertension.


1. Patient was not made aware before hand that the relationship was terminated. Patient had not seen this doctor for the last year or so.

2. Condition was blood clot in groin, thigh swelling, lower back pain. Patient has an IVC filter so he probably wouldn't have died. Patient has history of DVT. Patient was eventually treated by another hematologist, put on anti-coagulation therapy, and released. The new hematologist had to go about obtaining all records from the previous hematologist.
 
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This is a 76 year old widow who was hospitalized three years ago. The primary care provider consulted with a cardiologist who took over the care of the patient who was diagnosed with a heart condition which might best be managed with surgery. The patient wants to avoid surgery and so is treated by the cardiologist for several years with medication and lifestyle changes although the patient admits to not following the prescribed plan of care as directed. Furthermore, the patient has not been paying the required co-pays and owes a few hundred dollars for office visits. We don't know if the physician has sent this bill to collections or has any written policy shared with patients on unpaid balances.

Now the patient comes into the ER with shortness of breath and swelling of the ankles. A short inpatient hospital stay and medical management of the acute condition will be a quick fix although surgery is still recommended for long term management. The ER calls the cardiologist who declines to see/admit the patient.

Has the cardiologist done anything unethical?

If this is the first time the patient has been informed they're fired I say yes. An acute exacerbation which requires emergency care isn't a reasonable cue to get rid of a patient.
 
I wouldn't treat him unless no other physician could be found if I were in private practice. Non-compliance would be the fastest way to get me to show you the door.

u have 20 seconds to comply

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u have 20 seconds to comply

But what if you've asked this patient to take a diuretic (water pill), lose weight, cut back on the salt in her diet, quit smoking and cut out alcohol....

She admits to skipping the diuretic once or twice a week when it would interfer with her activities, she's managed to lose only 5 pounds (needs to lose 50), still eats some high sodium foods and drinks on special occasions (about once a month) and has cut back on smoking but has not quit.

This is the sort of "non-compliance" that docs are often facing.
 
This is a 76 year old widow who was hospitalized three years ago. The primary care provider consulted with a cardiologist who took over the care of the patient who was diagnosed with a heart condition which might best be managed with surgery. The patient wants to avoid surgery and so is treated by the cardiologist for several years with medication and lifestyle changes although the patient admits to not following the prescribed plan of care as directed. Furthermore, the patient has not been paying the required co-pays and owes a few hundred dollars for office visits. We don't know if the physician has sent this bill to collections or has any written policy shared with patients on unpaid balances.

Now the patient comes into the ER with shortness of breath and swelling of the ankles. A short inpatient hospital stay and medical management of the acute condition will be a quick fix although surgery is still recommended for long term management. The ER calls the cardiologist who declines to see/admit the patient.

Has the cardiologist done anything unethical?

If the ER in this country cannot turn you away, the cardiologist should at least take that into consideration and make that visit. Then he should treat the patient, terminate the relationship and hand them to someone else. Doctors are businessmen and humanitarians but you can't just act like a businessman at all times. If I was a doctor on an airplane and they said someone is having a heart attack, I would help them and hand them off to the appropriate people on the ground. I wouldn't just keep quiet because I wouldn't get paid or it wasn't my problem.

In my story, the patient has paid all the office copays but has not paid the part that insurance will not reimburse (which is usually wayyyyy more than $20-50). Also my case deals with stuff that can kill you right away.


Here's another curve ball that I forgot to mention. Since the patient was not seeing "Doctor A" for a year, he was complaining about these symptoms and made an appointment with a primary care doctor for an evaluation. The primary care doc sent him to the hospital to have an MRI. The MRI showed a blood clot in the groin and the radiologist and this primary care doc conferred that the patient should be sent to the ER stat. In the ER, the ER doc asked the patient his history and who his hematologist was. The patient told the ER doc that "Doctor A" was his hematologist. ER doc calls "Doctor A" and tells him that his patient is in the ER with a clot in his groin. "Doctor A" says he is not interested in seeing him.
 
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If the ER in this country cannot turn you away, the cardiologist should at least take that into consideration and make that visit. Then he should treat the patient, terminate the relationship and hand them to someone else. Doctors are businessmen and humanitarians but you can't just act like a businessman at all times. If I was a doctor on an airplane and they said someone is having a heart attack, I would help them and hand them off to the appropriate people on the ground. I wouldn't just keep quiet because I wouldn't get paid or it wasn't my problem.

In my story, the patient has paid all the office copays but has not paid the part that insurance will not reimburse (which is usually wayyyyy more than $20-50). Also my case deals with stuff that can kill you right away.


Here's another curve ball that I forgot to mention. Since the patient was not seeing "Doctor A" for a year, he was complaining about these symptoms and made an appointment with a primary care doctor for an evaluation. The primary care doc sent him to the hospital to have an MRI. The MRI showed a blood clot in the groin and the radiologist and this primary care doc conferred that the patient should be sent to the ER stat. In the ER, the ER doc asked the patient his history and who his hematologist was. The patient told the ER doc that "Doctor A" was his hematologist. ER doc calls "Doctor A" and tells him that his patient is in the ER with a clot in his groin. "Doctor A" says he is not interested in seeing him.

I would probably have seen the patient, but the case as you describe it doesn't exactly sound like clear cut unethical behavior. It doesn't sound like the ER was requesting an emergent consultation, but rather follow up.

Basically I think its unethical to terminate a patient a particular time if there is another time in the near future when you would be able to terminate the relationship with less risk to the patient or if you can't arrange continuity of care. If they're really consulting for a chronic condition rather than the acute exacerbation I think transfering care to a new practicioner might be at least debateably ethical.
 
I would probably have seen the patient, but the case as you describe it doesn't exactly sound like clear cut unethical behavior. It doesn't sound like the ER was requesting an emergent consultation, but rather follow up.

Basically I think its unethical to terminate a patient a particular time if there is another time in the near future when you would be able to terminate the relationship with less risk to the patient or if you can't arrange continuity of care. If they're really consulting for a chronic condition rather than the acute exacerbation I think transfering care to a new practicioner might be at least debateably ethical.


Due to the nature of the illness, the ER wanted to hand the patient over to "Doctor A" because "Doctor A" is aware of the patient's history and can provide the necessary care to get rid of the clot. Because "Doctor A" refused to see the patient, it is almost like starting all over. The new hematologist does not know this patient and will prescribe a treatment plan that may or may not be in this patient's best interest.

I understand that money is a factor and maybe the patient didn't want the initial surgery but in the end the patient is still a patient who is sick.
 
Depends on whether you're a Kantian ethicist or a utilitarian :) ... The former might say you have an obligation to serve the patient until you have given her explicit forewarning that you will not be providing care to her in future. The latter would evaluate the circumstances: Are we to assume that we would have nothing else to do besides treating this patient? Or would our efforts be better served with a patient who does comply, or has a more immediately life-threatening condition?
 
So, in the OP's story the patient has seen the hematologist for years but continues to see a primary care provider as well. In the ER, the hematologist is called to admit the patient on the basis of their ongoing relationship but the hematologist says, "Call someone else, I'm finished with that guy" Provided that somone with similar skills is available, it does not appear unethical.

BTW: copay is the patient's share of the bill after insurance. It seems to me that the physician should have a policy -- either that the patient provides a credit card number & authorization and a charge will be made if the balance on the account is not paid with 90 days (what my kids' doctor instituted a few years ago), work with the patient to set up a payment plan, or send the bill to "collections" to make it clear to the patient that non-payment is not an option.
 
I can't see it as being unethical.

Who's to say that if 'Dr. A' were to see the patient during the emergency visit, and afterwards the patient was still non-compliant with some to all discharge instructions that the same scenario wouldn't happen again and again.

Dr. A has a right to refuse a patient as long as they see to it that the patient has another doctor available once he steps outside of the picture.

Now if the patient was presented under emergency circumstances and Dr. A was the only physician available in the hospital or even the city/county (unlikely, but it can still happen) then by Dr. A refusing the patient it would become unethical.
 
I can't see it as being unethical.

Who's to say that if 'Dr. A' were to see the patient during the emergency visit, and afterwards the patient was still non-compliant with some to all discharge instructions that the same scenario wouldn't happen again and again.

Dr. A has a right to refuse a patient as long as they see to it that the patient has another doctor available once he steps outside of the picture.

Now if the patient was presented under emergency circumstances and Dr. A was the only physician available in the hospital or even the city/county (unlikely, but it can still happen) then by Dr. A refusing the patient it would become unethical.

This is interesting. Do you think I am a softy for wanting to help this patient? If I was a doctor, I could see myself at least making that ER visit. But you make the point that "Doctor A's" actions were perfectly justifiable.
 
Non-compliance would be the fastest way to get me to show you the door.

Yes, because the role of the Doctor is to force patients to follow their commands, rather than to educate them about THEIR health and THEIR treatment options that will affect THEIR lives (not yours, you do not have to go through the rigors of treatment). You can hate "non-compliance" all you want, but I would not want a doctor with an attitude such as this to treat me.
 
Yes, because the role of the Doctor is to force patients to follow their commands, rather than to educate them about THEIR health and THEIR treatment options that will affect THEIR lives and not yours. You can hate "non-compliance" all you want, but I would not want a doctor with an attitude such as this to treat me.

I feel the same way as you. Oddly, it is these aggressive docs that usually have a lot of respect. I think the respect is in response to fear.

Man I wish there was a textbook for doctors demeanor's. I have to learn this stuff.
 
I feel the same way as you. Oddly, it is these aggressive docs that usually have a lot of respect. I think the respect is in response to fear.

Man I wish there was a textbook for doctors demeanor's. I have to learn this stuff.

Sadly, you can provide the highest quality care and education conceivable, but if the patient is not made to understand how critical it is to comply with your advice, YOU look like a bad doctor, and the family may come after you if the patients passes.
 
This is a 76 year old widow who was hospitalized three years ago. The primary care provider consulted with a cardiologist who took over the care of the patient who was diagnosed with a heart condition which might best be managed with surgery. The patient wants to avoid surgery and so is treated by the cardiologist for several years with medication and lifestyle changes although the patient admits to not following the prescribed plan of care as directed. Furthermore, the patient has not been paying the required co-pays and owes a few hundred dollars for office visits. We don't know if the physician has sent this bill to collections or has any written policy shared with patients on unpaid balances.

Now the patient comes into the ER with shortness of breath and swelling of the ankles. A short inpatient hospital stay and medical management of the acute condition will be a quick fix although surgery is still recommended for long term management. The ER calls the cardiologist who declines to see/admit the patient.

Has the cardiologist done anything unethical?

Is she an old witch, or would she bake you cookies if you came over? I think that solves it.

:p
 
Transfer the records and let the hospitalist admit the patient.
 
In my mind, it would have been unethical for the physician to not see the patient in an acute setting.

If I were the physician, it would play out along the lines of...see the patient in the acute setting, discharge the patient from your practice once discharged from the hospital/physician's responsibility, send bill to collections. From there on out, if another ER calls, she's no longer your patient.
 
In real life, the ED would be calling the medicine team on call to admit this patient. They would read the previous notes and admit them to inpatient status and then consult heme, probably the next morning. Most likely they'd call the heme fellow on call (or resident) who at some point would get ahold of the previous attending, who could defer to someone else at that time if he didn't want to staff this patient. Unless you're in a tiny rural
setting you're going to have more than one hematologist on staff.
 
Yes, because the role of the Doctor is to force patients to follow their commands, rather than to educate them about THEIR health and THEIR treatment options that will affect THEIR lives (not yours, you do not have to go through the rigors of treatment). You can hate "non-compliance" all you want, but I would not want a doctor with an attitude such as this to treat me.


But what's the point of continuing to see a patient who does not act upon their "education"?

If you won't comply with medical orders you are, in effect, refusing treatment.

Anyways, I do not think it is unethical to refuse the patient. Turn medical records etc. to other doctors that are willing to treat the patient. The doctor-patient interaction is a relationship, sometimes it just doesn't work out. A patient who does not listen to one doctor may listen to another.
 
This happens all the time. Doctors refuse patients frequently in the ER. Here the patient goes to whoever is on all call for the hospital or certain group of physicians. It all works out.

I had a doctor tell me to get out of his office before. He didn't like what I asked him. He has huge anger issues and is not working at the hospital anymore, but that is an example of a personal instance.

Things work both ways. Patients can fire their doctors also. :)
 
I would do the same thing as the doc and not accept him back bc the pt is non compliant and a risk. The money I really wouldn't stress over. Pts who don't follow drs orders are a huge liability.
 
And then another thing, wouldn't the doc get paid for the hospital visit since the hospital will be billing the insurance company? Even if they don't pay, the hospital still has to pay the physician.
 
Drizz summed it up well. I don't see why this doc would have to come in unless he's the only available attending AND has hospital privileges. This just doesn't happen anymore. There are teams of physicians in the hospital for a reason.

The physician, if he wants to terminate the relationship, must provide information for another physician and transfer the records as stated earlier.
 
Drizz summed it up well. I don't see why this doc would have to come in unless he's the only available attending AND has hospital privileges. This just doesn't happen anymore. There are teams of physicians in the hospital for a reason.

The physician, if he wants to terminate the relationship, must provide information for another physician and transfer the records as stated earlier.

Usually the ER doc finds another physician after a long and heated pissing match. ;)
 
And then another thing, wouldn't the doc get paid for the hospital visit since the hospital will be billing the insurance company? Even if they don't pay, the hospital still has to pay the physician.
This is true IF the physician is employed by the hospital. However, in a private practice model, the physician bill is separate from the hospital bill and in most cases the patient will be responsible for a portion of both bills (co-pays).
 
Yes, the patient was in the ER because the condition he was being treated for returned. Instead of seeing him in the ER, "Doctor A" said he was not interested in seeing him period.

The ER doc then had to arrange for another specialist to treat him.

By doing this, the new specialist will have no experience with this patient and as a a result, I think the patient's health might have been compromised in some way.

I thought that the right thing to do would be for "Doctor A" to see the patient despite the other outstanding issues and then once the patient was better, he should have told him that he was severing the relationship.

Instead of this, "Doctor A" just appeared to leave the patient hanging.

I wanted to know if this is ethically correct.

Actually, the way some/many hospitals work is that there is a hospitalist or an on-call physician for a given group of doctors. Thus, it is often the case where the outpatient provider does NOT come to the ER to see the patient, and that whichever doctor is "in-house" will go, learn about and treat the patient.

If Doctor A was practicing in a more "old-school" or rural setting where the outpatient provider follows their patients when admitted, then I agree, the doctor should fulfill their obligation (Doctor A should have "fired" this patient in a more elective fashion if that was their plan, not during this emergent situation).

Do you know for sure that Doctor A hadn't sent out a letter notifying the patient that they won't be in a patient-doctor bond?
 
This is interesting. Do you think I am a softy for wanting to help this patient? If I was a doctor, I could see myself at least making that ER visit. But you make the point that "Doctor A's" actions were perfectly justifiable.

Part of this is not understanding how busy doctors are. You think of it as "that ER" visit. In reality, it is several visits/calls/obligations. If you're a PCP with several hundred-thousand patients under your care, you can't afford to keep caving in when you shouldn't. There just aren't enough hours in the day.
 
Due to the nature of the illness, the ER wanted to hand the patient over to "Doctor A" because "Doctor A" is aware of the patient's history and can provide the necessary care to get rid of the clot. Because "Doctor A" refused to see the patient, it is almost like starting all over. The new hematologist does not know this patient and will prescribe a treatment plan that may or may not be in this patient's best interest.

I understand that money is a factor and maybe the patient didn't want the initial surgery but in the end the patient is still a patient who is sick.

Again, I think you are overestimating the difficulty for the new provider to review a patient's chart to initiate treatment. You are also underestimating the time and effort it would take doctor A to get cought up. Doctor A sees 10-20 patients a day. Doctor A hasn't seen this patient in a year. How much do you think doctor A still remembers about this patient?
 
I wouldn't treat him unless no other physician could be found if I were in private practice. Non-compliance would be the fastest way to get me to show you the door.

You'll be very poor and without many patients. 80% of American health problems are secondary to poor choices.
 
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