Firing patients

[cbrons]

I am an IM physician (outpatient and inpatient) but don't know which other busy enough board to post this in.


I had a patient trespass into our office space today looking for me to complain that I wasn't giving her narcotics (the patient did not have an appointment with me, they saw one of the midlevel providers for a separate issue). When the patient was accosted by staff, she proceeded to scream at our front desk staff until my nurse went out and spoke with her. (I was not in the clinic at the time, I was actually caring for patients in the hospital).

I am an employed physician, I do not own the practice in which I work. I told the practice manager that I will no longer be seeing this patient. She wants me to send the patient a certified letter stating that said patient is dismissed from the practice, but that I will see her for up to 30 days until she finds a new physician or non-physician provider.

In my opinion, the administration should be the ones to ban this patient from the premises for violating basic standards of behavioral decency. I do not know why I am being asked do the dirty work for them. It would seem to me that the administrator herself should be the one making the decision and notifying the patient (and banning her from the practice as a whole).

Am I looking at this the wrong way?

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[AMEHigh]

I’m still young in my career but yes I agree with you and that’s how I’ve seen it done. That’s essentially an administrative task, so you shouldn’t have to deal with it. They should write it, I’m sure there are templates they have, and then mail it certified. The letter doesn’t have to name you at all. It should just say that the patient can no longer be seen at X office by any staff and that goes in to affect 30 days after receipt of the letter.

 

[deleted87716]

They're your patient, not the administration's.

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[SLC]

Patients don’t get dismissed from my (employed) practice, unless I want them dissmissed.

My advice is to take ownership of how the clinic operates, or someone will take ownership from you.

 

[deleted480308]

You are firing them, not the admin. Write the letter and be done with it

 

[VA Hopeful Dr]

I’m still young in my career but yes I agree with you and that’s how I’ve seen it done. That’s essentially an administrative task, so you shouldn’t have to deal with it. They should write it, I’m sure there are templates they have, and then mail it certified. The letter doesn’t have to name you at all. It should just say that the patient can no longer be seen at X office by any staff and that goes in to affect 30 days after receipt of the letter.

This. In my employed office, I tell the office manager to dismiss a patient and she sends the standard dismissal letter.

 

[yeasports]

agree with above,
make sure you include in the letter that you will see him/her for medical necessary problems over the next 30 days but not under any circumstances will you or anyone in your office write for opioid pain medication.
you will never see them again

 

[Saddleshoes]

She wants me to send the patient a certified letter stating that said patient is dismissed from the practice, but that I will see her for up to 30 days until she finds a new physician or non-physician provider.

For legal reasons, this is the best way to do it.
However, you can make the 30 day deal for emergency treatment only.

 

[MedicineZ0Z]

There have been cases of patients showing up and shooting doctors or stabbing or other violent acts due to not getting opioids. Does anyone have mental prep for such situations when going into the room with a drug seeker? I feel like the literal physical approach to visits with these patients needs to be different.

 

[VA Hopeful Dr]

There have been cases of patients showing up and shooting doctors or stabbing or other violent acts due to not getting opioids. Does anyone have mental prep for such situations when going into the room with a drug seeker? I feel like the literal physical approach to visits with these patients needs to be different.

That's pretty rare on the whole and very rare for primary care, I suspect since we can always punt to pain management.

 

[deleted87716]

There have been cases of patients showing up and shooting doctors or stabbing or other violent acts due to not getting opioids. Does anyone have mental prep for such situations when going into the room with a drug seeker? I feel like the literal physical approach to visits with these patients needs to be different.

As @VA Hopeful Dr said, that doesn't happen very often. Most of the time, it isn't what you say, but how you say it that makes a patient angry. Rather than simply saying "no," say something along the lines of, "Well, I can't do that because ____ (why you're looking out for the patient's best interest), but I can do ____ (suggest a better way to help them)."

Also, never fight fire with fire. If the patient gets angry or rude, always remain calm, polite, and professional. Remind the patient that you won't tolerate bad behavior (this applies to my staff as well), and - if necessary - suggest that if they aren't willing to work with you, you simply may not be able to help them. When possible, offer an alternative source of care (e.g., pain management).

I've had a few people get pissed off at me over the years (not always about controlled substances), but the worst that has happened is a couple of bad online reviews. That being said, take threats seriously, whether they're made in person or otherwise. Call the police if you have to. And keep physical security in mind. The door from our lobby to our clinical area is locked (it has a remote release in the front office), and the front office staff has a code phrase to warn those of us in the back if something's going down.

 

[B1GM0N3Y86]

I am still pretty young in my Attending life, but if a patient meets criteria to be dismissed (noncompliance w/ medical treatment, rude behavior to myself/staff, dishonesty, no shows, irretrievably damaged therapeutic rapport) they are sent standard 30 day dismissal letter with my signature at the bottom. Usually, they have previously also been warned during an office appointment if I start to see potentials (pt's have no showed x 2, not getting labs done multiple times, not taking meds for any clear reasons). I explain to patients that I did not spend 10 or so years going thru schooling and residency to Enable patient's "poor behavior habits," and thus I wouldnt be able to be their PCP if they dont have any intention of turning off their path of self destruction. At times they get upset, other times they dont. For those who need to ask "why doc," I inform them that dismissal may lead them to a physician outside the practice that may better connect with them and achieve a Therapeutic Rapport. About 4 in 5 of Noncompliant patients or No Showers change their ways.

I took over a panel of a pcp from my office who was running a mini pill mill. 20-25% of his panel was on a controlled, with about 1/2 of them on multiple ones, and normally they also had Neurontin with Robaxin/Skelaxin mixed in there. Most of these scripts I did not agree with when looking over a patient's chart. If this was the case, all of these patients were given the SAME 3 options:
1. We can find an alternative medication to help treat your medical condition, while tapering off your current medication.
2. You can be referred to a Pain Mgt or Psych provider in the general region and I will provide a 30 day supply of current dose.
3. You can establish with an alternative medical provider outside this practice to serve your primary care needs and I will provide a 30 day supply of your current dose.
(all pt's informed that if they choose option 2 or 3 and they fail to establish with the specialist or new pcp by time current script ends, I will start the tapering off the medication)

I took this approach to help protect myself. I did have multiple complaints, however admin (which we dont normally agree on much stuff) did agree that I gave all patients reasonable options which made the patient complaints bogus.

I know a lot of what I have said may be a bit TOO stern for some, however i was not trained to enable childish and/or self destructive behaviors.

P.S. After this first contract, I def understand more on what to look for in my next job.... Truly is a Learning Experience.....

 

[Miles Gloriosus]

I am an IM physician (outpatient and inpatient) but don't know which other busy enough board to post this in.


I had a patient trespass into our office space today looking for me to complain that I wasn't giving her narcotics (the patient did not have an appointment with me, they saw one of the midlevel providers for a separate issue). When the patient was accosted by staff, she proceeded to scream at our front desk staff until my nurse went out and spoke with her. (I was not in the clinic at the time, I was actually caring for patients in the hospital).

I am an employed physician, I do not own the practice in which I work. I told the practice manager that I will no longer be seeing this patient. She wants me to send the patient a certified letter stating that said patient is dismissed from the practice, but that I will see her for up to 30 days until she finds a new physician or non-physician provider.

In my opinion, the administration should be the ones to ban this patient from the premises for violating basic standards of behavioral decency. I do not know why I am being asked do the dirty work for them. It would seem to me that the administrator herself should be the one making the decision and notifying the patient (and banning her from the practice as a whole).

Am I looking at this the wrong way?

Technically you have to be the one to dismiss patient.

What I would tell the admin is for him/her to type out a letter and leave it on your desk for you to sign. Hand it back to them for them to mail.

 

[MedicineZ0Z]

That's pretty rare on the whole and very rare for primary care, I suspect since we can always punt to pain management.

Rare, but over a long career it's not extremely unlikely to have some sort of engagement depending on your patient population.

 

[VA Hopeful Dr]

Rare, but over a long career it's not extremely unlikely to have some sort of engagement depending on your patient population.

If we're talking an actual physical altercation, then yes it's still very unlikely.

 

[Vandalia]

There have been cases of patients showing up and shooting doctors or stabbing or other violent acts due to not getting opioids. Does anyone have mental prep for such situations when going into the room with a drug seeker? I feel like the literal physical approach to visits with these patients needs to be different.

The problem is that national coverage of rare events makes them seem likely, when it fact they are incredibly rare. People see something on the news or social media that happened on the other side of the country, and they think it happened just down the road.

I hade a patient about a year ago who refused to be seen my a neurosurgeon because having listened to the "Doctor Death" podcast, she was convinced that the neurosurgeon would be on cocaine and would transect her spinal cord.

There was also the case of the family physician many years ago who refused to provide a referral for a patient to an oncologist unless she had sex with him.

Not to mention the physicians who attacked/killed administrators when they were denied credentials and/or fired/dismissed.

You are far more likely to be killed on the drive to work, or be eaten by a bear while hiking, than be killed or even attacked by a patient. Remember these events get the same amount of air-time as the guy who won $500M on Powerball. That does not make either event likely.

Not primary care, but the same issue applies, but this didn't even make the Top 100 things I was worried about.

 

[FrustratedFamDoc]

If it's the usual I want pain meds and you're not giving them to me temper tantrum, it's typically a quick an easy signed form letter from you and it's the last you'll hear from them. It's your patient, you determine their disposition. Sure they'll be upset but chances are you're not the first doc that has fired them and by now, they know the routine.

 

[hallowmann]

You have to dismiss them and give them 30 days until they find another physician. You can specify emergent/medically necessary care.

You should also specify that you won't give them opioids.

That's how it works. They can write the letter, but its from you or on your behalf as the physician in the physician-patient relationship.

Also, regarding assault, exceedingly rare and less so if you're reasonable about it. Give them other options or explain the issue. "Sorry it's the law" or "they'll take my license" is a completely reasonable backup way to respond that is hard to argue with.