Firing Patients

[Anasazi23]

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Again from the APA daily newswire.

Physician explains reasons for firing patients.
In the Cases column in the New York Times (6/10, F6), California physician Rahul K. Parikh, M.D., describes his struggle in dealing with the "confrontational" mother of a young patient. He writes that "putting up with this lady had taken more time than it was worth, and it interfered with my taking care of her son." Therefore, he decided to fire his patient. Dr. Parikh explains, "The physician-patient compact basically states that a doctor will care for a patient in exchange for compensation, and that the patient will heed the doctor's advice. Patients who disagree with their physicians, or just dislike them, are free to go elsewhere." Likewise, "this mutual contract gives a doctor the right to dismiss a patient." Reasons for firing a patient include "failing to pay or missing multiple appointments," as well as "[r]efusing to adhere to treatments," or "being abusive to the medical staff." Nevertheless, Dr. Parikh urges physicians "to exercise this option sensibly. Doctors cannot fire a patient in dire straits," nor can they "refuse to see patients because of their race, age," or sexual orientation.

I've already fired quite a few patients in my young career. In every case, I and my other patients have been better off for it. Of course, I remain with some very difficult and time-consuming patients. That's expected of course and every practice has them. I also feel that I was lucky in the sense that my residency has been understanding in these regards in which I chose to bring the matter up. Others may not be this fortunate

I'm wondering what others' experiences are in cases like these?

 

[Faebinder]

I'm interested to hear how this is handled in other residencies out there.

 

[Chrismander]

I also feel that I was lucky in the sense that my residency has been understanding in these regards in which I chose to bring the matter up. Others may not be this fortunate

I'm wondering what others' experiences are in cases like these?

Sazi, can you comment a bit more about your own experiences? I didn't know residents were able to fire patients at all. Did they just get reassigned to another resident, or did they end up going entirely elsewhere? How bad did it have to get before you considered this option?

Sorry for all the questions, just very curious about this. 🙂

 

[sunlioness]

I've fired patients for multiple no-shows. We can do this after they miss three appointments without 24 hours notice. After this, they can no longer be seen by anyone in our clinic. I've also told people that I couldn't see them until they got treatment for their substance use/dependence, which is something we don't really do.

 

[Anasazi23]

Sazi, can you comment a bit more about your own experiences? I didn't know residents were able to fire patients at all. Did they just get reassigned to another resident, or did they end up going entirely elsewhere? How bad did it have to get before you considered this option?

Sorry for all the questions, just very curious about this. 🙂

Well, there have been patients that consistently go against the established treatment plan, or break the "rules" of the outpatient settting. I recall a particular case where a woman remained in chronic delirium with severe psychotic symptoms. She and her husband (with his own severe axis II pathology) would call constantly, take only portions of the medicines they felt were useful, and so on. I had referred them to an alternate level of care, which they consistently refused. Eventually I had to close the book on the patient since they were not following the established course of treatment.

A more recent case was from a psychotherapy case was difficult to treat, again due to severe character pathology (narcissism) that was just impenatrable. I told him he needed a higher session rate or something, and that our interventions had been essentially useless after nearly 2 years of therapy. I again referred him to the psychoanalytic institute. Yes, it was a sort of punt, but as Hannibal said, "His therapy was going nowhere."

 

[alina_s]

We have rules similar to sunlioness' about firing after no-shows. I have fired a patient for that before. We also don't treat substance abuse in one of the clinics, but those patients are supposed to be screened out in the intake interview. I do think other people have had to refer patients out because it emerged that substance abuse was their primary problem. There are also policies about firing for not following the treatment plan, but those are hazier. I had one patient I really wanted to fire because we weren't making any progress and didn't seem likely to because she had a lot of secondary gain and didn't seem interested in changing; I was eventually allowed to stop seeing her for therapy, but her insurance had run out too, and I am not sure if I would have been allowed to fire her if she had still been covered. The suggestion from my attending had been to keep seeing her until she got what she wanted out of the therapy (unclear) and quit on her own.

 

[Ritz]

'Firing' is used here in a more stronger context than just dropping a pt form the clinic because of breaking general rules. He is referring to actually refusing to see the patient even if the pt is not breaking any general rules. The Physician feels inadequacy of therapeutic relationship due to some external factors- the mother in this example. It requires good experience and courage to practice this aspect of Medicine. The closest I have heard is that you can have a first interview and refuse to have patient come back to your clinic-mainly in Psychodynamic therapy context. And the worse scenario is dumping !

We have rules similar to sunlioness' about firing after no-shows. I have fired a patient for that before. We also don't treat substance abuse in one of the clinics, but those patients are supposed to be screened out in the intake interview. I do think other people have had to refer patients out because it emerged that substance abuse was their primary problem. There are also policies about firing for not following the treatment plan, but those are hazier. I had one patient I really wanted to fire because we weren't making any progress and didn't seem likely to because she had a lot of secondary gain and didn't seem interested in changing; I was eventually allowed to stop seeing her for therapy, but her insurance had run out too, and I am not sure if I would have been allowed to fire her if she had still been covered. The suggestion from my attending had been to keep seeing her until she got what she wanted out of the therapy (unclear) and quit on her own.

 

[Anasazi23]

'Firing' is used here in a more stronger context than just dropping a pt form the clinic because of breaking general rules. He is referring to actually refusing to see the patient even if the pt is not breaking any general rules. The Physician feels inadequacy of therapeutic relationship due to some external factors- the mother in this example. It requires good experience and courage to practice this aspect of Medicine. The closest I have heard is that you can have a first interview and refuse to have patient come back to your clinic-mainly in Psychodynamic therapy context. And the worse scenario is dumping !

It's actually common practice for psychiatrists to have an "initial consultation period." This is actually written into the practice agreement with the patient. I know attendings enforce this all the time, and I did it also recently as well with another axis II patient with substance abuse issues. In other words, the first couple patient visits are considered "consultation," and in no way obligate the psychiatrist to continue treatment should there not be a good "match" or simply if the physician chooses not to treat the patient. In other words, if you agreed to see a patient who called you on the phone, and discover that they're going to be a time-sucking raging borderline with multiple parasuicidal gestures, calling your phone 2x daily, after the initial interview, the psychiatrist can refer the patient out without breaking any sort of obligation to the patient.

Another advantage of outpatient private practice I guess.

 

[skee lo]

Three years ago I informed my psychiatrist that I had decided to discontinue treatment and terminate my relationship with her due to dissatisfaction. A few weeks later she sent me a letter indicating that she was discharging me from her practice due to my noncomlpiance. Gotta love psychiatrists.

 

[sunlioness]

Nice way to generalize.

 

[alina_s]

'Firing' is used here in a more stronger context than just dropping a pt form the clinic because of breaking general rules.

That's my point- as residents, we were given clear criteria for how to deal with rule-breakers but not for patients that we just can't work with, and it's hard for us (in my clinic at least) to terminate with patients we aren't making any progress with.