Patients who no longer want services

[finalpsychyear]

Just double checking if a patient decides they are no longer interested in receiving services from your office and do not want medications does it still require a formal discharge letter to be sent to the patient or just documentation in the chart that this was decided per the patients request.

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[Ironspy]

Where I have been chart documentation of the patient wanting to terminate care would be sufficient and no letter needed to be sent.

If it’s a problematic patient, I’ve sent a portal message confirmation termination. Benefit of this is that it has a read receipt

However, laws are state dependent and you should look into what your state requires to terminate care and/or reach out to the risk management department of your med mal carrier for guidance

 

[VA Hopeful Dr]

Send a letter just to cover your backside.

When a patient says they're going to find a new doctor, I still send a letter confirming that they said that. That way I'm not responsible for 30 days of emergency care.

Now I'm family medicine, so it's not like someone will be stabilized and then leave my care, but it's easy enough to gin up a letter saying that that still sounds very nice and it's just confirming that they are going to not follow up with you.

 

[clozareal]

Yes. Formal letter sent via certified mail.

 

[MacDonaldTriad]

Patients have the right to refuse for you to continue care. You can send letters swearing you are not abandoning the responsibility to provide care, but documenting that you think the patient requires further care and was offer such and that you offered to provide referral is needed. All of these things help, but hang onto and put into the file all communication that documents the patient asked to no longer be your patient. The former is still needed, but the latter releases you from being complicit in the transfer of care.
This happens and when I have heard of such situations, the psychiatrist is usually not upset about the change.

 

[Sushirolls]

I've kept it simple. I just oblige, and make a note. Or if patient sent me a luminello message, save it to chart. The big thing I try to document in addition to that is how I review how people can get their records. That's as far as I go. I close the chart down once the billing concludes.

 

[brazilianpsych]

Isn't this a case of psychiatrist becoming neurotic about something they shouldn't be? Lawsuits against psychiatrist are very low, and I cannot imagining getting sued because patient stopped showing up. That's insane.

I imagine if other specialties do that. If I go to a cardiologist and never show up again, will he hunt me down, sending a letter to my address? I find that very hard to believe.

Anyway, I'm still not out of residency, but I wouldn't do anything if patient stopped showing up. We don't do anything at the residents clinic.

 

[comp1]

The comments about private practice on here always make me very glad to be employed.

 

[Sushirolls]

Isn't this a case of psychiatrist becoming neurotic about something they shouldn't be? Lawsuits against psychiatrist are very low, and I cannot imagining getting sued because patient stopped showing up. That's insane.

I imagine if other specialties do that. If I go to a cardiologist and never show up again, will he hunt me down, sending a letter to my address? I find that very hard to believe.

Anyway, I'm still not out of residency, but I wouldn't do anything if patient stopped showing up. We don't do anything at the residents clinic.

There was a case in WA state, where stable patient, had routine follow up in 90 days. During that time, commited murder, or suicide or both.
Some living victims or family, sued psychiatrist. Psychiatrist lost. Despite everything Psych said was patient was stable, 'I had no idea there were issues' based on last point of contact.

So these are the types of things get psych on edge.

Patients who ghost me, we send closure letters.

I ghosted a PCP clinic once to test their policies out, when I moved once, and they sent me a closure letter, too. Was a Big Box shop. Nice to see a Big Box shop rendition of it.

 

[calvnandhobbs68]

The comments about private practice on here always make me very glad to be employed.

Lol you don't get relieved from needing to formally discharge patients if you're employed you know.

 

[calvnandhobbs68]

There was a case in WA state, where stable patient, had routine follow up in 90 days. During that time, commited murder, or suicide or both.
Some living victims or family, sued psychiatrist. Psychiatrist lost. Despite everything Psych said was patient was stable, 'I had no idea there were issues' based on last point of contact.

Do you remember what case this was and if this actually went to court or settled ? Would be interested to see what the details of the case were because this sounds pretty ridiculous. To keep using the cardiology analogy, would be like a cardiology patient having an MI between routine followup appointments with no new contact made or signs of worsening and the cardiologist being successfully sued.

 

[Sushirolls]

Do you remember what case this was and if this actually went to court or settled ? Would be interested to see what the details of the case were because this sounds pretty ridiculous. To keep using the cardiology analogy, would be like a cardiology patient having an MI between routine followup appointments with no new contact made or signs of worsening and the cardiologist being successfully sued.

I don't remember the details, just 4-7 years ago. Money was paid out. Can't recall if settled or court. Was in Spokane area.
I only filed away in my mind how if any one has a WA license that the case basically turned upside down mental health liability.
But I don't think it has materialized in real world changes in practice in that state or liability rates.
I know one Big Box shop there, from various circles, that they started being more active with the closure letters.

 

[ObsequiousAplomb]

I don't remember the details, just 4-7 years ago. Money was paid out. Can't recall if settled or court. Was in Spokane area.
I only filed away in my mind how if any one has a WA license that the case basically turned upside down mental health liability.
But I don't think it has materialized in real world changes in practice in that state or liability rates.
I know one Big Box shop there, from various circles, that they started being more active with the closure letters.

Volk v. DeMeerleer

From the top of google:

Volk v. DeMeerleer (Majority and Dissent)

Jan DeMeerleer murdered Rebecca Schiering and her nine year old son Philip, and attempted to murder Schiering's older son, Brian Winkler. After the attack, DeMeerleer committed suicide. DeMeerleer had been an outpatient of psychiatrist Dr. Howard Ashby for nine years leading up to the attack...

law.justia.com

Does Volk v DeMeerleer Conflict with the AMA Code of Medical Ethics on Breaching Patient Confidentiality to Protect Third Parties?

Volk v DeMeerleer may conflict with professional guidelines regarding physicians’ obligations to breach patient confidentiality to protect third parties.

journalofethics.ama-assn.org

 

[Sushirolls]

Volk v. DeMeerleer

From the top of google:

Volk v. DeMeerleer (Majority and Dissent)

Jan DeMeerleer murdered Rebecca Schiering and her nine year old son Philip, and attempted to murder Schiering's older son, Brian Winkler. After the attack, DeMeerleer committed suicide. DeMeerleer had been an outpatient of psychiatrist Dr. Howard Ashby for nine years leading up to the attack...

law.justia.com

Does Volk v DeMeerleer Conflict with the AMA Code of Medical Ethics on Breaching Patient Confidentiality to Protect Third Parties?

Volk v DeMeerleer may conflict with professional guidelines regarding physicians’ obligations to breach patient confidentiality to protect third parties.

journalofethics.ama-assn.org

The forensic Psychiatrist expert witness 'when patients express suicidal thoughts they often reveal homicidal thoughts upon further inquiry.' No.
No, they don't. I have had 0 patients in past 5-6 years exhibit both SI/HI. And even when I worked inpatient years ago, that was like less than 5% of patients would exhibit both SI/HI. Even Psych ED patients are maybe 30% bother SI/HI, but of those, tiny fracture still expressing SI/HI the next morning after their intoxication from XYZ wears off.

I can't believe this expert witness has such a mismatch to their CV. If this is what it takes to be a forensic psychiatrist, heck, I should start offering expert testimony now. [shaking head]

Everything about that case is nauseating. I had to stop reading it part way through.

 

[The kitchen sink]

The forensic Psychiatrist expert witness 'when patients express suicidal thoughts they often reveal homicidal thoughts upon further inquiry.' No.
No, they don't. I have had 0 patients in past 5-6 years exhibit both SI/HI. And even when I worked inpatient years ago, that was like less than 5% of patients would exhibit both SI/HI. Even Psych ED patients are maybe 30% bother SI/HI, but of those, tiny fracture still expressing SI/HI the next morning after their intoxication from XYZ wears off.

I can't believe this expert witness has such a mismatch to their CV. If this is what it takes to be a forensic psychiatrist, heck, I should start offering expert testimony now. [shaking head]

Everything about that case is nauseating. I had to stop reading it part way through.

This case makes no sense without more details

Do they expect psychiatrists to read minds ?? I don’t get how the court decided this was a reasonable verdict ….

 

[clausewitz2]

Important to understand that the WA Supreme court opinion here is not saying the psychiatrist it was liable. It is reversing the trial court's summary judgement dismissing the case, saying that plaintiffs did adequately demonstrate that there was a question of medical negligence at stake and thus a tort did in fact exist.

I recommend reading the opinion, the court lays out its thinking in a particularly readable manner.

EDIT: if you read it, you see once again a key problem is that the treating psychiatrist didn't document his thinking or any kind of informed assessment. This is where the negligence comes from - they concede prediction is extremely difficult but hold that a mental health professional has to at least try.

 

[Sushirolls]

Important to understand that the WA Supreme court opinion here is not saying the psychiatrist it was liable. It is reversing the trial court's summary judgement dismissing the case, saying that plaintiffs did adequately demonstrate that there was a question of medical negligence at stake and thus a tort did in fact exist.

I recommend reading the opinion, the court lays out its thinking in a particularly readable manner.

EDIT: if you read it, you see once again a key problem is that the treating psychiatrist didn't document his thinking or any kind of informed assessment. This is where the negligence comes from - they concede prediction is extremely difficult but hold that a mental health professional has to at least try.

I might circle back and read it fully through.

But we still have the AMA journal of ethics article saying, to paraphrase, "WTF?"

 

[clausewitz2]

Money quotes:

"Ashby and DeMeerleer had a psychiatrist/outpatient relationship that spanned nearly nine years. Ashby also conceded that he and DeMeerleer shared a special relationship for the purposes of Petersen. The existence of this relationship triggered the duty expressed in § 315 of the Restatement and defined by the Petersen court, whereby Ashby had a duty to take reasonable precautions to protect anyone who might foreseeably be endangered by DeMeerleer's dangerous propensities.

At several different meetings, DeMeerleer informed Ashby of suicidal and homicidal thoughts. DeMeerleer never specifically named Schiering or her children, but this was not required by Petersen. Ashby knew of DeMeerleer's history of suicidal and homicidal thoughts, knew that DeMeerleer had attempted to act out suicide and retribution at different times, recognized that DeMeerleer was unstable at their last meeting, and knew that DeMeerleer had a history of noncompliance with his antipsychotic medications....

Knoll [plaintiff's expert witness]'s affidavit states that Ashby's failure to schedule additional meetings, follow up with DeMeerleer, and monitor DeMeerleer's condition was a breach of professional standards and was a causal and substantial factor of the harms that befell Schiering and her sons. The only evidence proffered by Ashby and the Clinic to rebut this contention was several affidavits from DeMeerleer's family and friends wherein they stated that DeMeerleer did not outwardly evince any indication that he would act violently. None of the affidavits supplied by Ashby and the Clinic speak to the professional psychiatric standards with which Ashby was to comply."

The outcome was the case being remanded to the trial court to actually be tried, not an immediate judgment in favor of the plaintiff.

 

[calvnandhobbs68]

Important to understand that the WA Supreme court opinion here is not saying the psychiatrist it was liable. It is reversing the trial court's summary judgement dismissing the case, saying that plaintiffs did adequately demonstrate that there was a question of medical negligence at stake and thus a tort did in fact exist.

I recommend reading the opinion, the court lays out its thinking in a particularly readable manner.

EDIT: if you read it, you see once again a key problem is that the treating psychiatrist didn't document his thinking or any kind of informed assessment. This is where the negligence comes from - they concede prediction is extremely difficult but hold that a mental health professional has to at least try.

I do think this is very ridiculously broad and they're really stretching at times. They totally delve into believing the "mind reading" thing ex:

"Additionally, if predicting a patient's dangerousness without at least some amount of accuracy was not possible, mental health professionals would not be entrusted to do so for civil commitment or sexually violent predator proceedings when such determinations can result in an indefinite deprivation ofliberty."

Not addressing the obvious questions of 1) Do these assessments actually accurately predict future violence? and 2) Are these assessments way more in depth and contain a lot more information/observations than your general outpatient psychiatric clinic? (obviously they do)

Knoll [plaintiff's expert witness]'s affidavit states that Ashby's failure to schedule additional meetings, follow up with DeMeerleer, and monitor DeMeerleer's condition was a breach of professional standards and was a causal and substantial factor of the harms that befell Schiering and her sons. The only evidence proffered by Ashby and the Clinic to rebut this contention was several affidavits from DeMeerleer's family and friends wherein they stated that DeMeerleer did not outwardly evince any indication that he would act violently. None of the affidavits supplied by Ashby and the Clinic speak to the professional psychiatric standards with which Ashby was to comply."

I do think this is the killer for them. Why had a previously violent patient with bipolar disorder not been back back in the clinic for 3 months when she basically wrote in the last note he wasn't stable? I'm not sure you're going to find any psychiatrist that states that this would be the standard of care if they haven't at least tried to schedule appointments with him or reach out to him.

I actually think the paragraph before that is a lot more "woo woo mind reading" crap. Yeah, he expressed SI/HI over the course of YEARS and didn't kill anyone until 3 months after that last appointment...was she supposed to just constantly warn anyone he was around all the time? I totally get this was just to remand this back to the trial court but as the AMA article notes, it is a supreme court opinion that is going to be used to support further cases in WA either way.

 

[Stagg737]

I think the idea that we’re required to send a letter “formally discharging” outpatients who decline or refuse further care is ludicrous unless it’s some form of court-ordered treatment or they have a guardian. These are adults with an ability to make decisions for themselves, not children.

Makes me glad my outpatient role is only a consult clinic and that my role as a consultant is clearly outlined.

 

[whopper]

Isn't this a case of psychiatrist becoming neurotic about something they shouldn't be? Lawsuits against psychiatrist are very low, and I cannot imagining getting sued because patient stopped showing up. That's insane.

No.

If you terminate a patient, or a patient decides to fire you, (or leave or whatever) unless it was something such as moving to a different area, that is already in a zone where this specific demographic the pool of patients have an increased likelihood of some type of cluster B drama.

I've had patients I haven't seen in years contact the office and demand a refill of meds, be problematic with my receptionist, and create some other type of "Karen" drama. You terminate the patient it's official. It's over. You can now remove this from your RAM.

While this type of patient is by no means a majority, I call it "Emotional Economics." If 5% of my patients were like it, and most people think 5% is very low, it's not low at all. That would mean of the on-average 75 patients I see a week, this is going to happen a few times a week. Going to work every day with a good likelihood of this happening at least once a day is draining, will hurt your ability to function, and unreasonably harm your office productivity not just in the sense of your income, but ethically in the sense that it harms your ability to see and heal patients in need of help.

How often do I have to terminate a patient because of something like the above? A few times a year. Earlier in my practice during it's formative stages it was a few times a week. What caused it to go down was when you start up you take everybody. Now, most of my patients I've had for years and the ones that fit the above demographic were pruned off.

The other counter argument is if they have a cluster-B be they're in need of help. Oh yeah sure I agree with you, but we're psychiatrists, meds don't help cluster B, we usually aren't trained in DBT therapy, and in DBT therapy one of the main modailities of care is to hold patients responsible for their actions. Often times people believe healthcare providers must always be "healing" as never tell anything distressing. We are in our place telling narcissists they have an ego-sensitivity problem. We are in our place in telling a borderline PD patient we cannot tolerate them missing multiple meetings, etc.

(IF you want to tell me how I'm such a terrible person because of the above paragraph, 1-you don't know DBT, my wife specializes in it, and holding a patient responsible for their own actions with repercussions is actually a part of that therapy. You are being therapeutic by giving the patient a repercussion. 2-IF you continue some type of treatment that you know is not appropriate such as trying to medicate a cluster B disorder with a med you are in the wrong for doing so. I've seen several psychiatrists unsuccessfully treat cluster B patients for years with no success, with the patient being misdiagnosed with Bipolar Disorder, and becoming obese of having some other problem because of the meds. Oh-but continue to tell me how it's "wrong" to not medicate a patient with a med that has no benefit on their disorder).

The last 2 patients I terminated were causing Karen-dramas. One missed 3 appointments, we called her several times, would not answer the phone and during one of our sessions was giggling during the meeting cause, "cause I'm on meth and I love it!," telling me she had intention of stopping. The other one's wife kept showing up to my office and yelling at my assistant, but after several bona-fide attempts to get her to stop, I had to tell the patient in an ultimatum that I will either get a restraining order on her, or he has to step up and get her to stop. I asked him to set up a meeting between him, her and I so we could hash it out in a well-intentioned attempt to save the treatment relationship before I terminated and he didn't do anything. (I wrote about this in another thread). He wouldn't do anything so I terminated him as a patient and she stopped showing up.

Now trying to be accommodating, there are patients who you may confuse for a problematic patient, but after careful consideration you realize there may be some extenuating circumstance. Also some selfish doctors will terminate patients simply because they are difficult, but within a realm where that patient just can't help it such as financial circumstances, they do have a cluster B but they're working on it and it is showing signs of slow improvement. This is where this is a grey area. You shouldn't terminate a patient just cause it's easier on yourself. I imposed on myself a "3 strikes your out" rule, I require of myself that I address to a patient what the problem is and give them some room to try to fix it, document it all, and follow all of the recommendations with termination letters (1 month prescription of meds, 3 referrals, send out by certified mail).

 

[vanfanal]

I think the idea that we’re required to send a letter “formally discharging” outpatients who decline or refuse further care is ludicrous unless it’s some form of court-ordered treatment or they have a guardian. These are adults with an ability to make decisions for themselves, not children.

Makes me glad my outpatient role is only a consult clinic and that my role as a consultant is clearly outlined.

Agreed that it's utter hogwash. But these who end up being dismissed from a practice for one reason or another are the very pts who have immature coping and defenses and do in fact behave as children.
As noted above, psych has some unique liability risks; the cards pt who dies from an MI is seen differently from the psych pt who harms others,

 

[vanfanal]

I was "fired" by a patient last week. Things felt off for a while, passive aggressive comments and the patient was unhappy with my setting boundaries around ongoing substance use. So things came to a head. I documented in the record that the pt said they would see one of my colleagues in clinic. Then the nurse manager also documented the request separately.

So it sounds like for completeness the group would still suggest I send a discharge letter?
Anyone care to share some example, publicly or privately.

Also, how far do you go in providing referrals? I can't expect people are maintaining lists of others accepting new pts.

 

[finalpsychyear]

No.

If you terminate a patient, or a patient decides to fire you, (or leave or whatever) unless it was something such as moving to a different area, that is already in a zone where this specific demographic the pool of patients have an increased likelihood of some type of cluster B drama.

I've had patients I haven't seen in years contact the office and demand a refill of meds, be problematic with my receptionist, and create some other type of "Karen" drama. You terminate the patient it's official. It's over. You can now remove this from your RAM.

While this type of patient is by no means a majority, I call it "Emotional Economics." If 5% of my patients were like it, and most people think 5% is very low, it's not low at all. That would mean of the on-average 75 patients I see a week, this is going to happen a few times a week. Going to work every day with a good likelihood of this happening at least once a day is draining, will hurt your ability to function, and unreasonably harm your office productivity not just in the sense of your income, but ethically in the sense that it harms your ability to see and heal patients in need of help.

How often do I have to terminate a patient because of something like the above? A few times a year. Earlier in my practice during it's formative stages it was a few times a week. What caused it to go down was when you start up you take everybody. Now, most of my patients I've had for years and the ones that fit the above demographic were pruned off.

The other counter argument is if they have a cluster-B be they're in need of help. Oh yeah sure I agree with you, but we're psychiatrists, meds don't help cluster B, we usually aren't trained in DBT therapy, and in DBT therapy one of the main modailities of care is to hold patients responsible for their actions. Often times people believe healthcare providers must always be "healing" as never tell anything distressing. We are in our place telling narcissists they have an ego-sensitivity problem. We are in our place in telling a borderline PD patient we cannot tolerate them missing multiple meetings, etc.

(IF you want to tell me how I'm such a terrible person because of the above paragraph, 1-you don't know DBT, my wife specializes in it, and holding a patient responsible for their own actions with repercussions is actually a part of that therapy. You are being therapeutic by giving the patient a repercussion. 2-IF you continue some type of treatment that you know is not appropriate such as trying to medicate a cluster B disorder with a med you are in the wrong for doing so. I've seen several psychiatrists unsuccessfully treat cluster B patients for years with no success, with the patient being misdiagnosed with Bipolar Disorder, and becoming obese of having some other problem because of the meds. Oh-but continue to tell me how it's "wrong" to not medicate a patient with a med that has no benefit on their disorder).

The last 2 patients I terminated were causing Karen-dramas. One missed 3 appointments, we called her several times, would not answer the phone and during one of our sessions was giggling during the meeting cause, "cause I'm on meth and I love it!," telling me she had intention of stopping. The other one's wife kept showing up to my office and yelling at my assistant, but after several bona-fide attempts to get her to stop, I had to tell the patient in an ultimatum that I will either get a restraining order on her, or he has to step up and get her to stop. I asked him to set up a meeting between him, her and I so we could hash it out in a well-intentioned attempt to save the treatment relationship before I terminated and he didn't do anything. (I wrote about this in another thread). He wouldn't do anything so I terminated him as a patient and she stopped showing up.

Now trying to be accommodating, there are patients who you may confuse for a problematic patient, but after careful consideration you realize there may be some extenuating circumstance. Also some selfish doctors will terminate patients simply because they are difficult, but within a realm where that patient just can't help it such as financial circumstances, they do have a cluster B but they're working on it and it is showing signs of slow improvement. This is where this is a grey area. You shouldn't terminate a patient just cause it's easier on yourself. I imposed on myself a "3 strikes your out" rule, I require of myself that I address to a patient what the problem is and give them some room to try to fix it, document it all, and follow all of the recommendations with termination letters (1 month prescription of meds, 3 referrals, send out by certified mail).

Agree with you. The last year have spent a lot of time getting rid of trouble making patients who scream and curse at staff when they keep reminding them they are way behind on copays and large balances, repeatedly leave messages that they are out of meds, and it almost seems staff are making more effort to schedule consistent follow ups then they are to avoid the former issues. With the ability to do virtual there are really no excuses not to have consistent follow ups provided payment is not a concern.

 

[Stagg737]

Agreed that it's utter hogwash. But these who end up being dismissed from a practice for one reason or another are the very pts who have immature coping and defenses and do in fact behave as children.
As noted above, psych has some unique liability risks; the cards pt who dies from an MI is seen differently from the psych pt who harms others,

I'm fine with having to send discharge letters to people we are dismissing from our practice or "firing". If we are the ones cutting off care, then I do think we really need to be providing some level of bridging care to the patients. Imo a 1-2 month supply of meds + referrals to other prescribers is completely reasonable.

I was "fired" by a patient last week. Things felt off for a while, passive aggressive comments and the patient was unhappy with my setting boundaries around ongoing substance use. So things came to a head. I documented in the record that the pt said they would see one of my colleagues in clinic. Then the nurse manager also documented the request separately.

So it sounds like for completeness the group would still suggest I send a discharge letter?
Anyone care to share some example, publicly or privately.

Also, how far do you go in providing referrals? I can't expect people are maintaining lists of others accepting new pts.

This is more what I was referring to. If the patient is leaving or firing us, imo it's ridiculous that we should be expected to send them a "discharge letter" or be held responsible for further care. I realize some cases/courts have deemed otherwise, but it's just a symptom of a larger societal problem of infantilizing patients and the need to assign blame elsewhere when something goes wrong.

If they're just moving to another colleague in your clinic idk why you'd need to send them a letter. I don't send letters, but like I said above that's only because I'm a consult clinic and the expected end point is that the patient returns to their PCP's care which is documented in the contracts with the clinics we work with before I even see the patients. When I refer back to PCP, we do send them the most recent progress note (or eval if that's all I did) with documentation that PCP is expected to take over care again.

 

[whopper]

One missed 3 appointments, we called her several times, would not answer the phone and during one of our sessions was giggling during the meeting cause, "cause I'm on meth and I love it!," telling me she had intention of stopping.

Correction: She had no intention of stopping the meth. So then I asked why see me? "My parents told me if I didn't see a doctor they'd stop paying my rent and food."

Clarifying on "emotional economics," I've had patients that literally when I terminated them, I felt freedom. Again it wasn't cause I terminated someone in need of help who was sick, but often times a patient who seemed to enjoy the toxic drama they were causing. Of course such a person is in need of help, but they will not get better unless they admit they have a problem. I've had patients that made me frustrated to the point of actually having physical symptoms. Not just me, but seriously almost everyone in my office. I've had patients I've terminated and the entire office is saying, "thank God!"

In many of those cases the person didn't even want to see me, but were forced to do so by a family member or their job, hence they didn't even want to get better. Narcissism-the textbooks are right. It almost doesn't do well with treatment. If the person identifies they have a problem they're already on the road to recovery, but if it's a problem they're not going to want to pay and spend the time to get something fixed when they don't want to get better.

 

[smalltownpsych]

Identifying and discharging toxic patients is a skill. I also wanted to add or clarify that this is more common with substance abusers and legally involved patients than my run of the mill Borderline PD type patients so Cluster B that leans more toward the antisocial is how I would put it. Also, most of the worst really are just looking to use us as an excuse to dodge or deflect from their bad behavior. I like to say that being an a-hole is not a disorder and most of my patients regardless of diagnosis can be nice and respectful and if not, then we will nit work with them. Part of a treatment relationship is collaboration and these types of patients always say or do something that we can document as to why they would be better served elsewhere.

 

[brazilianpsych]

Wait, but no one is talking about firing problematic patients. I will provide an example. Bob was fired and lost his girlfriend, he gets depressed and sees you. You start Lexapro. Bob comes back 1mo later, he is doing well. He got a new girlfriend and a new job. You make another appointment in 3mo and Bob never shows up again. How do you guys keep track of this? I am just curious, I will most definitely not going after these patients when I have my practice.

 

[hamstergang]

You make another appointment in 3mo and Bob never shows up again. How do you guys keep track of this? I am just curious, I will most definitely not going after these patients when I have my practice.

I keep a list in Excel and note the date of last visit. Periodically, I sort by that column and see if I've lost track of any patients and then decide what's appropriate for either trying to get them scheduled or closing them out. I don't want the liability of having people officially be patients of mine without me seeing them.

 

[vanfanal]

I keep a list in Excel and note the date of last visit. Periodically, I sort by that column and see if I've lost track of any patients and then decide what's appropriate for either trying to get them scheduled or closing them out. I don't want the liability of having people officially be patients of mine without me seeing them.

Interesting. This is making me re-evaluate PP. this is so different from other opt specialties. I guess it's well known that we're a neurotic bunch, but human behavior is often unpredictable and the legal system is.....well to quote from Primal Fear "If you want justice, go to a whorehouse. If you wanna get f***d, go to court."

 

[brazilianpsych]

I keep a list in Excel and note the date of last visit. Periodically, I sort by that column and see if I've lost track of any patients and then decide what's appropriate for either trying to get them scheduled or closing them out. I don't want the liability of having people officially be patients of mine without me seeing them.

What if your computer gets hacked and someone steals this excel list? Or do you put like just the pts mrn?

Sounds a lot of work tho. Not gonna lie, I don't think I will do that in the future. Very interesting tho.

 

[smalltownpsych]

Wait, but no one is talking about firing problematic patients. I will provide an example. Bob was fired and lost his girlfriend, he gets depressed and sees you. You start Lexapro. Bob comes back 1mo later, he is doing well. He got a new girlfriend and a new job. You make another appointment in 3mo and Bob never shows up again. How do you guys keep track of this? I am just curious, I will most definitely not going after these patients when I have my practice.

We can’t treat or be expected to treat patients that don’t come in for treatment. I would think the potential for a potential lawsuit in the above scenario is extremely low. I pay insurance so that I don’t have to worry about risks like that.

 

[clausewitz2]

We can’t treat or be expected to treat patients that don’t come in for treatment. I would think the potential for a potential lawsuit in the above scenario is extremely low. I pay insurance so that I don’t have to worry about risks like that.

Agreed, a lot of the aforementioned case turned on "so this established patient with a significant history of violence and homicidal ideation came to your clinic, said they were unstable and thinking about killing someone, and then for 3 months you did not attempt to do anything to arrange a follow-up appointment?"

 

[hamstergang]

What if your computer gets hacked and someone steals this excel list? Or do you put like just the pts mrn?

Sounds a lot of work tho. Not gonna lie, I don't think I will do that in the future. Very interesting tho.

I don't have patient names, just an identifier like an MRN. I also include diagnoses so I can track how much I'm seeing of everything and the spread of ages. Much of that is just for my own general interest, not sure it's useful.

It is extra work but not so awful. I imagine that most EMRs should be able to run a report that gets the same data, it's just not always obvious how to do so. My practice is actually about to change EMRs and so I might stop tracking on the side. The key is to start this, whether in Excel or in the EMR, early before you have too many patients and not enough time.

Besides doing this for my own neuroses, it is also useful for getting patients re-engaged sooner. Many patients who have disappeared stay disappeared, but some will schedule a follow up shortly after I reach out even though they weren't reaching out on their own. If you are paid per patient seen in some way, you might be incentivized to do this periodically. You might also be able to see a patient before a crisis and not just after something terrible happens and so they then remember to call.

 

[TexasPhysician]

Would you see the patient again?

In my state, a patient can leave for 5 or whatever years and then decide to return for a follow-up. Without a discharge letter, you can’t just turn them away without risking abandonment penalties. You can require a re-eval or being seen before refills are given. You can’t just say no. However, if you send a termination letter offering availability for 30+ days or confirm their termination of you, you are finished/protected from this issue.

I’m sure this varies state by state.

 

[Bartelby]

I agree with TexasPhysician. Closing out the patient's chart might provide some small amount of liability protection for those who just fall off, but given that the patient is not following up with you I think the liability risk is low. More important is whether you are leaving an open door for them to re-add to your schedule. If you never actually terminate care with the patient and you don't have a policy spelled out in any agreement they have signed, the patient might just re-appear including when they are in crisis. If you are not comfortable with that, notifying the patient that you are closing out their chart makes sense.

 

[whopper]

We can’t treat or be expected to treat patients that don’t come in for treatment. I would think the potential for a potential lawsuit in the above scenario is extremely low. I pay insurance so that I don’t have to worry about risks like that.

Exactly. We don't have a private detective who follows up on patients.

There are situations where patients need this type of follow-up. It's called a case manager. Most (and I mean most in the sense that pretty much no) private offices have case managers, nor will private insurance pay for them. Patients who need case managers will usually be on Medicaid).

You're not expected to keep every single person you've seen in your head, nor does the professional standards or the law expect this of you. If they don't come back that's on them.

BTW the line, "We don't have a private detective who follows up on patients." I've actually had to say this when asked questions like, "my son hasn't seen you in 5 years and he was in need of help!"

 

[whopper]

Was writing this in a different thread, but this applies better on this thread.

Just on a rant, I remember a patient's mother, who I terminated, complained to the medical board about me, because they wanted me to refill Clozapine (again pt was terminated and months before the request, at that time got a new psychiatrist), and the patient refused to do labs. Further, the patient or his mother couldn't bring up anything I did that was wrong (illegal, unethical, or below the standard of care) other than "Dr Whopper is an uncaring doctor." The board sent me a letter asking me to explain myself.

The reason why I terminated the patient was because there was no release for the mother, the patient pretty much didn't give any care about treatment, he refused to sign a release, and she would berate my assistant and I for things that were not our fault. E.g. the pt said he had no mental illness, so the mother was mad at me because I couldn't convince him he had a severe mental illness. (I didn't learn the Jedi Mind Trick in residency).

Given that it was obvious the patient was terminated (so there was no treatment relationship), and that the patient's mother (the patient never requested it himself) wanted Clozapine without labs, I told the patient and his mother there's no treatment relationship, and if they wanted medication to go to their current doctor or go to the ER cause they'll need labs (they wanted the Clozapine ASAP). I kept thinking to myself WTF is wrong with this board? They should've thrown the case out before even bothering me. I told the board this was a "prima facie case." In the law that means the court can tell upfront the case has no merit so it's thrown out so no one's time is further wasted. The patient even admitted they had no relationship with me, had a new doctor, and didn't want to do labs for Clozapine, and I told the patient to go to their current doctor or ER.

In any case, yes I was acquitted, but only after I had to get a lawyer, and spend hours to draft an explanation on a case that already was obviously prima facie. Oh well whatever.

Point is, you should terminate any patient where there is just slight suspicion there could be future drama after they don't come back. Your fiduciary responsibility to deal with their BS is now done. IF that same person contacts you back later, and wants to work with you in a non-toxic manner you still have the right to restart a treatment relationship, but now you can cleanly tell them to leave you alone and not deal with their toxic drama.

(Yes I know schizophrenia is a terrible disease for anyone, and the mother was in a terrible situation, but she was getting mad at me for doing things I couldn't do such as violate HIPAA, and not use the Jedi Mind Trick).

A few months later an academic institution took over this former patient's care, and the institution contacted my practice and every psychiatrist at the location begging to take this guy. We all said no. Then they begged again a few weeks later. I can only imagine the drama going on.

 

[clausewitz2]

Was writing this in a different thread, but this applies better on this thread.

Just on a rant, I remember a patient's mother, who I terminated, complained to the medical board about me, because they wanted me to refill Clozapine (again pt was terminated and months before the request, at that time got a new psychiatrist), and the patient refused to do labs. Further, the patient or his mother couldn't bring up anything I did that was wrong (illegal, unethical, or below the standard of care) other than "Dr Whopper is an uncaring doctor." The board sent me a letter asking me to explain myself.

The reason why I terminated the patient was because there was no release for the mother, the patient pretty much didn't give any care about treatment, he refused to sign a release, and she would berate my assistant and I for things that were not our fault. E.g. the pt said he had no mental illness, so the mother was mad at me because I couldn't convince him he had a severe mental illness. (I didn't learn the Jedi Mind Trick in residency).

Given that it was obvious the patient was terminated (so there was no treatment relationship), and that the patient's mother (the patient never requested it himself) wanted Clozapine without labs, I told the patient and his mother there's no treatment relationship, and if they wanted medication to go to their current doctor or go to the ER cause they'll need labs (they wanted the Clozapine ASAP). I kept thinking to myself WTF is wrong with this board? They should've thrown the case out before even bothering me. I told the board this was a "prima facie case." In the law that means the court can tell upfront the case has no merit so it's thrown out so no one's time is further wasted. The patient even admitted they had no relationship with me, had a new doctor, and didn't want to do labs for Clozapine, and I told the patient to go to their current doctor or ER.

In any case, yes I was acquitted, but only after I had to get a lawyer, and spend hours to draft an explanation on a case that already was obviously prima facie. Oh well whatever.

Point is, you should terminate any patient where there is just slight suspicion there could be future drama after they don't come back. Your fiduciary responsibility to deal with their BS is now done. IF that same person contacts you back later, and wants to work with you in a non-toxic manner you still have the right to restart a treatment relationship, but now you can cleanly tell them to leave you alone and not deal with their toxic drama.

(Yes I know schizophrenia is a terrible disease for anyone, and the mother was in a terrible situation, but she was getting mad at me for doing things I couldn't do such as violate HIPAA, and not use the Jedi Mind Trick).

A few months later an academic institution took over this former patient's care, and the institution contacted my practice and every psychiatrist at the location begging to take this guy. We all said no. Then they begged again a few weeks later. I can only imagine the drama going on.

I take it they didn't accept the simple line 'if I write it, the pharmacist will not dispense it, because it is illegal under federal law without the labs'?

 

[whopper]

Pretty much. We explained it was black and white that we were not even allowed to write the prescription due to the lack of labs. We were nice the first about 8-20 times the patient's mother was screaming at us. After that we said we'll going to have consider a restraining order.

The same patient's mother, when I first started with the guy, complained that I was inept because he was just discharged from the hospital, and I didn't have his records. I told her this was the first time I was seeing her son, and that it's the hospital's responsibility to send me the records, and they didn't send it. Of course we requested after we saw him the first time, but that was a major complaint she had in her complaint to the board. Despite the explanation, she spent several paragraphs stating only an inept and terrible doctor wouldn't have the records ahead of time.

For this reason, I added the rule that the patient themselves, not the social worker or family has to setup the appointment. Every single time the social worker setup the discharged patient's appointment, the patient either didn't show up, and/or we almost never are given their hospital records. Each single time the patient told me the social worker told them the records would be sent to me.

I know for a fact that the patient in many of these cases, did tell the social worker to have them send me the records. I also figure I know what's going on. Social worker asked medical records to send it out. MR (Medical Records but they're also mentally re____) told them they would, and then just hung up the phone and went back to watching Price is Right on their mini TV on their desk. I know this cause every single hospital I worked at the MR lady never did her job, was obese, and was watching what I call unemployment TV (Divorce Court, Judge Judy, Price is Right, with commercials for some type of beauty salon school). The manager of MR never kept track of the requests they got, how many were sent out, if the employee didn't do their job they weren't punished, and if they did do their job they weren't rewarded.

I've worked in over 10 hospitals and each MR person fit the above description, except the obesity thing that was 8 out of 10 of them.