Toxic Patients

[ShuperNewbie]

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Question to the group here esp the old guard:

How do you guys deal with extremely difficult patients? / How often have you fired patients?

I've got this patient who's got a very clear personality disorder, calls our front desk every few minutes on the daily, screams at staff on a regular basis, dictates his own care, threatens self harm when he doesn't hear back from us within minutes (had to call the cops on him a few times), demands infusions that his naturopath recommends to him... the list goes on. I like to consider myself a pretty patient dude but I'm starting to reach the end of my patience with this patient (pun fully intended). Craziest thing is he doesn't even have cancer (I'm seeing him for a heme problem) and he's just taking a disproportionate amount of time away from patients who are -actually- sick. I've tried to offer him second opinions but he kind of just latches on to us because, despite his behavior, we (unfortunately) fall on the good side of his split. Honestly just looking for any sort of advice at this point.

 

[HemeOncHopeful19]

Honestly I am young but have had situations like this but they usually have self corrected in the ways you have already tried (getting them to go elsewhere).

I feel like in this case I’d go to my boss/CMO and tell him “we need to no longer see this patient for safety/well being of the staff, what is the process that our legal department has come up with for this situation?”

If that did not work (in my PP group I think that would be plenty) I would probably respectfully but firmly state something to the effect of “ok, if you are not willing to help then I again am not comfortable caring for this patient and I will plan to transfer their care to you at their next follow-up.”

If that also did not work I’d start looking for a new job because life is too short to work somewhere that those two options don’t work IMO

I also make sure to try and document the **** out of my notes because these types of patients tend to not follow up with referrals for biopsies or surveillance scopes/scans etc.

Edit:
Also depending on the issue I might just give them a 1 year follow-up? I feel like at least in my practice because I’m so used to seeing my cancer patients every 1-2 weeks that I tend to see my benign heme patients way more often than any other specialist sees their patients for CKD/GI/Endocrine issues

 

[CopaceticOne]

I’m not hemeonc, but had one of these type patients on my clinic panel during residency. The good news for me was that this wasn’t a new situation for the health system to deal with. So they provided the following guidance:

Clear boundaries:
1) There was a response policy that stated do not expect any reply from phone calls / MyChart messages for at least 24-48 hours.
2) There was some policy language about frequency of calling clinic. I have no clue what the number was, but if it was exceeded the phone people defaulted to launguage of needing ‘for issues to be addressed during an appointment, shall that be scheduled?’ (They would only offer standard open clinic slots)
3) Behavior towards clinic staff was strict. No yelling at or threatening staff.

Consequences:
1) During the next followup clinic visit which was (scheduled for a long established time slot) I laid out the policies and explained that if these were violated patient would be discharged from my panel. There was a X strike system, kinda like the general no-show policy.
2) When they initially violated, as their prior behavior showed they would, the staff just followed the rules. I called them the next day (using the 24hr timeframe) and calmly answered their concern then highlighted that they had gotten their first strike. Sent a letter (physical and MyChart) documenting the violation and the future consequences for misbehavior.

Things got better after the strict behavior, still annoying but not the huge time stuck it had been.

With your patient’s threat of self harm, don’t feed into that behavior and immediately call back. Take the threat seriously from a patient safety standpoint and do the appropriate community mental health outreach / EMS / police wellness check thing.

If the patient has a psych doc reach out to confirm with them what they can help with in managing these problem behaviors. If the patient does not have a psych doc, make sure to clearly make an outpatient consult referral and state why (your sincere concern about their safety and the not normal behavior of self harm).

Sorry you’re dealing with this. Beat of luck.

 

[ShuperNewbie]

Thanks @HemeOncHopeful19 and @CopaceticOne for the incredibly thoughtful and sound advice. Apart from being really helpful, it also makes me feel a little less lonely hearing other peoples' experiences with this. Thanks for taking the time to respond 🙂. I'll try all of this.

 

[bobsmith]

Clear boundaries:
1) There was a response policy that stated do not expect any reply from phone calls / MyChart messages for at least 24-48 hours.
2) There was some policy language about frequency of calling clinic. I have no clue what the number was, but if it was exceeded the phone people defaulted to launguage of needing ‘for issues to be addressed during an appointment, shall that be scheduled?’ (They would only offer standard open clinic slots)
3) Behavior towards clinic staff was strict. No yelling at or threatening staff.

+1 to this

I had a patient who would repeatedly call at all times of the day/night and would always try to bypass our nursing triage and demand to talk to the on-call doctor immediately.

The doctor who had this patient before me basically enabled all of this behavior (essentially would add the patient on for visits all the time, return calls immediately at all times of the day, etc). Due to this and an inconsistent response from our nursing staff / on call providers, this patient just kept getting through and kept thinking that was OK. Literally hours of time spent getting nowhere with this patient because the same concerns would just come up again a week or two later.

I did essentially what was said above and laid out very clear boundaries, and also, as above, cleared it with our management to make sure there were no issues if I dismissed this patient from my clinic if the rules were not followed.

...this patient then promptly left my clinic and found a new provider.

 

[dozitgetchahi]

Question to the group here esp the old guard:

How do you guys deal with extremely difficult patients? / How often have you fired patients?

I've got this patient who's got a very clear personality disorder, calls our front desk every few minutes on the daily, screams at staff on a regular basis, dictates his own care, threatens self harm when he doesn't hear back from us within minutes (had to call the cops on him a few times), demands infusions that his naturopath recommends to him... the list goes on. I like to consider myself a pretty patient dude but I'm starting to reach the end of my patience with this patient (pun fully intended). Craziest thing is he doesn't even have cancer (I'm seeing him for a heme problem) and he's just taking a disproportionate amount of time away from patients who are -actually- sick. I've tried to offer him second opinions but he kind of just latches on to us because, despite his behavior, we (unfortunately) fall on the good side of his split. Honestly just looking for any sort of advice at this point.

At every job I’ve worked thus far, verbally abusing the staff is a one way ticket to being discharged from the clinic. So if this guy is screaming at staff on a regular basis, he should have already been fired as a patient. Follow the law per your state for how you have to do this (a notification letter and 30 days of medication is typical, such that they can find a new provider). I would be surprised if your admin gives you pushback on this - even the godawful admin at my first lousy job was ok with me firing pts that did stuff like this.

 

[Plutarch02]

It is still your right to end a patient physician relationship you can cite something generic like irreconcilable differences provide referral to another provider and 30 days of medication.