What's your policy on taking back a non-compliant patient who fried you?

[sprawl2]

So I have this patient who agreed to a trial of psychotherapy and I would mange her medications during the course. She has been struggling with compliance - not showing up, canceling, despite knowing my policy. She fired me eventually. A month later, she called my office, requesting to re-start psychotherapy. However, I am not even taking in new patients for follow-ups anymore because I will soon go on pat leave starting in May (which she is well-aware of) nor do I have room within my standard office hours to take her back.

What would you do in my shoes?

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[deleted480308]

I would not accept them

 

[NickNaylor]

However, I am not even taking in new patients for follow-ups anymore because I will soon go on pat leave starting in May (which she is well-aware of) nor do I have room within my standard office hours to take her back.

What would you do in my shoes?

Sounds like there’s really not a decision to be made...

 

[sprawl2]

Thanks for the replies.
Ethically, those are reasonable responses, right?
I am not legally obliged to restart therapeutic relationship immediately once fired by the pt. I believe that they may go through the same route of re-referral from their family docs if they choose to.

 

[WisNeuro]

If you made reasonable follow up referrals if asked, you're ok. It only gets dicey if the patient is in crisis when you are terminating.

 

[orbitsurgMD]

So I have this patient who agreed to a trial of psychotherapy and I would mange her medications during the course. She has been struggling with compliance - not showing up, canceling, despite knowing my policy. She fired me eventually. A month later, she called my office, requesting to re-start psychotherapy. However, I am not even taking in new patients for follow-ups anymore because I will soon go on pat leave starting in May (which she is well-aware of) nor do I have room within my standard office hours to take her back.

What would you do in my shoes?

Typically, if you are "fired" you do not have to do anything, including take the patient back if they change their mind. It is presumed when they initiate the termination that the patient has already made acceptable arrangements for followup care that they want (or don't want, whichever). The patient doesn't get to un-ring the bell.

 

[hamstergang]

However, I am not even taking in new patients for follow-ups anymore because I will soon go on pat leave starting in May (which she is well-aware of) nor do I have room within my standard office hours to take her back.

I wouldn't take back a patient that fired me -- don't want to have to deal with that. But if you don't have space for more patients, why is this even a question worth asking?

 

[whopper]

When building my new practice I've terminated quite a few patients. As time went by less terminations cause I started getting a more reliable patient population cause the bad ones were pruned off.

I don't feel bad in pretty much all the terminations. E.g. 1 person failed to show up 3x, I let her go the no show fee once, she changed her phone number and never told us so when we called her she never answered, when we finally got her new phone number she didn't set up her VM so we couldn't leave messages...yada yada yada.

I offered to have her SKYPE my office cause she told me transportation was sometimes a problem. She still didn't show up for the SKYPE call.

You think I'm going to feel bad about this? It's not my fault.

In hindsight some of those people I terminated lessened my liability. Non-compliant patients are riskier patients especially if off meds they known to have severe symptoms. If someone, for example is non-compliant, has a bad outcome (and it's not your fault but theirs) sometimes their friends, families, even the patients themselves want to blame you. All they can think of is bad outcome + doctor = doctor's fault. Yeah you'll win if it goes to court but who wants to waste them time? If you terminate and do it the right way (follow the state's rules, gave them chances) well they're out of sight and now out of mind. It's over you don't have to worry about it anymore.

I don't terminate patients easy. I give chances but after they've failed the chances-3 strikes you're out and I don't feel bad nor will feel bad on my end for me. I will feel bad in the sense that the patient could've done better but it's their responsibility, not mine, to at least follow the directions.

 

[Shikima]

When building my new practice I've terminated quite a few patients. As time went by less terminations cause I started getting a more reliable patient population cause the bad ones were pruned off.

I don't feel bad in pretty much all the terminations. E.g. 1 person failed to show up 3x, I let her go the no show fee once, she changed her phone number and never told us so when we called her she never answered, when we finally got her new phone number she didn't set up her VM so we couldn't leave messages...yada yada yada.

I offered to have her SKYPE my office cause she told me transportation was sometimes a problem. She still didn't show up for the SKYPE call.

You think I'm going to feel bad about this? It's not my fault.

In hindsight some of those people I terminated lessened my liability. Non-compliant patients are riskier patients especially if off meds they known to have severe symptoms. If someone, for example is non-compliant, has a bad outcome (and it's not your fault but theirs) sometimes their friends, families, even the patients themselves want to blame you. All they can think of is bad outcome + doctor = doctor's fault. Yeah you'll win if it goes to court but who wants to waste them time? If you terminate and do it the right way (follow the state's rules, gave them chances) well they're out of sight and now out of mind. It's over you don't have to worry about it anymore.

I don't terminate patients easy. I give chances but after they've failed the chances-3 strikes you're out and I don't feel bad nor will feel bad on my end for me. I will feel bad in the sense that the patient could've done better but it's their responsibility, not mine, to at least follow the directions.

Do you send a letter with alternatives once you terminate? Do you place any kind of formal termination summary in your chart?

 

[orbitsurgMD]

Do you send a letter with alternatives once you terminate? Do you place any kind of formal termination summary in your chart?

You do not need to specify reasons for termination or suggest alternatives if you terminate. Some people suggest calling the local hospital physician referral line or county medical society for names of doctors accepting new patients, but you don't have to do either. When you initiate the termination, you need to offer some kind of bridge coverage and ideally with specific terms for that coverage and have in place enough medication prescribed for that same period. You can, for example, say you will cover emergencies only and only through the emergency room at your hospital but no routine services and no office appointments during that bridge period, so there is a clear understanding that you are not doing business-as-usual during the transition. Most people give a month bridge but that varies by state and in some places it can be less. It is a good idea to be specific in your letter as to what date the bridge coverage ends ("in any event, not after x-date.") In cases of serious breach of the doctor-patient relationship, termination can be immediate and complete; that should be reserved for only the most serious events, criminal activity against the provider, or threats of harm to the provider or his staff. In those instances, I also suggest seeing an attorney about additional action including a restraining order by a court.

Letters should be sent one copy by first-class mail and one certified. Keep a copy in the patient record. Flag the file in the chart and your practice management program that the patient was terminated so if someone else is doing your scheduling they won't re-schedule them later.

 

[hamstergang]

You do not need to specify reasons for termination or suggest alternatives if you terminate. Some people suggest calling the local hospital physician referral line or county medical society for names of doctors accepting new patients, but you don't have to do either.

This varies by state. In NJ, you're required to "make reasonable efforts to assist the patient in finding another provider and the transfer of the medical records" if requested.

 

[splik]

never let patients fry you. half-baked is acceptable if they are especially grandiose and kleptomaniacs might try to poach you, but never EVER let a patient fry you.

 

[OldPsychDoc]

never let patients fry you. half-baked is acceptable if they are especially grandiose and kleptomaniacs might try to poach you, but never EVER let a patient fry you.

Disappointed that it took 12 posts and five days for someone to come up with this...

 

[thoffen]

Disappointed that it took 12 posts and five days for someone to come up with this...

I was gonna but it wouldn't have been as good as splik's.