Sunday, February 5, 2012

When Should a Doctor Fire a Patient?

His signature is, 'Your're Fired!'.
Photo by Gage Skidmore

Rarely, I have fired patients from my practice. Why do I do this? You might think that we send out termination letters to patients who haven’t paid their medical bills. We don’t. We try to work with these folks and will keep seeing them as long as they are making the barest effort to address their financial responsibilities. If they refuse to make any payment, or won’t return our billing office’s phone calls, or are hostile to our staff. then we may withdraw as their physician, provided there is no medical urgency present. Our office will see patients who have no medical insurance so that these folks have access to medical care.
The process of terminating a professional relationship between physicians and patients is well presented in EverythingHealth, one of my ‘must read’ medical blogs.

The more typical reason why we fire patients from the practice is because of continued behaviors and actions which place them and me at risk. For example, if a patient with cirrhosis, a severe liver condition, will not keep scheduled medical appointments, we may have to cut him loose. I can’t accept the responsibility for his health or a medical catastrophe if the patient is conspiring against himself. If a patient won’t take his medicine for Crohn’s disease, and it’s not a matter of affordability, then I need to reassess whether I want continue serving as his gastroenterologist. If he ends up in an operating room to face emergency surgery that could have been avoided had he followed medical advice, could he convince an attorney with some tortured logic that my care was inadequate? I can imagine the deposition with an attorney asking me pointedly:

“Doctor, did you know that your patient wasn’t taking the medicine because he was worried it might cause side-effects? Why doesn’t your office note mention this?”

“Doctor, why didn’t you write the patient a letter after his office visit encouraging him to take his medicine? Don’t you think this might have helped? Was a 44 cent stamp to much to invest in your patient’s health?”

“Doctor, if it was so important that your patient take his medicine as prescribed, why didn’t you take 2 minutes to call him to reinforce the advice? Were you simply too busy?”

“Doctor, the patient never knew that failure to take the medication could result in a colostomy. Why doesn’t your office note specifically document this risk? Of course, had my client known this, he would have swallowed the medicine with zeal and enthusiasm.”

Of course, we care for patients who reject our medical advice. Medical care is a collaborative process and patients are ultimately charged with making the decisions, although many are happy simply to accept our guidance. This acceptable practice is distinct from, “I’m not taking any high blood pressure pills and you can't make me!”

So, there are times that we fire patients from our practices. Perhaps, some readers can offer comments explaining why patients decide to fire us.  

34 comments:

Psych Client said...

well this is an interesting topic. I've gone through more than a few psychiatrists because the side effects of many mood stabilizers and antipsychotics have resulted in me gaining 45 pounds and they don't seem to care and try medicine changes while I am working in a high level position. its affecting my performance so the last psychiatrist suggested coming off vyvanse the one drug keeping me working. so now I don't have him I fired him and need to find a Dr that can treat both bipolar and my add. but this is hard to find. my bipolar is minor level two mostly depressive. I feel lost and alone. seroquel has ruined my body and I'm embarrassed to be seen in public. I am a complex case but I dowhatever these doctors say but they don't hear me

Toni Brayer, MD said...

Psych Client: Try to find a psychopharmacologist to adjust your medication. I feel for you with the weight gain and difficulty finding the right combo but keep trying to find a physician who can handle complex medication issues.

Dr Kirsch: Thanks for the nice shout out. You are right on with your examples of how physicians can be sitting ducks in a courtroom. Patients who put themselves at risk also are risky for doctors in ways most people would not think about. Thanks for a great piece.

Ian Random said...

It sounds like you are a real good doctor to continue to see folks without due compensation. Next time someone complains about doctors only being in it for the money, ask them how they would feel if a client didn't pay them for their services. I believe there is one case where a doctor cannot see a patient that you failed to mention. When a lawyer is scaling up a pill lawsuit, they initially sue the prescribing doctor. I wish that every doctor would attach a bill for legal services incurred when that happens to the patient.

Anyway, I find myself on the verge of firing my doctor, if he doesn't change a treatment that isn't working. I feel I need, ironically enough, a doctor in your speciality. But just like me with my doctor, I feel a doctor should have no qualms about firing a patient.

Anonymous said...

At first read, I was initially negative regarding your attitude towards noncompliant patients. After further consideration I understand that in our litigious environment, doctors can be at risk when patients don't follow a proscribed treatment plan.

I am however, as a patient, frustrated by doctors who are dismissive of my attempts to engage in an educated discussion regarding my concerns and attempted inputs. Said doctors would like to give medications (often from free samples) without a discussion of potential side effects or just a wave of the arm and a don't question me attitude.

When you consider the amount of information that medical science does not know, particularly on individual levels vs. generalized population outcomes I find this difficult to deal with. In reference to your concierge type plan, I can understand why one would choose to see a doctor who is actually interest in me as a patient, not a number or a member of some vast generalized population.

Thanks for your thoughts of all here. I think it is a discussion that needs to happen more often!

Anonymous said...

Well, I never returned to one because he said he would not spend money on me in order to diagnose what turned out to be a complete traumatic tendon rupture - resulting in multiple surgeries and a poor outcome. And another one who scolded, berated, and chastised me for daring to take a stand, stating "Who do you think you are?" because after all "I was just another middle aged woman."

Renoliz said...

I still remember the doctor that wanted to talk about my seizure meds while I was completely naked for a gynecological exam. I told her I wanted to talk about that with my clothes on.

She then insisted that I get a mammogram for a baseline at the age of 40 or 41 and I said that I didn't think mammograms were appropriate at my age and with my history. She told me it me my fault if I died.

The next doctor treated me like a complete nutcase because I was twitching [my eyebrow, my toe, my gut]. Geez, you middle aged women are just dumb, nervous wrecks.


In the meantime I had a swollen gland in my neck which the specialist said was caused by my ears being too clean. It turned out to be my parotid gland. He then told me if I had it operated on I would be "deformed for life". I looked it up online and found out it needed to be taken care of so I found another physician who successfully operated me. I am not deformed although I do have a bit of a scar on my jaw line.

I finally found a nice physician assistant who listened to me. She didn't cure me but having someone nice and smart to talk with did help. I started taking B vitamins and the twitching went away after several months. I quit taking the B vitamins because I forgot to for several months and the twitching was coming back. So, I started taking them again and the symptoms went away again.

Michael Kirsch, M.D. said...

Appreciate comments. After 20 years of practice, firing a patient is a very rare event. Physicians (and patients) work to make the relationships succeed. Not surprisingly, there are at least 2 sides to every story, so patients and physicians may not agree on the circumstances that led to the parting.

Cynthia Taggart said...

I believe it would be great if doctors fired more patients. In they were forced to seek alternatives, for example, they might not suffer so much from their prescription drugs. "Rackateering in Medicine" is such a wonderful book that should be on every patient's must read-list. In fact, it should be required reading in high school. We would save so much money in healthcare if physicians just stuck to "catastrophic care only," and people flew to Canada or China for "systemic" issues. I don't know how doctors can have any pride in their work when all they do is write prescriptions all day.

Andrew Price said...

When I first read your post I have to say I strongly disagreed with what you had to say. But after rereading it I have to say I still disagree, but I understand why. You can read my rationalisations here:
http://shakesandstones.blogspot.com.au/2012/02/should-doctor-be-allowed-to-stop.html

I enjoy reading your blog and I hope you appreciate my comments. Cheers, Andy

Andrew Price said...
This comment has been removed by the author.
Michael Kirsch, M.D. said...

Cynthia, I agree that many physicians wrote too many prescriptions. It is also true that too many patients demand them. Thanks for your commment, Andy. Hope to see you back on the blog.

mikki wolfberg said...

I have fired many Drs. over the years. I generally fired them because they were not listening and I or family members were treated with disrespect. I agree with the comments that having someone who will listen to you and engage in a meaningful discussion about options is extremely important. There are almost always various ways to treat ailments. I like to be presented with the options, the long term effects, side effects, etc. and being given the opportunity to make a decision. Thanks for writing Dr. Kirsch. You bring a much needed personal touch to the medical profession.

Anonymous said...

Thank you Dr. Kirsch for your reply to my post. You stated that patients "ask" for prescriptions and that is the reason they are dispensed. But the article "When Should a Doctor Fire a Patient?" is arguing whether a doctor should stop seeing a patient if he/she does not do what the doctor prescribes for his/her health. Question: Why, then, would the doctor simply provide patients with a prescription simply because they ask for it? Moreover, in my case, I wish the doctor did fire me; he told me my symptoms were all in my head when I had a burst appendix. The problem I faced after he "fired" me was that doctors after him would not help me either. It is water under the bridge, but I ended up sending my medical reports to a doctor in China and got help and I am doing quite well today.

Anonymous said...
This comment has been removed by a blog administrator.
Michael Kirsch, M.D. said...

Mickey, you sound like a stellar patient, informed and empowered. The anonymous commenters asks, "Why, then, would the doctor simply provide patients with a prescription simply because they ask for it?" To respond adequately would take an entire blog post. Patient demand fuels health care costs. With regard to antibiotics, many patients are convinced they are needed even when they have viral infections/colds. It can be difficult or impossible to convince them otherwise. Refuse to prescribe and these patients may fire the doctor. I'm not condoning the practice, but for many physicians it's easer to write a script than to spend 15 minutes trying to convince the patient that ATBs are not needed.

Anonymous said...

Michael,

Sorry I missed the discussion. Enjoy your explanation of why doctors fire patients, and expect you've been bombarded with reasons why patients fire doctors.

I wish the issue were more black and white. As a lay person, I respect the education and training and sacrifice that accompanies the acquisition of the M.D. But I resent that some doctors seem to think this sets them totally apart from the hoi polloi.

I was recently asked what I most wanted in a doctor, and without hesitation, my response was "one who listens, who respects my anecdotal revelations, and who PARTNERS with me.

It's easy to make all these issues black and white: doctors do the bidding of big pharma vs. patients, duped by TV ads DEMAND drugs. Long life leads one to the conclusion, however, that medicine--both from the practicing end and the receiving end--comes in many, many shades of gray.

BTW, my husband was 'fired' by his endo (at the time the big switch from natural insulins to rDNA-synthetic insulin occurred). Without discussion of why synthetic insulin was problematic for hubby, the MD merely stated: "If you don't trust me (no evidence or discussion involved), find yourself another doctor. Fortunately, THAT decision had already been made by hubby.

Thanks for the discussion . . . it's one that needs much exploration by both the givers and takers of medical intervention.

Melody

Michael Kirsch, M.D. said...

Melody, appreciate your thoughtful comment. Agree that listening on both sides is critical is is often in short supply. Please visit again.

Anonymous said...

Absolutely doctors should have the right to dismiss a patient who simply will not work with them.

I would like to think this is a rare exception, though, and that most of the time the issues can be worked out when both parties take the time to listen to each other.

It might surprise you to know that at the moment I'm terrified my doctor will dismiss me. Why?
Because the communication between him and his nurse doesn't seem to be very good (don't know whose fault it is and don't care), and I keep getting conflicting messages.

Doc: We're going to adjust this prescription to a higher dose.
Nurse: OMG, what do you think you're doing, taking a higher dose?
Doc: I want you to follow up with labs in 3 weeks.
Nurse: Why are you at the lab? We don't have an order for you.

I've tried to set the record straight with her, to no avail. The followup labs have not been done, and I'm afraid I'm going to get dinged for it. I'm also supposed to make a followup appt. and I haven't done that either, because right now I'm feeling confused and jerked around, and I don't want to show up in his office and have everyone wondering, "Why on earth are you here?"

Does this make me noncompliant? I'm not sure the doctor is aware of the extent of the issues I'm having with his nurse. If I complain, even if I'm polite, does that permanently label me as whiny and difficult? I'd like the opportunity to discuss it with him in hopes of improving the situation with his nurse, but I don't know if that opportunity is ever going to happen.

Docs are in the power position. It behooves them not to let the axe drop until they have a good understanding of what's really going on with the patient.

Megan Campbell Smith said...

How to find a good doc = How to be a good patient. It's about relationship building!

I am thrilled to find so many people engaged in the question of what makes a good doctor-patient relationship.

If you want to participate in a beta media project addressing the Doctor-Patient relationship - please follow me @mentellemedia

Learn about our work with doctors at md-update.com. Thanks, and let's stay in touch!

dianeNYC said...

On the flip side, fired my physician. He was overly aggressive with treatment, with no regard for my holistic self, killing fleas with (surgical, pharmaceutical) sledgehammers so to speak, lest he leave himself vulnerable to a suggestion of not trying hard enough should the condition recur. I suffered needlessly, to protect his ass.
He had a bad case of Me Tarzan You Jane as well.

Cynthia Taggart said...

Don't you miss the doctor whose face you cannot recall, the one you stayed with for years and who did the simple, commonsense things?

Anonymous said...

Dr. Kirsch, that's very true but what are your rights as a patient? My Dr's office called today saying she was terming me for non payment of what my insurance didn't pay, however, I made arrangements to pay @ my follow-up on 6-8-12. I don't have to see her very often & I have no problem paying my bill, I was just unemployed & in school. I think it's so unfair because now I have to find a new Dr comfortable prescribing my anxiety meds. If your Dr is dishonest with you, u'll never know the truth.

Anonymous said...

I recently was fired from my Pediatricians office because we missed a few appointments over the course of four years. We had called and canceled and left a message but they said they did not receive it. We canceled the last one because my child had a fever and we didn't want them getting shots while they were sick. I received a certified letter stating that we should seek care elsewhere and they would only see my children for sick visits. I then received a letter saying I couldn't miss one more appointment. It was as if the left hand didn't know what the right hand was doing in this office. I found this letter offensive and tried to discuss it with the office manager. I was basically told that when I had my old insurance they payed for a missed visit but now that I am on NJ Family Care they can't charge for the missed visit. I can not help but think this is about money and not about patient care as it should be. Although this is an inconvenience, I realize I do not want my children seeing a doctor/doctors who have such a policy. It was never intentional to miss any appointments but due to the economy and the size of our family things happen, schedules change and we did call and leave a message. I think this type of behaviour from a medical professional is dispicable.

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Pearl said...

My doctor fired me because I was too demanding. I suffer from Lupus, HTN, DM, several bulging disc. I didn't ask but for a referral and MRI to see a specilist and I got the boot. For many months I have tried to make an appointments with him for months and even had to fax him to tell him what was going. I finally had to go in to because of severe pain and saw the FNP who was rude and the experince was horrible. I finally got to see him and he dimisses me from his practice because I am too demanding. We had a very good relationship at least I thought. I am very grateful that I am a nurse because I strongly feel that all patients should have some knowledge about there illnesses. Was I asking to much??

Cynthia Taggart said...

Andrew Price - are you complimenting me on my blog, or are you complimenting the creators of this blog. My blog is better.

Pearl,
It is a good thing he fired you. You don't want to be with that animal any longer.

Hotspur Writing said...

Medical Professionals seem more concerned with prescribing unnecessary preventive medicine procedures than attending to their customer's needs ( patients ). Going to the Doctor is like walking past a Side-Show at a Carnival or strolling down the Red-Light District at the tip top of midnight; constant "Selling" of services unwanted or not needed. Medical Professionals mostly talk but rarely listen. I'm ADD and must go to get my prescriptions filled. A visit to the Doctor's is listening to a bad Used Car Salesman selling me a Chevy with 300,000 miles on it. The Customer is treated like the business owner and the Doctor believes he\she is the customer. I've only seen it decisively in two Professions; Academia and The Medical Profession. I've advised my children to stay away from both Professions as the two-Medical and Academia-are mostly filled with Self-Absorbed Hucksters.

Michael Kirsch, M.D. said...

@hotspur, which professions would you endorse for your kids?

Anonymous said...

I have never fired a patient for non-compliance but do fire patients for being repeatedly belligerent as well as not adhering to agreed upon contracts in regards to the use of chronic narcotics (calling for multiple lost prescriptions, early refills, getting narcotics from multiple doctors, and even one patient who admitted she was selling them for money and wanted me to continue to provide them for her!). Since narcotic abuse/misuse is sharply on the rise and because physicians can be held responsible for deaths and other morbidities resulting from it, it is imperative that boundaries be set in this regard.

In the era of the patient-physician relationship I do feel that we are partners on a TWO sided relationship which means we both have input and responsibilities. Just like with any relationship boundaries and expectations should be discussed and when these are either overstepped or unmet then it is in the best interest of both parties to no longer continue the relationship.

On another note I am saddened by how physicians are viewed/portrayed in recent decades and feel that it is becoming more difficult for me to find joy in a field that I went into to help people, to listen, and to make a difference. There are many obstacles that continue to affect how I practice that many lay-people do not consider:
1. having to see 25-30 patients a day in order to keep the practice going (this gives me 10 to 15 minutes at most to spend with a patient and accurately diagnose, design a treatment plan, discuss the potential side effects, and document to avoid a lawsuit if something goes wrong not to mention if the patient has 2 or 3 complaints they are upset that I don't have time to deal with them. Unfortunately the current healthcare system does not have a set up that allows us to spend an hour with each patient (which i'm sure many of us family physicians actually would enjoy).
2. Fear of litigation - some decisions I make to order tests, diagnostic procedures, and treatments are for fear that if I miss something I will be sued (rather than trusting the 12+ years of education and training I have had).
3. Patient expectations - I believe this has already been mentioned but again sometimes it is just easier to give the patient what they want rather than what is in my best clinical judgment. They will either find another doctor or give a negative patient satisfaction survey that ultimately can affect physician compensation (how we get paid).
4. mistrust of doctors that sometime are based on previous justifiable experiences and othertimes on disillusions of what doctors do and how hard we work for our patients. I think sometimes people believe we make millions of dollars and work 9 to 5. couldn't be farther from the truth and then you throw in the $250,000 in medical school loans we have to repay.
5. battling insurance companies!!! It is extremely frustrating to have to argue with insurance companies to pay for a medicine I need for a patient or for a diagnostic test I ordered.

In the end doctors are only human! We have feelings and make mistakes like everyone else. And most of us truly are in medicine to help other people make their lives better

Anonymous said...

I think most people want to know if their doctor is thinking about what they say, not just applying palliative care. I remember that scene in "Lorenzo's Oil" where the mother is glaring down at a physician and asks, "How could you not know? It's so obvious." I think that scene will burn in my mind forever because that is what is frightening when one goes to the doctor, the absence of thought. It's been said by Goethe, Carl Jung and many others throughout history that only about 50% of the population "thinks." Most people are "practiced" and their functioning "knowledge-based." But like the guy who can fix a vintage motorcycle when others haven't a clue because he thinks about the totality of the equipment, people like to see a genuineness of thinking. Thinking is "caring" and "moral." Thinking does not take much time either. And playing the Devil's Advocate for a moment here, it might be wise to take but a moment's interest in the patient. Did you go horseback riding when you were young? Were there a lot of flies around? Do you remember what you ate prior to your severe indigestion on the 5th of December? Do you eat pork? Have you experienced insomnia or lock jaw recently? Has your dog been sick lately?

Anonymous said...

Great post!

I agree both doc and patient should be able to fire the other. I think it would be helpful on the part of both parties that before such an incident happens, they meet to discuss it constructively first before it is done. Really would be eye opening for both sides.

I do have a concern though. I had a doc who fired me for non compliance & unproductive relationship, even when I had said nice things about his people and practice. I did say the physician gave confusing orders at time, and that's when I was fired. I had also questioned what the medical basis was for his comments to another doctor. He never answered & I never figured out why, his notes said I looked fine. Considering the ego of the guy, he said I pushed his buttons, asked too many questions (I had a number of complications), got angry with me over asking about all available treatments, etc. I am more relieved than anything. I'm not happy that I have no specialist care, but at least I don't have the problem of dealing with him. I'm sure he's saying the same about me. The problem is that a lot of women think he's gorgeous. I don't, and I work in a male dominated industry, so I'm used to exchanging ideas, and being a partner vs. being told to go do things like a good little girl.

Oh well ...

Anonymous said...

Like another said on this thread, doctors come from "Me Tarzan, You Jane" mentality. That their practice and who they are is "knowledge-based" leaves open inquiry as it should from patients. The arrogance that rests with "knowing" something another doesn't know and then being arrogant because one "knows" more than another is vastly different from the greatness of the past when "intelligence" rather than "knowledge" was the mark of quality in a person. Today we now have a MASS of collective arrogance, with no originality whatsoever. Maybe that is why William Koch was killed?

Anonymous said...

I have had a nightmare experience. I had two acquaintances go to my doctor of 15 years. They then called mutual friends and told them all the doctor had said about me, my health and finances. I was appalled and was planning to discuss it at our next appointment. My insurance rep called doctors office and was told to never call there again and to tell me to find another doctor after fifteen years. I was stunned and immediately called to find out what was happening and was hung up on. I have a chronic condition and this specialist has treated me for 15 years. My insurance rep says she mentioned missed appointments, and I have never missed an appointment in my life. Doctor books 3 months out and if she scheduled me on a day that did not work then I would reschedule for the same time frame but always 30 days plus notice. I never have been a no-show. We were friendly and hugged as usual at my last appointment. When she had a child I brought a gift. I can only imagine that her "firing" me has to do with breaking the code of confidentiality. This whole nightmare of a situation has exasperated my illness and I haven't any physician care! This doctor needs to be held accountable

Eszter Tsvang said...

Does a doctor have the right to terminate me as a patient because I disputed a charge that was incorrect and then a month later I found out they wrote less refills on on my prescription than they said they would and because I disputed a charge a month ago, they refused to call my pharmacy to fix the prescription (after a month of telling me they'd take care of it) all because they didn't like that I stood up for myself? I personally find it petty that a doctor would refuse to call a pharmacy on my behalf AND terminate me as a patient after I made it clear that I didn't wish to return as a patient and I just wanted the prescription fixed.

On top of that, they made me sign a contract that was incredibly long about how I have to respect them yet they disrespected me several times.

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