RISK
MANAGEMENT GUIDELINES: Q&A
The relationship between a
physician and his or her patient exists until it is ended by mutual
consent, termination of the need for services, dismissal of the
physician by the patient, or dismissal of the patient by the
physician.3 For the purposes of this article, termination
will refer only to dismissal of the patient by the physician.
Termination of the professional
relationship with a patient should be a process, not an event. The
process may vary with individual circumstances. However, certain
basics are–or should be–a part of almost all
situations. And certain issues arise almost every time termination
is a consideration. They are presented below as questions,
together with the risk management guidelines that answer them.
Q. When is it
acceptable to end the professional relationship with a
patient?
A.
Termination is appropriate whenever the trust that once marked the
physician-patient relationship is so diminished that the
physician’s ability to give optimum patient care is
compromised. Some of the particular circumstances that give rise
to the need or wish to terminate the professional relationship are
presented in bullet form on the first page of this
article.
Reasons that be used for
termination include the patient’s gender, race, religion, or
sexual preference. In addition, patients covered under the Americans
with Disabilities Act (ADA) may be dismissed from the practice but only
for one or more of the reasons that a non-disabled person might be
dismissed, not because of the disability or illness.
Q. When is termination likely to be considered
abandonment?
A.
Terminating the professional relationship with patients in medical
crisis, with those undergoing or needing treatment for an acute problem,
and with pregnant women who are at more than 20 weeks gestation may be
considered abandonment. ProMutual Group suggests that termination
not be initiated in any of these situations until the crisis has been
resolved, the acute problem has passed, and/or delivery has taken
place.
Abandonment might also be alleged
if termination of the patient with a continuing medical need takes place
without apparent cause, if the physician does not give the patient
adequate time to find another practitioner, and if the patient suffers
injury as a result of the physician’s haste or carelessness in
terminating the professional relationship.5
Q. What is the best way to go about the process of
termination?
A. The
“best way” varies with the circumstance. In cases
where threatened or actual violence is directed toward the physician or
staff, termination may be verbal and immediate. In most other
situations written notification of the patient is the ideal. The
termination letter should include the following information:
- Reason for termination,
- Effective date of termination, usually at least 30 days from the
date of the letter,
- Statement concerning the importance of the patient’s finding
continuing medical care, if such care is required,
- Notification that care should be sought at a local emergency
department if medical attention is required after the 30-day period and
before a new provider has been selected,
- Referral source the patient may use to find another physician in the
community,
- Offer to send the medical record to the new provider at the
patient’s request.
A letter from a physician in a
group practice should specify whether the professional relationship is
being terminated only with the physician signing the letter, with
several members of the group (all of whom should be named), or with the
entire practice.6
The letter should be sent certified
mail, return receipt requested. A copy should become part of the
medical record.
In some situations the physician
may wish to precede written notification of the patient with a
one-on-one conversation to determine if there are any extenuating
circumstances that might help explain the behavior that has become the
reason for termination. It may be possible to resolve the problem
with a payment schedule, a mutually agreed-upon contract, or other
promise that makes termination unnecessary.
Health maintenance organizations
(HMOs), state agencies, and other insurers may have specific
requirements concerning termination. The physician should consult
and abide by these rules.
Q. What if the certified letter is returned
unopened?
A. The
returned letter (and envelope) should be filed in the medical record and
a duplicate letter sent in a plain white envelope showing no return
address. Some practices have found it helpful to follow up the
second letter with a telephone call. The entire process should be
documented.
Q. Is the 30-day notification of the patient a hard and fast
rule?
A. It is not
a legal mandate. However, it is the generally accepted minimum
period of time to allow the patient to find a new
provider.1,6,7 It does not need to be honored when the
patient threatens or commits violence against the physician or office
staff or when the patient commits a criminal act involving the practice,
for example, stealing a prescription pad or selling narcotics that have
been prescribed by a member of the practice. It should be used as
a guideline, not a hard and fast rule, in all other situations.
Q. A colleague told me I don’t have to tell the
patient the reason for termination. Is this true?
A. Openness
and honesty should be as much a part of the termination process as they
are a part of the physician-patient relationship. Patients have a
right to know not only why their relationship with the physician is
being terminated but also that termination is for cause, not whim or
bias. This is the position not only of ProMutual Group but also of
the American Medical Association.1
Q. Many of the physicians in this area are not accepting new
patients. May I give a patient I’m terminating from my
practice the names of specific physicians who do have openings?
A. It is far
better to offer a referral source than to give specific names. The
patient who has a negative experience with someone whose name you offer
may blame you for that experience and, in a worst case scenario, involve
you in litigation. In addition, referring a problem patient to a
colleague may be perceived negatively by that colleague and others.
A few situations that are not
necessarily part of every termination process are, however, likely to be
a part of many physicians’ professional experience.
Q. Is there a rule about the number of times a patient can
cancel an appointment before considering termination?
A. There is
no rule. Practices must decide for themselves the number that
works most effectively for them. ProMutual Group suggests that
three consecutive missed appointments may be reason to consider
termination. However, extenuating circumstances, for example, lack
of transportation or a pressing family situation, may point to a need
for discussion rather than termination.
Physicians may wish to include in
their practice brochure a statement about their policy on missed
appointments, letting patients know that a missed appointment deprives
another patient of an opportunity for an office visit and that a given
number of missed appointments will be considered reason for
termination.
Q. A patient who is suing me has made another
appointment. Do I have to see her or is the suit justification for
terminating the professional relationship?
A. If the
patient is calling you for continuing treatment of an ongoing acute
problem, you should probably see her. If the problem is chronic or
if she is calling you about a new medical issue, you may want to both
cancel the appointment and begin the termination process, explaining to
her that given the circumstances, you believe another practitioner might
be better able to meet her medical needs.
Q. I have a patient who hasn’t paid her bill within
the past several months. Do I have the right to refuse to see her
until her bill is paid?
A. The
medical care of an active patient should not be contingent upon whether
or not the patient’s bill is paid. However, a
patient’s consistent failure to meet his or her financial
obligations to the practice may be reason for terminating the
professional relationship. Before the patient schedules another
visit, either have a member of your staff call her or, if you know her
well, take a few moments yourself to call her to discuss concerns about
the status of her bill. Determine whether or not she is dealing
with loss of a job, family illness, or any financial emergency that may
be affecting her ability to pay her bills and try to work out a payment
schedule with her. If she is unwilling to enter into such an
agreement–or if she subsequently fails to meet its
terms–consider terminating your relationship with her.
Follow the conversation with a termination letter.
Q. A friend of our family is a noncompliant patient.
She doesn't keep appointments, follow screening recommendations, or take
her medications. For personal reasons, I would prefer not to
terminate my professional relationship with her. However, I feel
that I need to do something. What are my options?
A. You may
wish to have the patient sign a summary informed refusal to acknowledge
her refusal of preventive care, including screening. Individual
informed refusals may be signed if the patient informs you in advance
that she will not take a particular medication or follow a particular
therapy. At some point you may wish to have a discussion with this
patient to determine what her expectations are of you or any other
physician, and how you might be able to work together. If
compromise seems unlikely, you may wish to reconsider termination.
Q. I was the on-call urologist when a patient I had
terminated from my practice for noncompliance came in to the hospital's
ED. I diagnosed a kidney stone that needs further treatment. What
is my responsibility to this patient with whom I had an extremely
difficult relationship in the past and whom I do not want to see in my
practice again?
A.
ProMutual Group suggests that a physician who cares for a patient in the
ED should see that patient at least once in the immediate post-ED
period. In this situation, make sure you let the patient know that
his visit to your office is a one-time event and because ongoing care is
important, you will give him a resource to help him find another
physician, assuming that he is not already under the care of another
urologist. Given the acuity of the patient’s medical
condition, you would be wise in this case not to simply assume the
patient has found another provider but rather to follow up and make sure
the patient is under the care of another practitioner.
In a case such as this, you would
also be wise to notify the patient’s primary care physician
(PCP)of the ED visit and to let him or her know, in writing, of the need
for follow-up. Although the patient would not need to give his
authorization for communicating personal health information to another
physician for purposes of treatment, there would certainly be no harm in
obtaining the patient’s written authorization for you to contact
the PCP.
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