Firing a patient: Know when and how to do it

March 1, 2007

Calling it quits in any relationship is a source of discomfort, but when it's the physician-patient relationship, it must be handled precisely and with caution. You want to avoid angering patients or leaving them without the urologic care they need. By the same token, if you or your patient are disgruntled with the relationship, there may come a point when you need to fire the patient. Here is some advice to help you through it.

Patients who may warrant discharging generally fall into one of three categories.

A patient who won't follow your medical advice, who fails to adhere to the treatment plan, who doesn't take medication, and who doesn't show up for scheduled appointments is a non-compliant patient. If you can't rein in the patient and persuade him to change his behavior, you need to address it and send the patient on his way.

Finally, there is the patient who owes the practice money. Your billing department's efforts to collect have been ignored, and it's clear the patient has no intention of paying off the account while treatment continues and the account balance grows.

In each of these scenarios, it is obvious that the relationship with the patient is being compromised and cannot continue. The patient needs to move on, and the sooner, the better!

Regardless of the reason, when you determine it is time to sever the doctor-patient relationship, it is critical to proceed with cautious, but deliberate actions. It is also important to document your steps to create a history and to track what actions have been taken. When you are ready to take action, it is important to seek the opinion of your malpractice carrier to ensure your disposition provides you with needed protection.

Start by making sure the patient is not abandoned and that care is not withdrawn during a medical crisis. Usually this means giving the patient up to 30 days to find and obtain another urologist.

Communicate and document

Begin the process by having a face-to-face conversation with the patient about your decision to terminate the relationship. This dialogue will give you and your patient a chance to clear the air and to avoid misinterpretation.

It is important to finalize the termination in writing by outlining your decision, the patient's current condition, and recommendations for the patient so his or her urology care is not compromised (see a sample discharge letter at http://www.urologytimes.com/dischargeletter). This letter must be carefully crafted, and should be sent by certified mail, return receipt requested. It should be direct and should cover all the bases.

Start by confirming your decision to discharge the patient and the rationale behind your decision, and provide a specific date of termination. The date will depend on the patient's medical condition and his or her ability to find a qualified physician to take over care. The date usually ranges from 2 to 4 weeks.

Your letter should describe the patient's current condition, advise him to select another physician, indicate whether follow-up care is immediate, indicate the prognosis if the patient does not obtain follow-up care, and inform the patient of other urologists in the area who can provide further care. It is important to let the patient know that you will be available if treatment becomes emergent or acute in the interim.

Let the patient know that you will provide the new physician of choice with a copy of the patient's medical records when you receive a written authorization from his or her office and that you are available to consult with the new physician, if requested.