Should you fire your patient?

Do you have a patient who consistently misses appointments? One who refuses to follow treatment plans and goals you have decided on together? One who doesn’t pay their bills? Or, worse yet, a patient who is belligerent and rude to you or your staff? All of these may be grounds for firing them.

Just as patients can leave their physicians to seek care elsewhere, physicians can request that their patients seek care elsewhere as well. Quite simply put, physicians can fire their patients.

Problematic patients can be fired, but you must be sure to have an ironclad reason for doing so in order to remain beyond reproach in every way. According to guidelines from the American Medical Association (AMA), the reasons a doctor may dismiss a patient include the following:

• Patient non-compliance
• Failure to keep appointments
• Rude or threatening behavior
• Non-payment of fees
• Closing your practice

But, how a “difficult” patient is defined is certainly more subjective than objective. Helen Lippman, MA, and John Davenport, MD, JD, Kaiser Permanente Orange County, Irvine, CA, offered some guidance in their article on patient dismissal, published in The Journal of Family Practice.

“Indeed, there are many ways a patient can be difficult, including exhibiting habitual hostility, chronic drug-seeking behavior, or consistent noncompliance; breaking appointments at the last minute; or being a no-show. You may wish you could ‘fire’ the worst offenders but be concerned about professional and ethical responsibilities and the legal risk you might face. Ironically, though, struggling to maintain a chronically stressed physician-patient relationship is often riskier than a well-timed termination. The key here, however, is the persistent or extreme nature of the difficulty,” they wrote. “When a dismissal is prompted by a one-time occurrence or lower-level offense, what constitutes a reasonable response is not always clear-cut.”

When you shouldn’t fire a patient

In light of this ambiguity, it may be helpful to know when you should not fire a patient.

As a physician, you cannot legally or ethically fire a patient for the following reasons:

• Based on discrimination for race, color, religion, national origin, HIV-status, sexual orientation, gender identity, or other attributes that are nationally recognized as discrimination.
• During ongoing acute medical care, such as pregnancy or chemotherapy.

Under the following circumstances, patient termination should either be delayed, or require additional steps:

• During an acute phase of treatment, termination must wait until treatment is completed. Examples of this include patients in immediate postoperative stages or those undergoing medical workups for diagnoses.
• In areas where you, as the practitioner, are the only source of medical care within a reasonable driving distance, you need to continue giving care to problematic patients until they can make other arrangements.
• In cases in which you are the only source of a specific type of specialized medical care, you must continue care until the patient is safely transferred to another physician who is qualified to provide this specific care.
• Patients who are members of prepaid health plans cannot be discharged until you have communicated with the third-party payer to request their transfer to another practitioner.
• Patients with uncomplicated pregnancies can be discharged during the first trimester as long as you give them enough time to find another practitioner. During the second trimester of pregnancy, termination can only happen if the pregnancy is uncomplicated. During the third trimester of pregnancy, terminations should only be made under extreme circumstances, such as illness on your part.
• A patient’s disability cannot be the reason for termination unless it lies outside of your expertise.

If you belong to a group, you may want to terminate the patient from the whole practice to avoid the possibility of treating him/her in an on-call situation.

Grounds for immediate patient dismissal

While proper reasons and forethought should go into any patient dismissal, any patient who threatens violence or physical assault should be dismissed immediately. Such events have been named “sentinel incidents” by the American Academy of Family Physicians (AAFP), and constitute grounds for immediate dismissal.

“Despite the emphasis on resolving problems with patients, there are times when dismissal can and should occur, with little warning and no negotiation. In its home study course, the AAFP describes this as a ‘sentinel incident’—a single occurrence so egregious that it damages the physician-patient relationship beyond repair,” wrote Lippman and Dr. Davenport.

“When a sentinel incident occurs, the best course is likely to be to forego any attempt at resolution, call the police or your facility’s security officer, and, if appropriate, to immediately prepare to ‘fire’ the patient,” they added.

Other examples of egregious offenses that call for immediate patient dismissal include blatant sexual advances, sexual assault, theft, falsifying medical records, or any criminal activity carried out in the physician’s office.

Giving written notice

According to the AMA’s Code of Medical Ethics, physicians considering withdrawing from a case must notify the patient well enough in advance to allow the patient time to find another physician, as well as facilitate transfer of care when appropriate.

Terminating a patient formally involves written notice—via certified mail, return receipt— to the patient that he/she should find another healthcare provider. Keep all copies of the letter and any other correspondence you may have in the patient’s medical record.

Such written notices should include the following:

• Do not include a specific reason. No specific reason for termination is required, and often, a vague, catchall phrase can be effective. Examples of this are: “inability to achieve or maintain rapport” or “The therapeutic practitioner-patient relationship no longer exists.”
• Include an effective date. When giving this date, be sure to allow the patient a reasonable time frame during which he/she can establish a relationship with another practitioner. State regulations differ, so be sure to check them. Usually, 30 days from the date of the letter is adequate.
• Make suggestions for interim and continued care. Avoid recommending any other healthcare practitioner by name. Suggest local referral services, hospitals, or community resources.
• Offer a copy of their medical records. Offer to send these to the patient’s new physician. Enclose an authorization document to the patient, which they must sign and return to you.
• Remind the patient that their medical care and follow-up are their
• Provide medication refills only up to the date of termination.

The AAFP provides some examples of patient dismissal letters.

“The events that led up to the dismissal, however, including any discussions you had with the patient about them, must be documented in the medical record. Put a copy of the letter and the certified mail receipt in the chart, as well,” concluded Lippman and Dr. Davenport.