When it’s time to say goodbye

SacopulosIssue2-2012What you should know about terminating the doctor-patient relationship.

By Michael J. Sacopulos, JD

At some point during your career, you will be faced with the decision to terminate a patient. Technically speaking, both doctor and patient are free to end their relationship at any time. Yet as a doctor, you have an ethical and legal obligation to handle such a situation in a professional manner that fully protects the health and welfare of the patient.

It is vital that you ensure that the termination of the patient relationship is done properly and does not constitute abandonment.

“I am in the communications business and failure to communicate between a provider and patient upsets me,” says Julie Gross Gelfand, a public relations director in Rockville Centre, N.Y.

Roughly two years ago, Gelfand went in for a routine dermatological care appointment and says she got so nervous that she fainted. The rest of her appointment went fine and she went home. When she called to make another appointment, her calls went repeatedly unanswered.

“I was quite furious when my follow-up calls were not returned. The more I thought about it, I think the doctor was between a rock and a hard place. I recognize the reality of legal liability and the difficulties that creates for medical practices,” Gelfand says.

Gelfand believes she was terminated as a patient. Did her dermatologist terminate her properly? Absolutely not. But before examining the preferred ways to terminate a patient, consider the reasons why some providers might want to end a relationship with a patient:

  • too many missed appointments
  • failure to pay for services
  • noncompliant with recommendations or treatment
  • inappropriate behavior with doctor or staff
  • disruptive to the care of fellow patients

Patients have to do their part

The considerations for terminating a patient apply to every field of medicine including psychiatry. Ankur Saraiya, MD, has been practicing for more than 10 years in New York and says that terminating a patient is generally an uneventful process.

“The main problem is the patient not holding up their end of the bargain in the treatment contract,” Saraiya says.

Most often, Saraiya’s patients are terminated for missing appointments and not returning phone calls. Although a surprising thing tends to happen once a patient is formally notified that termination is under way.

“By initiating a termination, it basically alerts the patient that something is not right; ideally, they will get in touch with me and start coming to their appointments,” Saraiya says.

Steps you should take

When you feel like you are going to be moving toward a termination, document every phone call and appointment that is missed. If the patient has been habitually noncompliant with the treatment plan, ensure that he or she has an accurate understanding of the possible consequences.

Send the patient a letter drafted by an experienced lawyer confirming the termination and the reasons for this decision.

  • Be sure to send the letter certified mail with a return receipt requested.
  • The letter should be written to the point and devoid of innuendo.
  • The letter should give details on why you are terminating the relationship.
  • Put a copy of the letter and the postal receipt in the patient’s medical record.

Inform your office staff about the termination so they can handle any contact with the patient appropriately.

Robert Linden, MD, of Niantic, Conn., practiced internal medicine and geriatrics for more than 30 years. It was rare for him to terminate a patient, but on occasion it needed to be done.

“To lessen the shock for patients, I found that the dissolution should be taken out of the context of individual personalities with, instead, reference made to the ‘relationship.’ For example, the practitioner may write, ‘The above circumstances have led to a poor patient-physician relationship, which neither benefits me (the doctor) or you (the patient).’ This implies its best for both the patient and the physician if the relationship ends, the blame factor being minimized,” Linden says.

Considering patient care

The most important part of the letter is to determine and then state how long you are responsible for your patient’s care after the patient receives the discharge notice. The reason here is to avoid what is deemed abandonment.

  • If the patient is in need of medical care during the transition period, it is recommended that you continue to provide that care so the patient is not abandoned while he or she finds a new doctor.
  • If your patient will require ongoing medical care, make sure that fact is clearly conveyed.

“Give the patient enough medication, a one-month supply is considered to be the industry standard,” Saraiya says. You should also offer to provide the patient’s new doctor with a copy of the patient’s medical record.

“The letter should be specific and read, ‘I shall be available to attend you for a reasonable time after you have received this letter, but in no event for more than x days,” Linden says.

Taking a patient back

It happens: You terminate a patient but then realize it was a mistake. Linden can recall two instances that stand out.

Early in his career, he discharged a patient (who was also a friend) for not taking his recommendation and seeing a cardiologist.

“As I matured as a physician, I came to understand it’s OK to allow patients a major say in their care and that my friend had a right to refuse specialty consultation if he understood the potential consequences,” Linden says.

Another case that comes to Linden’s mind is when a long-time favorite patient sued him. Not because he did something wrong but because the patient’s attorney told her to drag him in on a lawsuit because his medical malpractice insurance would have deep pockets.

“The patient realized she was wrong, reconsidered, and proceeded to withdraw the litigation against me and the surgeon. I took her back into my practice. Needless to say, my lawyer and my partners were not happy campers.

But I thought it was the right thing to do. She had been a patient of mine for years, had chronic psychological issues, and now had metastatic breast cancer. It was a critical time for her, and she needed support,” Linden says.

This was a kind thing to do. But taking back a formerly terminated patient can be problematic and risky.

In the end, the important thing is to not abandon your patient once you find it necessary to end the doctor-patient relationship. Take the necessary steps to properly terminate the patient — for your sake and theirs.

MichaelSacopulosMichael J. Sacopulos, JD, is a partner with Sacopulos, Johnson & Sacopulos, in Terre Haute, Ind. His core expertise is in medical malpractice defense and professional liability mitigation. He can be contacted at mike_sacopulos@sacopulos.com or through sacopulos.com.