When you have no choice but to fire your patient
Key Takeaways
Many of us enter medicine because we value the therapeutic relationship with our patients. Still, when that relationship is repeatedly challenged, it not only makes the physician-patient relationship difficult, but sometimes we have to sever it.
For example, I once had a patient who was in recovery for an opioid use disorder and would continuously present to my office while under the influence. His urine drug screens repeatedly came back positive for opioids, thereby violating the rules of our opioid contract. I explained to him the gravity of this situation and the potential to be fired from our practice as a patient if he continued to misuse opioids.
Finally, after multiple warnings and conversations, I had no choice but to fire him. I sent him a certified letter with a requested return receipt, outlining the reasons for the termination and explaining that I would continue to direct his care for emergency issues until 30 days’ notice.
Reasons for firing a patient
The most common reasons for firing a patient include treatment nonadherence, follow-up noncompliance, office policy nonadherence, verbal abuse or violence, display of firearms or weapons, inappropriate or criminal contact, and nonpayment.
Data associated with firing a patient is scant, but one 2008 study of 526 primary care physicians published in the Journal of General Internal Medicine suggests that as many as 85% of primary care physicians have dismissed at least one patient.[]
Among physicians in the study who dismissed patients, 71% had dismissed 10 or fewer patients, but 14% had dismissed 11 to 200 patients. The most common reasons cited for dismissal were verbal abuse and drug-seeking behavior. Among physicians who dismissed patients, 40% cited verbal abuse, and 40% cited drug-seeking behavior as reasons.
Physicians in the study were also presented with 12 scenarios involving hypothetical patients and were asked whether they would dismiss them. Once again, verbal abuse and drug-seeking behavior were the top culprits in dismissals: 97% of the respondents would dismiss for verbal abuse, and 90% would do so for drug-seeking.
How to fire a patient
Firing a patient, or being fired by a patient, is one of the most difficult parts of being in a physician-patient relationship.[] However, when a physician begins to think about firing a patient, it is important to take a step back to try to understand the circumstances behind this potential decision more objectively, and to separate any emotions involved.
Patients are not necessarily at their best when they are sick—and when they act poorly, it may be a symptom of their distress rather than their medical condition. Patients who act out may be afraid, concerned, or frustrated, and they may have poor coping skills to deal with their emotions and frustrations.
In addition, there may be underlying reasons for why they are acting out. Even if those are legitimate (once understood), the behavior is unacceptable.
"We must take an objective step back and look at the scenario through a therapeutic lens while taking a collaborative and curious approach. "
— Kristen Fuller, MD
When the time comes for the firing, here is how you might approach it.
Sit down and talk
Talk to your patient and explain why you are considering dismissing them from your care, so they can understand. It's up to you to decide how much time to give them to improve their behavior, but it's important to lay down the ground rules of what needs to be done. Take time to listen to the patient, as maybe they have an explanation (excusable or inexcusable) as to why they are acting this way.
Be direct
Use direct statements such as, “If you continue this behavior, we have no choice but to no longer provide care for you, and you will have to go to another practice." This can be quite eye-opening for some patients. Of course, the ideal is for you to be able to work through the situation with your patient, but sometimes this goal is unattainable.
Send a certified letter
If the patient’s behavior does not improve within the agreed-upon timeline, it is your option to “fire” the patient. To do this, it is important to send them a certified letter with a return receipt requested, letting them know the reasons for the termination. It is important to continue their care for emergency purposes only, up to 30 days. This way, the patient's safety is at the forefront, giving them time to find another physician. If the patient does not pick up the certified letter and attempts to contact you after 30 days, you have the right to show them the certified letter of termination.
Inform your office staff
Be sure to alert your office staff and the patient’s insurance company of this termination. The termination should be kept private, due to patient confidentiality rules, when transferring medical records to their new physician.
Patients can fire you, too
Patients have the right to “fire” a physician, and it could be for any reason. Maybe the patient does not have a good relationship with their physician, or maybe the patient feels that the physician’s care is inadequate. Maybe the patient is tired of long wait times, or possibly the patient just feels that there is a better fit elsewhere.
It can be hurtful when a patient chooses to leave your practice and go someplace else, but if you did your best when caring for them, you probably have no choice but to accept the situation. As painful as it can be, you can try to take a healthy approach to the separation:
Don't fight back.
Reflect on the situation (maybe there is a learning lesson here and potential to grow).
Don’t take it personally.
Grieve, be upset, and vent in a healthy manner.
Accept it and move on (you have more patients to care for).
Sometimes patients just don't like you for whatever reason, even if you did nothing wrong. Sometimes we make one misstep, and the patient is done with us entirely. If you’ve been on the receiving end of repeated firings, though, there may be something to learn.
Firings—yours and your patients’—are case-by-case situations. Resolution is not always possible, but inevitably some self-reflection takes place.