Tuesday, June 10, 2008
The New York Times has a piece today by Dr. Rahul K. Parikh who writes about dealing with a difficult relative of a patient and deciding to end his relationship with the patient because of it. His decision-making process is rather interesting as are the many comments attached to the article from other doctors and patients. I actually didn't think that the mother was that bad - perhaps because I had some rather picky clients. The comment thread was quite illluminating as doctors spoke up about their right to end relationships with difficult patients. Dr. Parikh writes,
It wasn’t the boy I had a problem with. It was his mother. We had met a few months earlier, when I gave her 14-year-old son a diagnosis of mild asthma. I didn’t mind her tough questions, but her tone of voice put me on edge. She seemed suspicious, almost angry. Still, in the end I decided she was just a smart, assertive parent, and I let it go.
This time, she was more confrontational. She complained she had been “forced” to bring in her son for a physical because his school needed a doctor’s clearance before he could play sports. What kind of racket did we doctors have with schools? Why did she have to bring in her son when she knew he was healthy? I was taking her money for doing this?
I bit my tongue and tried to tell her why I thought they belonged here. Yes, he was probably very healthy. But an annual checkup could help him learn to take charge of his own health as he grew up, and it would give me a chance to encourage healthy choices and to get a good sense his emotional health during these challenging years. Finally, I pointed out, he was due for a tetanus booster. She was unimpressed. “I don’t believe in preventive care,” she said. “I’ll treat him for tetanus if he needs it.”. . . .
I have had my share of difficult patients and parents. But putting up with this lady had taken more time than it was worth, and it interfered with my taking care of her son. I wasn’t sure I wanted to do it again. I considered my options. I could be stoic, do my job and keep the boy in my practice. I could call his mother and ask her to keep her opinions to herself so I could focus on her son, though my instincts told me that this wouldn’t stop her. Finally, I could decline to see her son, and therefore her, ever again. In other words, fire my patient.
The physician-patient compact basically states that a doctor will care for a patient in exchange for compensation and that the patient will heed the doctor’s advice. Patients who disagree with their physicians, or just dislike them, are free to go elsewhere.
By the same token, this mutual contract gives a doctor the right to dismiss a patient. The most obvious reasons are failing to pay or missing multiple appointments. Refusing to adhere to treatments can lead to dismissal. So can being abusive to the medical staff. Of course, we need to exercise this option sensibly. Doctors cannot fire a patient in dire straits like severe pain, bleeding or a life-threatening situation. And of course, we cannot refuse to see patients because of their race, age, sexual orientation and so on.
But could I fire a patient because I didn’t like his mother? Colleagues who had studied the ethics and legal issues told me that the answer wasn’t clear-cut. . . . I thought about our conversation on the tetanus booster, when the mother said she didn’t believe in preventive care. I’m a pediatrician — prevention is in my DNA. If I accepted her view, I’d be compromising my conscience and my professional ethics. I couldn’t do that.
I wrote a letter addressed to my patient’s mother and sent by certified mail. I kept it brief: “Sometimes, a patient or family and doctor aren’t compatible. ... Therefore, I will be dismissing you from my practice.” I went on to advise them how they could get a new pediatrician and told them that until they found a new doctor, I would continue to care for her child’s mild asthma. Two weeks later, I received notice that they had gotten it. . . .