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Akron Univ. School of Law

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Tuesday, June 10, 2008

Firing the Patient

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. . . .

 

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Comments

I have been one of the patients being fired. The nurse that had worked for my Dr. for years seem to get it that when it, that when a patient was on strong pain meds such as Oxycontin she made sure she had it ready on the day it was due. She quit and the Dr. who I had known for years and had been his patient and what I thought friend for years fired me. He fired me because his new and very young nurse did not get it and did not have the meds ready on the day they were due.I complained to the office manager and the next day I got a letter firing me. I do not really understand why I was fired. I was in severe withdrawals on the day I complained about the nurse. I thought that he would get onto her not fire me. I had a Dr that was taking care of my pain needs . I only went to him for a bad knee. When I told him about my chronic pain issue he offered to take over my pain needs. Now I am out of a Dr. And the other one is not going to take me back as a pain patient because I told him I had someone else to do it. I never had problems with his old nurse but the new one is on a power trip because she did not like me.I heard her tell another nurse one day that she could not stand me. I tried to talk to her and be nice to her. She only got worse. So who was wrong in this case. The Dr did not even give me a chance to give my side of the story. He just believed her. I guess I should have just accepted the withdrawals each time she did not want to give me my Rx on the day it was due and keep my very incompetent Dr and nurse.Because these days most Drs and nurses just assume that everyone is a drug addict anyway and don't want to give pain meds to people. I have been a nurse for 27 years. I can no longer work due to the pain in my neck and back from pulling on patients and hurting myself. So that is what you get for years of service to the hospital patients is a kick in the teeth and a young judgmental nurse who has no idea what nursing really is all about. I can't wait until her day comes. Then she won't judge people anymore.

Posted by: Debbie | Sep 27, 2008 11:17:45 PM

I was stunned today to receive a letter from my primary care doctor firing both me and my husband. We have neveer had a disagreement of any kind.........This letter states the reason is because the PA in his office was deceptive and walked out on the clinic abruptly, so he does not feel he can be an objective and proper physician for us. What does this have to do with us? The PA is our son's girlfriend! I just don't get it. Why would a Doctor terminate a relationship and lose 2 patients without some conflict between them. My husband has recently been very ill with endo carditis and spent 5 weeks in the hospital and is still on home anti-biotic therapy. This just doesn't seem right. We both like our doctor and are puzzled by his actions.

Posted by: Janet Raso | Nov 18, 2008 8:06:25 PM

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