Wednesday, October 15, 2014

‘Problem Patients’: A Fresh Look at an Old Vexation


Every practice has at least one. Here's how to reduce irritation and improve outcomes.

Robert D. Gillette, MD

http://www.aafp.org/fpm/2000/0700/p57.html

Fam Pract Manag. 2000 Jul-Aug;7(7):57-62.
It was my good fortune to grow up with a father who was an old-school physician in the best sense of the word. Although he had many emotionally needful patients in his practice, I don't recall that he considered them “problem patients.” A small incident that occurred while I was growing up explains a lot about how my father approached patient care.

It is Sunday afternoon, and Dad and I are sitting in the living room. We hear a car in the driveway, a knock at the back door and then the voice of a neighbor conversing with my mother in the kitchen. The visitor's voice gets louder and more shrill as she talks about our cocker spaniel, saying how darling she is and how she just adores dogs. Dad listens for a minute, and then softly says, “She's afraid of dogs. Go put Greta in the basement.” I do so, and immediately the visitor's voice becomes softer and more relaxed.

My father was listening not only to what the woman was saying, but also to how she was saying it. Perceptive listening and insight into human nature are powerful tools that can help us understand our patients better and address their problems more effectively. This in turn makes patient care more pleasant and professionally rewarding.

KEY POINTS:

  • Problem patients often have special needs. Insight into human nature, perceptive listening skills and patience will aid physicians who care for them.
  • Problem patients' illnesses aren't curable in the traditional sense, so physicians shouldn't feel frustrated if, despite their best efforts, these patients make only limited improvement.
  • Visits that are short, frequent and focused will make problem patients feel cared for and understood and will help minimize the risk of burnout for physicians.

Understanding problem patients

Two basic concepts underlie our understanding of so-called problem patients. First, all humans have uncomfortable feelings. Our ability to tolerate them is influenced by our beliefs, emotional needs and external stressors. Somatic symptoms are more tolerable and have less impact when negative factors are under control and life is going well.


Second, some people perceive (usually unconsciously) that having symptoms serves a useful purpose for them. Such situations are seldom curable in the usual sense, since most problem patients are highly resistant to any form of insight-oriented counseling. Physicians should take a palliative approach and should not feel frustrated or guilty when their efforts fail to achieve a full recovery.
There are many terms used to identify a problem patient. “Difficult patient,” “thick-chart patient,” “hateful patient” and older pejorative terms such as “crock” and “gomer” are just a few examples. At the most superficial level, problem patients are defined by the feelings physicians have when they work with them. Frustration, uncertainty, anger and a feeling of being manipulated or controlled by the patient are common.


Another way to identify problem patients is by their behavior (see below). These patients also tend to be associated with a highly controversial and changing cluster of diagnoses that currently includes multiple chemical sensitivity and Gulf War syndrome.1

Typical problem-patient behaviors

Multiple symptoms involving multiple body systems
Vague and shifting complaints
Dependent, clinging behavior
Undue concern bout minor symptoms
Excessive preoccupation with physical disease
Poor response to usual methods of treatment
Hostile, demanding, dissatisfied
High utilization of health care services
Manipulative, exploitative, controlling
Seductive, sexually or otherwise
Unrealistic expectations of cure
Raises new problems as visit ends
Resistant to physician's recommendations
Noncompliant with treatment program
Difficult to communicate with
Rambling, unfocused
Self-destructive


A substantial body of research has linked problem-patient behavior to the psychological and social factors listed below. Some patients may require consultation with a mental health professional and psychometric testing. While a specific behavioral diagnosis can be helpful in guiding treatment (especially when deciding whether to aim for improved functioning or simple palliation), it's not necessary or practical in every situation.

Underlying psychological and social factors

Feelings of guilt, worthlessness, incompetence, shame
Loneliness, social isolation
Fear of abandonment
Life stress
Concern about personal safety: at home, on the street, other
Survivors of childhood abuse, sexual or other
Rational need for medical information or treatment
Somatoform disorders
Hypochondriasis
Personality disorders: dependent, obsessive or paranoid
Mood disorders: anxiety, panic, depression
Borderline personality disorder
Involvement with tort law or workers' compensation system

The other side of the coin

Evidence suggests that the “problems” do not lie exclusively with the patient. The American medical education system teaches a linear model of disease in which there is a sequence from symptoms to objective data to diagnosis to treatment and then to cure. Physicians who are educated in this system sometimes feel frustrated or guilty when this sequence breaks down, as it surely will when dealing with patients who don't want to get well.


The highly structured, often impersonal character of our medical facilities also tends to hinder the care of problem patients. Physicians in teaching clinics (as opposed to continuity-oriented primary care teaching practices) seldom have ongoing contact with patients, and increasing time pressures make it ever more difficult for the unhurried dialogue that's necessary to get to know patients as people. The inevitable result is that physicians trained in this milieu and new to practice are the ones most likely to perceive patients as “problems and to develop feelings of inadequacy and despondency when required to address multiple vague symptoms.”2 As they gain experience and confidence, they become more tolerant of people who do not meet their standard of rationality, and they also become more adept at persuading patients to forgo needless tests, consultations and treatments.

A practical approach for managing problem patients

The comprehensive strategy suggested in the following paragraphs may seem unduly burdensome, but experience has shown that it will save time, money and aggravation in the long term. Because each situation is unique, physicians must remain flexible; however, this approach will usually help produce favorable outcomes for patients.


1. Recognize problem behavior when it exists. An established patient may keep returning with ill-defined, fluctuating or otherwise problematic symptoms, or a new patient may offer a flood of complaints that suggest a behavioral cause. Either situation should alert the physician to the need for a comprehensive management approach.


2. Obtain the patient's perspective. There is often an understandable urge to cut a patient's “organ recital” short and finish the encounter as quickly as possible. Sometimes this is the only workable solution at an initial patient visit. If so, tell the patient that you want to spend more time evaluating him or her and ask your staff to schedule a follow-up appointment.


One way or another, there must be an opportunity for the patient to tell his or her story, with guidance and skillful questioning from the clinician. Ask about the illness and the patient's expectation about what should be done. Discuss what treatment has been prescribed in the past and the outcome. Ask the patient what he or she thinks is the cause of the illness, the prognosis and any perceived obstacles to improvement.


3. Take a structured history. This includes a general medical history and a psychosocial systems review. The latter is intended to elicit information about life stressors and the coping mechanisms and resources that the patient has available. Ask for the names of former physicians and the dates of and reasons for prior hospitalizations. A patient's reluctance to allow access to such reports may itself be a significant bit of data.


4. Do a routine physical examination and screening lab work. This will help to identify any coexisting biomedical problems and assure the patient that you care enough to do a thorough evaluation. Be sure to touch the part that hurts. It is usually unwise to start with a “megawork-up” to rule out any conceivable disease.


5. Complete any indicated testing promptly. Try to avoid falling into a pattern of ordering new tests and procedures each time the patient describes a new symptom.


6. Give the patient a timely report of your conclusions and plan. Acknowledge that the patient's symptoms are significant, and offer your willingness to work with him or her on a continuing basis.


Give assurance (when you can with confidence) that the findings do not portend disability or represent a threat to life. Listen to be sure that the patient understands and accepts what you are saying.


7. Set limited objectives. Having symptoms may be an important part of a patient's life, and diligent efforts to abolish them can have unfortunate consequences such as depression, angry denial, hostile behavior toward physicians or others, self-destructive actions, or simply switching to another physician. A more gradual approach will minimize this risk and may gradually encourage patients to relinquish the role of sick patient.


8. Schedule regular visits. It may be necessary to schedule appointments as often as weekly at first, but the interval should gradually be extended to perhaps once a month. Patients who miss appointments should be called and asked to reschedule. Regular patient visits will accomplish the following objectives:
  • They make patients feel cared for and understood.
  • They address small concerns before they become overwhelming to the patient.
  • They may gradually (slowly!) lead the patient to more mature thought patterns.
  • They reduce or eliminate unnecessary telephone calls, tests, consultations, hospital admissions and visits to the emergency department.
9. Keep visits short and focused. Encourage your problem patients to write down their health concerns and bring their list to each visit. Have them mark with an asterisk the one or two items that concern them the most. Address these, and, unless you see one that concerns you, leave the others for another day. Your goal should be an average visit of no more than 10 minutes in length.


10. Touch the patient. Start the visit with a handshake. Do a brief heart and lung exam, even if you have done it a dozen times before. End the visit with a pat on the back and assurance that you want to see the patient again at the next scheduled time.


11. Give the patient something to do. Prescribe some form of regular exercise, even if it is only a daily 20-minute walk. You may want to suggest vitamins and dietary modifications. Encourage your patient to get involved in hobbies, religious activities, group trips and the like. Some hands-on therapies such as chiropractic or massotherapy can be tried, although there is little evidence that they have more than palliative value.


Having a pet can be therapeutic for people with limited social contact. A pet provides an emotional attachment and some purpose in life. A dog may be a good choice for people with adequate physical, mental and financial resources. A cat is quieter and needs less care than a dog, and may be preferable for some patients. Smaller pets such as gerbils, fish or birds have shorter life spans and offer less opportunity for emotional attachment. You may want to encourage your patient to consult with a veterinarian about selecting an animal of appropriate size and temperament.


12. Use medicines selectively. Pharmacotherapy is seldom central in the management of problem patients and should usually be de-emphasized; however, medication is often necessary for coexisting depression, panic disorder or other specific indications.


13. Work with family and friends. Ask family and friends for their views of the patient's problem. Listen for genuine concern that can be put to good use with some coaching. Listen for destructive attitudes that can undercut your best efforts, perpetuate invalidism, dependency or shame. Of course you should always get the patient's permission before approaching the family, and avoid any interaction that could be interpreted as going behind the patient's back.


14. Work with your colleagues and staff. Be sure they understand and support your philosophy and plan. They don't necessarily have to accede to all of the patient's requests, but they should be friendly and call the patient by name. Discourage the use of pejorative descriptors that can promote negative attitudes toward patients in your practice. Listen to the insights that your team members have after interacting with your patients. They may point out something you've overlooked. Let them share in the work of providing emotional support and the gratification that comes when effective care leads to healthier behavior. Finally, be sure that they understand and honor their absolute responsibility to respect the privacy of these patients.

Managing problem patients in urgent care settings

It will be nearly impossible for physicians who care for problem patients in emergency departments and urgent care settings to use the same approach as those in primary care offices. Typical obstacles in the urgent care setting include lack of focus on continuity or on psychosocial considerations, a perceived need for immediate ing, a strong focus on protection against medicolegal risks and a highly controlled, high-tech environment designed to meet the needs of seriously diseased and injured patients.


It is probably wise to recognize at the outset that problem patients cannot be managed well in these settings. The best approach may be to address their immediate needs, tell them that their ongoing problems need continuity-based care, and make appropriate recommendations and referrals. Other useful steps include the following:
  • Make sure administrative procedures are as “patient-friendly” as is practical to minimize patient anxiety, hostility and mistrust before the patient and the doctor meet.
  • Read all information about previous visits by the patient to the emergency department or to other units in the hospital. Your organization should make this information readily available to you.
  • Don't feel obligated to provide absolute symptom relief for conditions (e.g., recurrent headaches) that can be more properly addressed in an office setting.
  • If you prescribe habituating drugs, do so only in amounts that will last until the patient can be seen elsewhere.
  • Get involved in addressing institutional limitations that interfere with providing any of the aforementioned services.

Preventing problem behavior

Considering the enormous social and economic costs associated with the care of established, late-stage problem behavior, it is striking to note how little attention has been paid to preventing the disorder. A literature search will turn up some important contributions, but it's likely they haven't been widely read. [If you're interested in reading more on the subject, see the reading list.] Although the following recommendations have not been scientifically tested, they are consistent with published information and clinical experience:
  • Listen for evidence of excessive preoccupation with illness in parents and young adults, and try to steer them toward a healthier, more mature perspective on their health.
  • Try not to “medicalize” problems of living. Avoid repeated CT scans for chronic headache patients, hysterectomies for those with pelvic pain, back surgery for inadequate indications, etc.
  • Provide competent, continuity-based care for chronic diseases like asthma or diabetes so that patients and their families do not become overwhelmed with fear.
  • Work in the public arena to blunt the excesses of the workers' compensation and tort law systems.

The realities of managed care

In the tumultuous, rapidly changing American health care system, we often encounter substantial barriers to managing problem patients effectively. The situation brings to mind a poster I saw in a plumbing shop years ago:


If you can't find time to do it right, how will you find time to do it over?

It is as much in the interest of managed care organizations' as it is in ours and our patients' to manage these cases properly, and we should say so, loudly and clearly. However, I must leave to others any discussion of tactics that may help physicians receive fair compensation for doing the job right.

Ten useful coping skills for physicians

Caring for “problem patients” requires strong interpersonal skills, character and emotional maturity. The following list of skills represents an ideal that few physicians can fully achieve, but with self-understanding and practice most of us can come close enough to serve these patients well.
  1. Allow patients to vent their feelings. Listen long enough to show your empathy, but set practical time limits.
  2. Strengthen your communication skills. Remember that as a physician, you're also a teacher and a coach. Tailor your explanations and guidance to each patient's needs and ability to absorb information.
  3. Become a more effective history taker. Ask the patient what's been happening in his or her life. Ask about the course of the patient's symptoms over time. Answers to questions like these may give you insight into the significance the patient attaches to the symptoms. They may also provide you with clues about what the patient is skipping over or not saying.
  4. Try not to judge. Understand the difference between having high personal standards and trying to impose those standards on patients. View patients' disruptive actions as opportunities to learn more about their concerns, beliefs and needs.
  5. Remain calm and confident. Stay in control while working with patients who are angry, depressed, manipulative, seductive or overly dependent. Strong, self-confident professionals can tolerate such behavior; others cannot.
  6. Understand your own strengths and vulnerabilities. Know when to set limits on patients' demands in order to protect yourself from burnout.
  7. Be patient. The problem behaviors you see in patients have taken many years to develop, and human behavior seldom changes quickly.
  8. Be proactive. Cultivate the ability to move ahead with patient care in the face of incomplete diagnoses and complex psychosocial problems.
  9. Avoid becoming an enabler. It's unhealthy for a patient to be overly dependent on you. There is a proper dosage for empathy, just as there is for digoxin.
  10. Respect your patients. Protect patients' confidentiality, keep promises and show that you respect their feelings.

A final thought

You can seldom turn problem patients around completely, but a humane and thoughtful approach to their care can make their lives (and yours!) more comfortable. I can attest from personal experience that problem patients can become grateful patients and that you may come, in time, to enjoy caring for that same patient whose name on your appointment list once turned your stomach into knots.

Additional reading

Difficult Patient Encounters in the Ambulatory Clinic: Clinical Predictors and Outcomes. Jackson JL, Kroenke K. Archives of Internal Medicine. 1999;159:1069–1075.
Field Guide to the Difficult Patient Interview. Platt FW, Gordon GH. Philadelphia: Lippincott Williams & Wilkins; 1999.
Improving Patient Communication in No Time. Belzer EJ. FPM. May 1999:23–28.
Managing Somatic Preoccupation. Righter EL, Sansone RA. American Family Physician. 1999;59:3113–3120.
Somatization Reconsidered: Incorporating the Patient's Experience of Illness. Epstein RM, Quill TE, McWhinney IR. Archives of Internal Medicine. 1999;159:215–222.
Personality Disorders Among Difficult Patients. Schafer S, Nowlis DP. Archives of Family Medicine. 1998;7(2):126–129.
Using Common Sense With Difficult People. Flanagan L. FPM. January 1997:67.
The Difficult Patient: Prevalence, Psychopathology, and Functional Impairment. Hahn SR, Kroenke K, Spitzer RL, et al. Journal of General Internal Medicine. 1996;11(1):1–8.
Comprehensive Cost-effective Care of the Multiple Problem Patient. Gillette RD, Black DJ, Romaniuk M, et al. Journal of Family Practice. 1986;23(5):431–438.
The Cultural Meanings and Social Uses of Illness. Kleinman A. Journal of Family Practice. 1983;16(3):539–545.

Dr. Gillette is a semiretired family physician and family practice educator and a member of the Family Practice Management Board of Editors.

This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.
 
1. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med.1999;130:910–921.
2. Crutcher JE, Bass MJ. The difficult patient and the troubled physician. J Fam Pract.1980;11(6):933–938.
 
Copyright © 2000 by the American Academy of Family Physicians.
           

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Tips for dealing with the difficult patient


Tips for dealing with the difficult patient

By Robert H. Blotter, MD


http://www.aaos.org/news/aaosnow/nov09/managing3.asp


Communicate, set boundaries, and extricate yourself carefully


When it comes to dealing with difficult patients, you’re not alone. Every office has them. You dread seeing their names on your schedule. Your staff puts off returning their calls. Clearly, something needs to be done to improve relationships with these patients, but what?


Difficult patients are dependent, clingy, and entitled at best; they may also be manipulative, self-destructive, noncompliant, litigious, and even hostile. They all, however, demand excessive amounts of time and attention from you and your staff. And despite your efforts, you frequently find yourself frustrated and exhausted after interactions with them and sense that they have similar feelings.


The following tips may help salvage a relationship before it’s too late.


Sharpen your communication skills



Before you take the easy way out and blame the patient for the fractured relationship, take a good look in the mirror. Are you doing everything you can to understand and address the patient’s underlying needs or expectations? In other words, are you effectively communicating with this patient?


I call this the “Maxine” rule. Whenever my mother, Maxine, visits the doctor, she calls me afterward. As the only healthcare professional in our family, I get all her unanswered questions and complaints, as well as a critique of her most recent medical visit and advice on how to interact with patients. Now when dealing with a difficult patient, I remember that advice: “slow down, listen, and don’t be arrogant.”


When you are working with a challenging patient, ask yourself, “Would my family member, who has no medical background or experience, be satisfied with this interaction?” If the answer is “no” or “maybe,” you may need to think about how to improve your communication skills. If you can honestly reply “yes,” then the reason for your communication problem most likely lies elsewhere.


Often poor communication and the resulting difficult relationship are by-products of the time constraints many of us face. Simply recognizing that you need more time with certain patients, and scheduling your day accordingly, can go a long way in addressing the problem. This tactic, however, will not help with the patient who is never content with the time you provide.


Create boundaries
Standardized approaches can help lessen the emotions involved in dealing with difficult patients. Reasoned, consistent processes that provide clear boundaries from the start can not only avoid problems down the road, but also help defuse situations before they escalate.


A uniform narcotic medication refill protocol is an easy place to begin. Our office has a policy of no medication refills on weekends or after hours on weekdays. This policy is widely publicized in our office, including signs in every exam room. This policy is widely publicized in our office, including signs in every exam room. Now, instead of arguing with a patient on the issue, we simply refer to our written policy.


A standardized approach can be expanded to other difficult patient issues as well. Deanna R. Willis, MD, MBA, and Ann Zerr, MD, outlined a three-tiered approach to challenging patient management (Fig. 1). Outlining your practice’s approach to difficult patients beforehand removes the emotion of the moment and reduces the possibility of defensive reactions.


The last resort
When efforts to salvage the relationship with a difficult patient are not successful, what are your options? Can you terminate your relationship with a patient?


The American Medical Association (AMA), in an opinion on termination of a physician-patient relationship, stated, “Physicians have an obligation to support continuity of care for their patients. Physicians do have the option of withdrawing from a case, but they cannot do so without giving notice to the patient, the relatives, or responsible friends, which allows the patient sufficient time to secure further care.”


In general, the AMA suggests giving 30 days notice. This suggestion is discretionary, depending on your individual circumstances; however, if you do not provide proper notice, you can be accused of patient abandonment. Because the definition of abandonment varies from state to state, it’s wise to consult your medical liability provider before terminating your relationship with a patient. It’s also a good idea to contact the patient’s third party payor, who may be able to provide a patient advocate to act as liaison between you and the patient and possibly help salvage the relationship.
If, despite all your best efforts, the relationship fails, you’ll need to take the following steps:
  • Send a written confirmation of termination via certified mail with return receipt requested.
  • Outline a specific period during which you will provide continued care.
  • Remind the patient that his or her medical condition requires care. Advise the patient to find another physician immediately.
  • Provide the patient with contact information for other physicians in your specialty or for a medical referral service.
  • Inform the patient on how to obtain a copy of his or her medical records from your office. Never withhold medical records even if the patient still owes your office money.
  • Personally sign the termination letter and keep a copy in your records.
Dealing with the difficult patient can be a challenge, but it’s a challenge that physicians can overcome. Improving communication skills, managing your time, and planning ahead are key.
In addition, formulating standard approaches and establishing office policies will help you handle difficult patients with empathy, fairness, and timeliness.


For more information and advice on practice management issues, visit the AAOS online Practice Management Center at www.aaos.org/pracman

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Carefully discharge difficult patients: Develop and follow a policy for problem patients to avoid legal ramifications

Develop and follow a policy for problem patients to avoid legal ramifications


Publish date: JUL 10, 2012



http://medicaleconomics.modernmedicine.com/medical-economics/news/modernmedicine/modern-medicine-feature-articles/carefully-discharge-difficult

In a perfect world, all physicians are perfect, all patients are perfect, and all doctor-patient relationships are perfect. But in the real world, this is not always the case. Patients can be a problem, and as a physician, you have a right to terminate your relationship with them.


Terry Salz
As tedious as it may seem, thorough documentation of your actions prior to dismissal is crucial. Documentation of office actions and attempts at a resolution should be the protocol for all offices. Insurance companies often state that if no documentation exists, it did not happen; you don't want the legal system to use this argument in its defense should one be needed.
Once a physician-patient relationship is established, the doctor has an ongoing responsibility to the patient until that relationship is terminated. Patient abandonment occurs when a physician fails to provide the necessary medical care to a current patient without adequate justification. Therefore, a protocol for patient termination is absolutely necessary.
Never discharge a patient based on age, religion, gender, or ethnicity. Have strict guidelines in place as to what constitutes grounds for patient discharge. If the staff does not have guidelines, it could create legal concerns later; if discharge practices are inconsistent, your actions could be considered discriminatory.


REASONS FOR TERMINATION


Warning signs that a relationship with a patient is significantly challenged or consistently devalued include failure by the patient to comply with a recommended plan of care, including subsequent appointments, and consistent no-shows. Physicians can discharge a patient for several reasons, including continual no-shows for appointments, nonadherence with a prescribed treatment regimen, threatening behavior, and nonpayment for services rendered.


No shows. No-shows create a loss of revenue, but when they become a chronic issue, taking action is critical. If the patient continues to schedule appointments and fails to show up, you also may put your malpractice insurance carrier on notice when you initiate patient dismissal. If this patient has a serious medical problem in the future, you do not want a lawsuit claiming abandonment.


Violent patients. Training your staff and having an emergency response plan in place is your best defense against violent events should they occur. Staff members should be able to judge whether a situation has escalated and then be trained to call 911 immediately. Remember, a false alarm is better than a tragedy. Should you or your staff ever believe that your lives are at risk, leave immediately. Dismissal of these patients should be handled with immediate notifications to the proper authorities and your malpractice insurance carrier.


Patients who don't pay. A patient's failure to pay a bill can occur for several reasons. Nonpayment is often an early warning sign that a patient is unsatisfied with his or her outcome, or it can simply be evidence of lack of funds. Always consider both options, and always try to determine why the patient has not paid. Doing so can be a difficult and uncomfortable process and therefore should always be handled by a staff member with excellent communication skills.


Patients experiencing financial hardship will appreciate the opportunity to make arrangements to honor their financial obligations. Patients voicing an issue regarding care via nonpayment always should be referred to the physician, who should then seek risk management assistance from a professional liability carrier.




Patients can be a problem, and as a physician, you have a right to terminate the relationship.
  • Thorough documentation of your actions before dismissal is crucial.


  • If your discharge practices are inconsistent, your actions could be considered discriminatory.


    • STEPS TO DISCHARGE


    Taking the proper steps to discharge a patient is critical to avoid legal consequences:
    • Put your dismissal policy in writing and practice it consistently. Make sure your staff members understand what constitutes a reason for dismissal and that you apply your own rules with consistency so no legal ramifications result.
    • Check your insurance carrier contract regarding discharge, and inquire about any responsibilities you may have to it in the process. If you are the patient's primary care physician, send a copy of the discharge letter to his or her managed care organization or preferred provider organization and make note of your doing so on the patient's chart. Urge the patient to select a new physician without delay.
    • Check your responsibilities to your malpractice insurance carrier. Document all correspondence of discharge. Carry out this policy without exceptions.
    • State your reason for dismissal in a letter to the patient; be as objective as you can. Give the patient 30 days (recommended) continuance of care. Make a referral for other physicians, but never suggest a specific physician. Send a copy of your medical records transfer form for the patient to fill out so that the new doctor has the information necessary to provide continuing care without delay.
    • Send the discharge letter to the patient via both regular and certified mail. Be sure to keep all documentation. Occasionally, a letter of dismissal does not reach a patient. Legal counsel has indicated that a physician cannot be held responsible indefinitely for a patient because of an unsuccessful attempt at notifying the patient via certified mail.
    • If the certified letter is returned undeliverable, mark the return date on the envelope, and attach the letter and envelope to the patient's chart. Once a termination letter is sent via certified mail to a patient who has moved and left no forwarding address or to a patient who has refused to accept the letter, you are no longer responsible for the patient's care.
    • Always offer to send medical records to the patient's new physician, whether or not the patient has an outstanding balance with you. Be sure to obtain a written request for the release of a copy of the medical records. If you elect to charge the patient for the copy of the medical records, inform the patient.





    Should a patient subsequently request medical attention from you, agree to treat the patient only if the situation is a genuine emergency. If it is not an emergency, then inform the patient diplomatically but firmly that their physician-patient relationship is irretrievably damaged, refer to the letter previously sent, and indicate a willingness to find the patient another doctor and transfer his or her medical records. Document these actions in the patient's record, and send a letter confirming the conversation to the patient at the new address, with a copy of the original letter of dismissal enclosed.


    BE PREPARED


    We must be realistic about patient discharges. They can occur many times within a practice, for many reasons. The goal is to be prepared and handle these situations and patients with professionalism to mitigate any liability issue that may arise later.
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