Ending the Doctor-Patient Relationship

The practice of medicine can be a very rewarding and satisfying profession. In order to provide effective and compassionate care to our patients, we must spend years in medical school and postgraduate training. During this time we are taught by our professors and attendings the appropriate way to diagnose and treat disease. However, the practice of medicine does bring with it patient encounters that do not always turn out the way we had expected or were trained for.

There are times when the doctor-patient relationship can become compromised. Whether the patient loses confidence in the physician, displays abusive language or conduct toward the office staff, or treatment directions (most commonly with not following medication directions appropriately) are not followed, such patient behavior must be dealt with consistently and fairly by the attending physician.

In my practice I had been treating a young male for several years. This patient did have several medical problems and would frequently show up late for office visits. When he presented to the office for his routine appointment and checked in late, my office staff informed him that he had missed his appointment and would have to reschedule. The patient failed to acknowledge the fact that I had discussed his problems with punctuality several times in the past and had even given him a written letter stating that we would reschedule his appointment if he presented late again in the future. The patient started to become very disruptive in the office and my staff called me out to the reception area to deal with him.

When I politely informed him that his appointment would need to be rescheduled, he began to use verbally abusive and profane language directed toward both myself and my office staff. I asked him to leave the office. Before I left the office that day, I drafted a discharge letter and sent two copies to the patient. One copy was sent by certified mail with confirmation of delivery and a second was sent via traditional mail. Enclosed in the discharge letter was a form to release his medical records to the physician of his choice.

A second example of patient misconduct involved the inappropriate use of narcotic pain medication. This particular patient was prescribed a medication to control chronic degenerative arthritis and a medication use agreement was signed when the medication was started. It is important to remember that such a medication use agreement is not a legal document- rather it is a written agreement between the treating physician and the patient stating the conditions and expectations that the medication will be prescribed to them. After failing to show for a random urine drug screen and pill count on two occasions, the patient was sent a letter informing them that I would no longer be able to provide such medication for him in the future. Also in the letter was contained language that I would continue to treat any other medical problems for him but if he chose to use controlled substance medications, he would be referred to a pain clinic. After the letter was received by the patient, he elected to move his care to another facility.

These are just two examples of patient behavior that must be quickly and consistently addressed by the attending physician. The practice of medicine is not perfect and neither are the patients that we treat. While the vast majority of the patients we treat are truly very honest and grateful for the efforts we provide to keep them healthy, there will be patients that will test the physician and our tolerances. Failing to address such behavior will positively reinforce continued behavior by these problem patients and will ultimately increase the physician's liability for such practices. Removing problem patients from our practice helps to create an enjoyable workplace environment for not only the physician but the office staff as well.

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