Suggestions for managing difficult patients

As a young doctor, I tried very hard to please all my patients. I never wanted any patients to have a bad experience or to leave with negative feelings about myself or my practice. As I matured as a doctor and saw that I was unable to make everyone happy, I learned better how to manage the difficult patient.

I would like to relate perhaps a fairy tale and how the message applies to healthcare.

An old man and his grandson were traveling with their donkey on their way to the market. At the start of the journey, the old man sat on the donkey while his grandson walked and guided the trip. A passerby saw the scene and said to the old man on the donkey, “You are a strong man; how can you let the little boy walk?” The old man nodded in agreement and got off the donkey and the young boy climbed on top. Another bystander saw the situation and said to the old man, “You are an old man, and your donkey is very strong so both of you should get on the donkey and ride into town.” And so, they changed again and both the old man and the grandson mounted the donkey. Again, they passed another stranger offering advice who said, “Why don’t you both walk and give the donkey a chance to rest?” As soon as they dismounted from the donkey, the donkey ran away!

The moral of the story is if you try to please everybody, you will lose your ass!*

This story leads me to a discussion on discharging patients that you don’t want to provide medical care. I have been in practice for over 40 years, and I can count on two hands the number of patients that I had to terminate from my practice. Dismissing a patient can be a sticky wicket but there is a process involved, besides denying care, that must be followed when terminating a patient.

The discharge process must be conducted in writing, and I suggest the letter be sent as a certified letter with a return receipt confirming that the patient did, indeed, receive the termination letter. The letter does not need to provide a reason for the termination. My letter merely states that “I feel that in the best interest of your medical care that you find another physician who can provide you with the medical attention that you require.” The termination letter must give the date that the termination will take place, which is usually 30 days, and an offer to provide a copy of the patients’ records to either the patient or to the physician who will be assuming their care. I think it is important to offer to provide emergency care only between the date the letter is sent and the date that termination will take place. It is important to notify your staff and your colleagues in the practice that no appointment should be made for the patient and prescriptions that have been previously written will be refilled if appropriate to do so.

Finally, if the patient has a referring doctor in the community or other physicians involved in their care, I will often call the referring doctor and let them know about the termination. I want the referring doctor to hear about the termination from me and not the patient.

Bottom Line: Terminating a patient is never a pleasant task, but on occasion discharging a patient must be done for the health and welfare of the patient, the staff, and yes, even the doctor. So, remember the lesson from the donkey: try as hard as you might make all your patients happy, and discharging an occasional patient may just prevent you from losing your “arse”! If you have any stories, experience, or advice on terminating a patient, please let me hear from you.

*As told to me by Dr. Kendra Reed, Professor of Business at Loyola University

Neil Baum, MD, a Professor of Clinical Urology at Tulane University in New Orleans, LA. Dr. Baum is the author of several books, including the best-selling book, Marketing Your Medical Practice-Ethically, Effectively, and Economically, which has sold over 225,000 copies and has been translated into Spanish. He contributes a weekly video for Medical Economics on practical ideas to enhance productivity and efficiency in medical practices.  His 5–7-minute videos and short articles provide practical ideas that can be easily implemented and incorporated into any medical practice. Dr. Baum can be reached at doctorwhiz@gmail.com.