The Why and How of Dismissing a Patient

Jennifer Frank, a family physician in private practice in northeastern Wisconsin, is more than willing to give patients a chance.  She doesn't want to fire them.

"I've been able to have very successful and meaningful relationships with patients that have been [let go] by other providers," Frank says. "Sometimes you don't need to fire them. There are ways to build relationships with these people and be successful and take care of them. The other part is when people are reacting in very antagonistic or negative ways, there is usually a reason why. …I try to give them the benefit of the doubt."

But for many doctors, the reality of the situation is there are other times when dismissing a patient is necessary. Especially if the problem has been boiling for quite some time, says Rebecca Fox, a pediatrician at FoxCare Integrative Pediatrics in Loudon County, Va. "If it's one bad day, we all have bad days. If it becomes a pattern of bad behavior, at that point, you need to say goodbye," she notes.  

John Davenport, a family medicine physician with Kaiser Permanente in Irvine Calif., has a unique perspective on patient dismissal. Not only is he a doctor, but he is also a lawyer. A

"Some of the common reasons [to dismiss a patient] are the patients who are noncompliant or not compliant with recommended treatment plans or vaccination schedules," Davenport says. "Anger management issues, failure to keep appointments … and sometimes seductive behavior [from a patient] makes it difficult on a physician or a patient who actively acts inappropriate towards the physician."

Reasons to Dismiss

The reason to dismiss a patient may very well depend on the specialty of the practice. For instance, pediatricians such as Fox are faced with potentially dismissing a patient because of the parents' choice on vaccinations. This has become especially prominent in recent years. A 2016 study in the journal Pediatrics found that the number of pediatricians who have had to ask anti-vaccine families to take their kids' care elsewhere has nearly doubled from 2006 to 2013, going from 6.6 percent to 11.7 percent.

"In my former practice, we had a 100 percent vaccination policy for childhood vaccinations. They were required. When I was getting ready to dismiss a patient, I gave [their parents] three times to change their mind," says Fox.

Other practices have to deal with patients on pain medication and opioids potentially abusing substances. Some doctors show patience with these patients, like Linda Girgis, a family physician in South River, N.J. She says dismissal in general is a last-case scenario and for pain patients, she'll refer them to a pain management specialist. She does clarify, if they are proven to have been "doctor shopping," by looking up patients on a state registry that tracks opioid abusers, they are terminated without question.

Other doctors who are dealing with patients on pain medication are less hesitant in dismissing patients who are potentially abusing pain medication. Rodney Adams, a healthcare attorney with LeClairRyan in Richmond, Va., says he dealt with an urgent care who once wanted to dismiss a patient who they thought was a drug seeker, but it wasn't readily evident.  Frank says she has already seen more rigidity from her peers when it comes to pain patients due to the increased guidelines on how to care for an opioid patient and scrutiny.

Non-payment has always been a reason to dismiss a patient, but it's changed in recent years with the emergence of high-deductible health plans, says Davenport. Frank agrees and says this is becoming a big issue since many patients are essentially not insured, having deductibles around $5,000 at her practice. "It's challenging. I have to be thoughtful of what's absolutely necessary that I have to push hard for, and what are things that I think are in [the patient's] best interest but is maybe not absolutely necessary," she says. "I have to prioritize for the patient. That makes me nervous."

An obvious reason to dismiss a patient is abuse to the staff. As a pediatrician, Fox has a particular challenge with this since parents can get overly protective of their children and take it out on staff.

"You don't want to be around someone who will snap your head off at every turn," she says.

Actions to Take

There are several actions practices can take to avoid a messy situation when dismissing a patient. The first, says Davenport, is to consider the case. "If I dismiss this patient, is it going to cause harm? That's number one. If you believe that it will cause harm, you have to be careful in how you dismiss that patient or whether you can dismiss them," he says.

If there are no other options, there is a process that needs to be in place, says Adams. Physicians have to write a certified letter to dismissed patients giving them a 30-day window to find a new physician. For a specialist, the wait time could potentially be longer. During that transition period, he says, physicians are required by law to provide emergency and urgent care so the patient is not abandoned.

This is Fox's process for dismissing a patient, along with giving patients a copy of their records for their new provider. Along with the letter and the 30 days, Frank will give the patient feedback as to why they are being dismissed so they can have a more productive patient-physician relationship with their next provider.

The best thing practices can do to avoid any potential legal pitfalls is establish ground rules at the beginning of the relationship. If a patient has been dismissed by another provider, let them know up front that this kind of behavior won't be accepted at your practice. "The earlier you can address this, the better it is for the patient and the safer you will be legally," Davenport says. "When you take a patient that's been [let go] by another practice, that's a high risk patient. … If you are aware of the reasons for dismissal, address it right up front."

Some experts, such as Davenport, say practices should have patients sign agreements regarding drug-seeking behavior, payment, vaccinations and other potential issues at the start. Others stress the importance of documentation in the chart (or perhaps a supplementary file) during the process, especially when it comes to the dismissal. "You have to have documentation somewhere that they were asked to leave because there will be times that if you don't have it somewhere in that chart, [the patient] will try to go somewhere else in your practice, such as another office, and the staff won't know [that they are not welcome]," says Fox.

Moral Quandaries

Most physicians will tell you that this is not a black and white issue. It's not easy to dismiss someone who needs care, even if they are behaving badly. By and large, physicians are in the profession because they like to help people.

Adams says most physicians let the issue linger. "Most physicians think the best of patients," he says. "They think they can convince the patient to be disruptive and non-compliant. It's a hard conversation to have, to dismiss a patient."

Girgis says even though it's perfectly legal and acceptable, and the right decision when a patient is being abusive, doctors can be reluctant to dismiss. Frank looks for alternatives before pulling the trigger, such as asking an uninvolved colleague for advice, talking to the patient directly, or just having a measure of compassion for whatever circumstance the patient is in.

Moral quandaries aside, physicians have to be OK with dismissing a patient from their practice for an appropriate reason.

 "If a patient is being abusive, either to your staff or financially abusing you … if this is a business arrangement, you don't have to put up with that. Asking them to leave for whatever your reason, you should have documentation, but it's your practice. You can ask people to leave," says Fox.