The Doctor Will Never See You Again

* FEBRUARY 8, 2010

The Doctor Will Never See You Again
Physicians Can Boot Patients for Unruly Behavior, Drug Abuse and Other Reasons, but Must Follow Rules

By MELINDA BECK

When is it appropriate for doctors to "fire" patients?

Patients can and often do leave doctors they don't see eye to eye with, find inconvenient or can't afford. But doctors must follow strict ethical rules when they want to dismiss a patient.

The list of reasons is relatively short, according to medical associations: Patients who are chronically abusive, disruptive or drug-seeking may be asked to leave a practice. So might those who habitually miss appointments or refuse to pay reasonable bills. Failing to heed medical advice isn't necessarily grounds for a split, but some doctors suggest that patients who won't quit smoking, use illicit drugs or have potentially harmful habits (daily enemas, say) might be more comfortable in another practice.
[HEALTHCOL] S.B. Whitehead

"Physicians talk about this all the time—the 'difficult patient,' " says Lori J. Heim, president of the American Academy of Family Physicians who practices at Scotland Memorial Hospital in Laurinburg, N.C. "A lot of problems arise because the physician and the patient just don't click."

One increasing point of contention: vaccinations. These days, some pediatricians refuse to care for children whose parents won't let them be vaccinated out of fear that vaccines cause autism, despite considerable evidence to the contrary.

"When we do the prenatal visits, we let families know up front that this is how we run things," says Marcy S. Baker, a Tampa, Fla., pediatrician. Vaccination "is the most important thing you can do to protect your child. If you don't trust us on this, will you trust us on other things?"

A 2006 survey by the American Academy of Pediatrics found that 74% of members who participated had one or more parents refuse at least one vaccination in the past year; 32% of those parents changed their minds after education efforts from the doctor. Only about 16% of pediatricians said they sometimes discharge families if the parents won't relent.

"The vast majority of physicians just agree to disagree," says Seattle pediatrician Douglas Diekema, former chairman of the AAP's bio-ethics committee. The group recommends that approach over severing relationships, he says, "because it gives you the opportunity to continue the discussion. Two years later, if the child gets whooping cough, the parents may well change their mind."

Doctors have plenty of professional leeway about which patients they choose to treat in the first place (as long as they don't discriminate on the basis of race, gender, age or religion). They can close their practices to new patients, refuse to accept some insurance plans or limit the number of Medicare or Medicaid patients they treat for financial reasons. But when they do start seeing a patient then walking away is considered unprofessional—and often in violation of state-licensing rules.

"You cannot abandon!" Raymond Scalettar, former chairman of the American Medical Association, explains in an email. AMA guidelines state that a doctor may withdraw from a case only after giving the patient enough notice to find another physician. State rules vary, but doctors generally must document the behavior, inform the patient what the problem is, give him or her a chance to change, then send a certified letter stating the relationship is over, while still agreeing to provide treatment as needed for another 30 days.

Sometimes difficult patients just want attention. Early in her career, Dr. Heim says, she developed a technique for dealing with those who were disruptive or rude. "I'd tell them, 'I want to touch base with you on the phone every other week or see you once a month until you are stable.' Then they knew they didn't have to throw a fit to have somebody pay attention to them," she says. "After a few months, I'd say, 'Do we need to do this so often?' They'd usually say, 'No, I'm good.' "

Dr. Heim did part ways with a patient after the state warned her that he was getting multiple prescriptions for pain medications from other doctors. She tried to get him into rehab but to no avail.

Some states, including North Carolina, now have password-protected Web sites that let doctors see whether a patient has gotten prescriptions for controlled-substances from another doctor. Some practices also require patients who need long-term pain medication to sign a contract promising not to lose, sell or abuse such drugs and not to seek them from other doctors simultaneously.

The contract approach also comes in handy with other kinds of problematic patients. Michael Bannon, a general surgeon and chairman of the ethics subcommittee at the Mayo Clinic in Rochester, Minn., recalls a patient who was treated for a year with a hole in her intestine that wouldn't heal. She refused to let nurses care for the wound, and she would lock herself in the bathroom for long periods. Dr. Bannon eventually realized the patient was reopening the wound herself with a pencil, and when confronted, she admitted it. After consulting with lawyers, the hospital drew up a contract with rules she had to obey.

"We said, 'We're not going to allow you to come back here with self-induced, recurring problems,' " says Dr. Bannon. The contract, he says, "creates a kind of time-out and a reality check for the patient." In this case, the patient didn't return.

The right of doctors to refuse to treat some patients was upheld by the Fifth Circuit Court of Appeals in the 1987 case, Brown vs. Bower.

John D. Bower, director of a kidney dialysis program in Jackson, Miss., ran out of patience with a teenage patient who would frequently miss his dialysis appointments, then go on beer-drinking binges and require emergency treatment. "I liked Mike a lot," says Dr. Bower. "But he was an incorrigible person. He would pinch the nurses on the butt. He would knock over trays of sterile equipment and he'd show up in the middle of the night needing dialysis."

When Dr. Bower told the patient he would no longer treat him, a local advocacy group sued. Dr. Bower argued that forcing a physician to treat a patient would violate the 13th amendment of the Constitution, which outlawed slavery, and the appeals court agreed.

In the end, Dr. Bower had to treat the patient anyway, because the hospital had funding under a law that required it to treat anyone in need of care. Four years later, the patient died in a car accident.

"There will always be patients like old Mike," says Dr. Bower. "I thought the world of him, but...I couldn't get him to see that it was his life we were talking about."

Write to Melinda Beck at HealthJournal@wsj.com

http://online.wsj.com/article/SB10001424052748703630404575053221001720404.html