treatment plan
You're Fired! Why, When and How to Dismiss Patients
BY WILLIAM TOWNSEND, OD

A state agency referred John, a 28-year-old Hispanic male, to our office for evaluation. His ocular history was significant for long-standing, poorly controlled glaucoma. Visual acuities were OD light perception, OS 20/30. Tensions by applanation were OD 32mmHg and OS 28mmHg. Gonioscopy showed open, heavily pigmented angles. Optic nerves were pale OU with 100 percent cupping in the right eye and 90 percent cupping in the left eye. Numerous eyecare providers had prescribed pressure-lowering drops for John, but at the time he presented to our office, he used no drops.

The Life of John

We spoke with one of the MDs who treated John, and he described a history of noncompliance. We told John why we had to lower his pressures and discussed treatment options including medications, laser and surgery. He declined surgery and argon laser trabeculoplasty, so we prescribed topical drops. A week later, his pressures were significantly lower. He failed to keep his next appointment and later presented with high pressures, admitting to not taking the drops for a month. We fired him as our patient.

The relationship between the provider of a service and the consumer of that service is considered "at will;" either party is entitled to cease all transactions unilaterally, subject only to general antidiscrimination laws.

Individuals who are noncompliant with their doctor's recommendations or medical advice risk injury to themselves and pose potential liability to their care provider. Healthcare providers have a special fiduciary responsibility to act in the best interests of their patients. This implies that the doctor is obliged not to abandon a patient in medical need.

Dismissal Tactics

We've established a policy to dismiss patients who berate, curse or threaten our staff, but other acceptable reasons exist. (For example, a patient who's disruptive to your practice or consistently noncompliant with your recommended treatment plan.) To protect yourself against such behavior, document patient noncompliance. It's usually permissible to terminate the relationship in such a case, but only after you take steps to avoid patient abandonment.

To dismiss the patient in an appropriate manner, give him adequate notice in writing, preferably by certified mail, return receipt requested. Also, explain to the patient why you're terminating the relationship and document notification and the reasons for termination in the patient's medical record.

Another important obligation in dismissing patients is to help them find another provider. Offer to transfer medical records to a newly designated provider once you have obtained a signed patient authorization to do so. Make sure you comply with all HIPPA regulations and continue to provide care until the patient is under care of the new provider.

You may also end your professional relationship with a patient who fails to pay you despite your staff's collection efforts -- with exceptions. (The most obvious being that you're obliged to provide care for your patient in a crisis situation.) You also must provide services in ongoing care situations until you've completed the transfer of responsibility. Consider consulting your attorney for forms that aid this transfer.

In the End

John returned to our practice months later, after seeing a glaucoma specialist who performed bilateral trabeculectomies. John's pressures were now in the low teens. He actually appreciated the fact that we fired him from our practice because it had jolted him into reality.

Dr. Townsend is in private practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center. E-mail him at drbill1@cox.net.