When should doctors be slower to dismiss?

While medical offices typically have good cause to dismiss patients who are violent or abusive, doctors and healthcare attorneys say they should be (and generally are) more circumspect in other types of frustrating but ultimately resolvable situations.

 Noncompliance

Joel Wakefield, JD, a healthcare attorney with the Nelson Law Group in Phoenix, Arizona, says noncompliance with medication or other aspects of physician care is probably the most common situation his physician clients face, and part of their concern is that they could still be liable if a patient’s health worsens. 

“They’re trying to take care of the patient, but they see the patient not being involved,” he says. “It is a combination of some people simply saying, ‘No, I’m not going to do that,’ especially if the treatment is uncomfortable or makes them feel weird, but it can blend into passive-aggressiveness, as well.”

This happens most often with patients who have multiple medical problems, or chronic mental health problems such as schizophrenia that interfere with their ability to comprehend their physician’s instructions or to properly care for themselves, says Gary LeRoy, MD, a primary care physician with East Dayton Health Center in Dayton, Ohio.  

But sometimes, a patient simply has a different agenda than his or her doctor, LeRoy says, based on an honest difference in priorities. “I might want to get their diabetes controlled, and talk to them about their labs. Their agenda might be that ‘my back hurts, and I want to get Vicodin.’”

Sandra Lewis, MD, a cardiologist in Portland, Oregon, and chairwoman of the American College of Cardiology’s ethics and discipline committee, recalls a patient with heart disease who wanted naturopathic treatment, which the physician did not provide. “I said, ‘You need to find a different cardiologist.’ Other than that, I really can’t remember ever firing a patient,” Lewis recalls.

Carrie Horwitch, MD, a Seattle-area internist, believes noncompliance should rarely lead to dismissal. “Those scenarios need to be taken on a case-by-case basis,” she says. 

 Confronting Collections

Collection issues can also lead to patient dismissal, although this is uncommon. Doctors in larger practices seldom even know when a patient falls behind on their bills, LeRoy says, and billing offices in those practices need to ensure that physicians are brought into the loop. As a Federally Qualified Health Center, East Dayton Health tries not to dismiss people for financial reasons, he says.

“We don’t ever send a letter out [to the patient] without informing the physician that this is something being considered,” he says. 

The center sends out two or three warning letters before discharge, which gives the doctor a chance to better understand their situation, LeRoy says. “Sometimes, you start connecting the dots when you start talking to the grandmother, the husband, the children. It makes it more clear why they’re having difficulties,” he says.

In smaller practices, where a doctor would be more aware of collections issues, LeRoy figures they probably also have more one-on-one contact with the patient and can try to work something out with them. “The key to that is communication, communication, communication,” he says. “You’re $2,000 behind, what do you want to do? … You still have to have a standard for triggering that discharge, so it’s not arbitrary.