How and when do you “fire” a patient

Unfortunately, if you see patients, you will encounter difficult and or rude ones. Good customer service skills will usually help you deal with almost all of them but occasionally a situation will arise where you need to “fire” a patient. While Dr. DeLoach and I have dealt with our share of rude, grumpy, difficult, and non-compliant patients in our careers, we have each fired only one patient in a combined sixty years of practice. We recommend that firing a patient always be a last resort and that you consider other options first. Your first choice should be to find a way to resolve the situation.  This is one time you as the doctor should step in and up as the mediator for the practice.  Make sure you have all the facts before discussing the situation with the patient.  Referring the patient elsewhere or taking them off of the recall system, can often be less problematic ways of dealing with the situation.

Some common reasons that doctors might want to dismiss a patient would include:

1. Rudeness or disruptive behavior. While this can often be a valid reason to dismiss a patient, good customer service skills can often turn these situations around. It is easy to be nice to nice patients. It takes exceptional customer service skills to deal with difficult patients and doing so can set your practice apart and often turn problem patients into happy patients who are active promoters of your practice.
2. Non-compliance. This is a common reason that doctors reach out to us about patient dismissal, but neither Dr. DeLoach nor I have ever dismissed a patient for this and would not. Dismissing a non-compliant patient will often result in worse outcomes for the patient. If you trust your skills as a doctor, where else can they turn to receive the exceptional care you offer them?  Non-compliant patients are often dismissed for fear of liability, but if a provider documents the non-compliance and documents the attempts to educate the patient, the liability is the patient’s. Education and patience are often better approaches for non-compliant patients. Try to work with the patient and try to help them understand the importance of treatment (informed consent), but also understand that you cannot force them to do something.  The patient ultimately has the legal right to make their own choices (informed refusal).
3. Theft – these patients often have no intention of coming back but for those who try, dismissal is certainly an option if not advisable.
4. Abuse of staff – physical or verbal abuse of your staff can and likely should be immediate grounds for patient dismissal. This is the only reason either of us have ever fired a patient.

This decision for dismissal should never be taken lightly, and you must handle properly by adhere to ethical guidelines and professional standards. Those would include:

1. Providing a dismissal letter to the patient
   • Keep the letter as simple as possible – do not overexplain or use excessive detail. Avoid stating a reason if possible.  An excellent statement is “I/we feel you seeking care from another healthcare provider is in your best interest.”  Much like firing an employee, the more you try to explain and justify the deeper hole you often dig.
   • State clearly the date termination becomes effective.
2. Consider any care needed – do not abandon a patient in need of care.
   • Let them know you will provide emergency care during the transition – usually 30 days minimum in most states.
3. Let them know they are entitled to receive a copy of their medical records – Even if the patient has an outstanding bill.
   • This is one situation where you want to pose no obstacle to full release of the patient’s medical record.
4. Provide information on how they can find another provider.
   • Offer to transfer records to the new provider upon receipt of a signed authorization to do so.
5. Be careful with the timing of the letter – don’t make yourself look guilty of poor care.
6. The discharge letter should be marked “personal/confidential” and mailed by certified mail, return receipt requested, to the patient’s last known address.  If urgent notification is needed, you can send the letter by HIPAA-compliant email but following up with a certified letter is essential.
7. File a copy of the letter and the receipt in the patient’s medical record.

Hopefully this is a situation that you never have to deal with, but if you do, try to focus on what is in the patient’s best interest.  Feel free to reach out to us – we are happy to help. We even have a template letter available for PCS clients.