How To Fire a Patient From Your Practice (Some Prefer To Say Discharge).

Any type of social interaction will create a relationship.  Whether that  interaction is with children, pets,  coworkers or the cash register lady at Walmart, a relationship is established.  I think patients and physicians form a relationship that is unique in so many ways.  The relationship can be emotional.  Patients are  vulnerable to the physical stress of their life situation.  Physicians and patients also carry on a business agreement.  Physicians usually agree to accept payment for services through a mutually agreed upon insurance contract.  The financial terms for both parties are established in writing.

As with all relationships, a common goal can often be interrupted by insurmountable road blocks.  If two parties fail to agree on the rules of engagement, either party will often walk away.  The physician-patient relationship is no different.  If the patient or the physician is uncomfortable with their role in the relationship, both have a right to terminate the relationship. If a patient wants to pick another doctor because their insurance coverage is better, the patient moves on.   If the doctor decides not to accept  insurance anymore or simply wants to release all smokers from their practice, they have a right to terminate the patient-doctor relationship at any time.

Sometimes the breakup turns nasty.  Patients may  fire their physician for not doing what they want.  Patients fire physicians all the time.  Strictly speaking, that means the patient has severed the relationship with that doctor.  Physicians can also dismiss toxic relationships as well.    Physicians may choose to release a patient for not paying their bills or for  being verbally abusive to staff.    Physicians may even release patients from their practice for lying, displaying manipulative or illegal behavior, drinking, smoking or being  resistant to medical recommendations.     Sometimes, physicians don't even express a reason for firing a patient. 

Some folks find the term to fire a patient offensive by  arguing patients can't be fired because they aren't being paid. Instead, they believe patients  fire doctors and doctors resign or discharge  their relationship with the patient.  I disagree.  The definition of being fired is to dismiss from a job.  When a doctor fires a patient, they are dismissing the patient from their job as a patient in their clinic.    The patient-doctor relationship is viewed by some as a position of servitude.  If the patient pays the doctor, the doctor's job is to serve the patient.  I disagree.  In spite of my skills,  I will never be compelled to provide my physician expertise on anyone's terms but my own.

Doctors provide recommendations under terms they have agreed to. Check the terms of your insurance arrangement with the patient if you wish to release them from your clinic so you can make sure you follow the correct protocols under your contract, if any.    Patients can fire  physicians for no reason at all and doctors can  fire patients for almost any nondiscriminatory reason at all.    In other words, don't break any civil rights and you should be fine.  It's also good practice not to discharge a patient during a medical crisis.

Most patients and most physicians will have a reason to be fired, whatever the reason is.  Physicians have an obligation to provide the patient with resources to  find another physician, not to find the physician for them.   Usual customary practice provides a 15-30 day grace period of coverage after termination of the relationship while the patient makes arrangements to find another physician, usually by contacting the local medical society.  Send the discharge letter by certified mail.  You can find a great discussion on how to discharge a patient from your practice as well as a good example of a discharge letter provided below and discussed here from a medical malpractice insurance publication.  
I find it necessary to inform you that I will no longer be able to serve as your physician. The reason for this decision is [indicate a reason or omit this sentence.]
As you [may] require medical attention in the future, I recommend you promptly find another physician to care for you. [You require ongoing medical attention for the following:] Contact the [local or state] medical society for the names of physicians who are accepting new patients.
I will be available to treat you on an emergency basis only until [insert date, 15-30 days after this letter is mailed]. This will give you time to find a new physician. Enclosed is an authorization form that permits me to send your new physician a copy of your medical records. Please complete the form and return it to me.
Have I been fired?  Yes.  Have I fired patients?  Yes.  In all cases,  the basis of the decision rested entirely on the inability to work in an environment conducive to a healthy recovery.  In all cases, patients were abusive, addicted to opiates or threatened physical assault.  Most patients who are fired by a physician are fired because of personality conflicts with the patient.  This makes a healthy physician-patient relationship impossible.  What I usually hear physicians say is, "I had to fire Mr. Smith. He's crazy.  He's nuts".   When I hear about doctors firing patients, the reasons are usually the same.  The patient is  abusive, demanding, demeaning, threatening, manipulative, or addicted and have made decisions not to seek or comply with appropriate medical therapies.   The most  common personality traits I see in patients fired by physicians are antisocial, narcissistic,  borderline or  dependent. Most physicians who are fired by a patient are grateful of the termination.  They breath a sigh of relief in making the toxic relationship dynamics a problem for someone else to deal with, as this crude medical e-card explains.

"The problem with most physicians is that they probably don't have a problem making problem patients someone else's problem."

Make your problem someone elses ecard humor

Facebook humor:

-->  I had a lady once overdose on her dog's Dilantin. I can just see it now. The dog goes to his vet and tells him that someone stole her medication. I'm sure the vet will fire the dog and tell it to get out of his doggone clinic.

Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.

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22 Outbursts:

  1. When I had my primary care office practice, I fired one patient every two months or so.

    It was best for both parties.

    Fired patients are well able to find a replacement for a primary care physician. That's not my responsibility. The patient needs to feel good about the new doctor, and that comes from doing his own research.

  2. If you're not providing a product, then you're providing a service. And to provide a service is to serve.

  3. uh did you miss the ethics lectures during 1st year at medical school? The doctor-patient relationship is not nearly as simple as the one between a bartender and his customer (or any other business relationship for that matter). It is definitely questionable ethically to dump a patient when there is NO REASON (your words: "There doesn't even have to be a reason for a physician to fire a patient from their practice.") and when it is unclear if they will be able to obtain another doctor (which the first commenter simply assumes will automatically and immediately happen; a very dubious assumption).

    And by the way, the "problem" patients are usually the ones who need help the most. Isn't that the whole point of being a doctor?

  4. I recently "fired" my rheumatologist and switched to a new one, and I need to do the same with my primary care physician. I have had the same dentist for 30 years, the same PCP for 8 years, the same gyn for 9 years, and the same rheumatologist for 6 years (since I started going to one). Often the only reason I change doctors is because one dies or retires (as in the case of my family doctor and cardiologist) or one moves (as my previous PCP did and my CNM/gyn did). I feel guilty about the recent need for chane because these are nice people who have done a lot for me--and yet suddenly are blaming me and turning Louise Hay-New Agey nutso (I truly can't help continuing pneumonia, it's exasperating) or being negligent with serious problems.

    When I had to carry medical records to a new doctor recently, I was surprised to see medical records from different practitioners recorded me as shy, pleasant, and very pleasant. The PCP's nurse groups me among her favorite patients (it's terrible to have been there enough to become one) and one doctor reassured me he liked me. And yet I have been fired by one doctor. I don't smoke, drink, or go psycho on office staff, but I did make a complaint about office policy that was affecting our family and proposed a solution. I didn't see this as anything we couldn't work out. But I've been very reluctant to ever express any concern to a doctor since and scared to even ask about alternatives.

  5. "In all cases, patients were abusive and addicted to narcotics, or indicated threats of physical assault. Or families making decisions for patients were engaged in irrational expectations causing harm to their patient family member."

    This really doesn't apply to me or my family. I hope this isn't the way my PCP and rheumatologist see me. While I take small doses of narcotics for intractable pain, I do without doses when needed (driving, concentration) and don't meet any signs for addiction. Maybe they do see me as psycho. Jeez, I don't know or have a way of knowing, only that they ignore test results indicating serious underlying conditions and I've had to get help from urgent care doctors instead.

  6. Slightly Disgruntled HospitalistFebruary 28, 2009 at 3:21 PM

    Did you read the whole "difficult patient" thing in NYTimes the other day? Especially the forum of doctor-bashing bloggers? I'm just curious. Whenever I read those, I want to cry and give-up. Do you ever feel like you are selfish for doing anything less than meeting every patient demand? For example, I knew I had several patients to discharge one afternoon. I had to wait until 1 for one of them to finish dialysis. When she wasn't done at 1 pm, I decided to go grab lunch really quickly. I walked to our office, heated up my lunch and got a page at 1:10 that she was back and wanted to go. I said that I would be back at 1:30 to 1:45. Well, she lived 2 hours away and didn't want to leave that late. I said it shouldn't be dark yet and I'll be there in half an hour or so. Apparently they were not happy with that so I skipped my lunch and discharged them when they wanted. I felt like a slave. The care would not be affected AT ALL by waiting 30 minutes. Yet I felt selfish for wanting to take a few minutes to eat lunch. This is a daily occurrence in different ways and I don't know how to combat it.
    I noticed that with this blog, you talked about "serving" the patients and I feel professional dissatisfaction when I just do what the patients want. I mean, I want my meal for free when I am "served by a waiter" but I don't get it. We are supposed to do the best thing for the patients, but we have limitations. There is only one of me. I can't be everywhere at once. I will sacrifice my meals and sleep to avoid any harm to a patient, but how much do I have to sacrifice to make everyone happy? This is burn-out...

  7. Slightly disgruntled hospitalist; no reasonable person demands that their doctor skips lunch. Having to wait 30 minutes is often understandable as a patient in this day and age; and I don't know anybody who thinks doctors are slaves or whatever you are talking about.

    But really, let's be clear: firing a patient for no reason without ensuring that they have alternative care is different; it is unethical as a physician.

  8. I transcribe for doctors all over the country. I can tell you that in the past 10 years, almost every practice discharge letter I have done has been very clear in its wording, why the patient is being discharged from the practice.

    Nine times out of ten it is for noncompliance and/or drug seeking behavior.

    Truthfully, I think the physicians were MORE than generous with their patience in trying to get these patients to clean up their acts. Usually the letter is the last of many documented "conversations" between the parties and typically it is the physician that has given the most effort.

  9. Slightly Disgruntled HospitalistFebruary 28, 2009 at 6:07 PM

    Technically the "reasonable patient" doesn't demand that I skip lunch because they don't know I was eating lunch. I could come in and tell them, but that seems unprofessional. It's not that they are trying to make me their "slave", but America is full of egocentric people (including doctors, of course). I feel like any action that is not what the patient wants me to do at that moment is considered a failure on my part - and then the forums on NYTimes go and prove it. And then another aside - there *are* quite a few patients that are unreasonable.

    Second, there is always a reason for firing a patient. Even if it that the doc is trying to cut back their practice so they can go to their kids baseball games. A patient gets 30 days. Do you want the physician to make the phone calls to new doctors for the patients too. On another aside, I had a patient express his concern about being able to afford his Vicodin the other day (20 pills costs about $15 at Target - I called and asked for him) By the way, this guy smokes a pack a day so he gets $4 a day from somewhere. I told him that some pharmacies are cheaper than others. He said, and I quote, "Why don't you go find out which one is cheapest and get back to me?" HUH? WTF! You can use a phonebook and a phone just as well as I can. Why don't YOU go call around and find out where you want to buy your medication? Needless to say, I called around and didn't find it anywhere cheaper. He left the hospital before I even got back to him. I know I am supposed to do the best thing for my patients, but I could tell you at least one story a day like this.

  10. Interesting, OHN--my letter said nothing, and I'd only been in twice. This was a brand new doc so maybe a lack of experience was part of it.

    Slightly Disgruntled, what you explain seems to be a reflection of a sense of entitlement people have in general lately. Teachers tell me students expect As now because they think they deserve it, not because they've earned it, because they've paid for a class. And 5 out of 5 disability spots were taken by "ableds" last week at the school even though they had no plates/tags and I need to use a wheelchair lift--it's just a sense of entitlement that's pervasive everywhere. While people may make suggestions to/ask questions of doctors, it doesn't make sense to make demands. People think they have the $ and they deserve what they want with it, whether it's an antibiotic for a virus or an unnecessary test that wouldn't change treatment. Same problem that teachers describe.

    And yeah, people do need to respect doctors' time--they do a lot outside that appt. time when things go wrong: consulting with other specialists, doing research into the causes of problems, calling me and ordering more labs based on what's found, providing needed documentation. The time that goes into these things is appreciated beyond belief, but I've found doctors look surprised when I thank them for their time because apparently others aren't doing so. I've also learned that patients treat nurses and nursing assistants like s***--they're not slaves or servants and a thank you to the person having to clean up your embarrassing mess goes a long way.

    If Vicodin guy was in that much pain, he wouldn't be complaining about the cost but would be grateful for the enhancement to his quality of life.

  11. Slightly Disgruntled HospitalistFebruary 28, 2009 at 8:38 PM

    Do you ever confront people who use disabled parking spots when they aren't? I am too meek. I watched someone get out of their car the other day and walk very normally into a store. I am sure the tag was for a family member. I didn't want to say anything in case I was wrong, but I was steaming. Many patients/people need those spots so it frustrates me when they take them up - but they will never get a ticket because they have the tag. ARRGGHH.

    I know the entitlement complex is all over (again, including doctors) but I do feel like we take a good amount of negativity. I'm not trying to tell tales of woe because I know I have it good, but I worry that if I feel so helpless that I want to leave medicine, many other must feel this way too.

    By the way, I often read your comments. I wish you were my patient sometimes. Despite what people think regarding doctors not wanting patients who have a lot of medical knowledge and who ask a lot of questions, most doctors find it refreshing to engage in an intelligent conversation regarding someone's health.

  12. How is a patient necessarily one out of their own free will? I'm not talking about the obese or smokers, but those who chose the wrong genetics/bad luck. And to think that a patient chooses that as their job is mighty presumptuous.

  13. Anon 503 "Slightly disgruntled hospitalist; no reasonable person demands that their doctor skips lunch."

    Yes they do, i have seen more than one patient mad on the ER when i go to have my lunch at 900 pm.

    Patients think they are the sole person in hospital, there can be 100 patients, but they think they are the only one.

    Patients are abusive, they ask for uncesesary tests, even uncesesary medications, they often come with a diagnosis, is arrogant to impose a diagnosis, if you are not even going trough out medical school.

    Patients lies most of the time, becuese they dont know, because they dont understand you, because they want to, there are several reasons on this, still they want an accurate diagnosis they want answers and fast.

    patients want everything fast, treatment diagnosis if you dot give them that on the first consult then you are crap.

    I have seen more than one patient say:
    relative of patient: I m friend of the major/hospital director/minister/every other highly position treat him/her well.

    Me: i will treat him as any other patient.

    ROP: suprised and with a scary face, you have to treat him well.

    Me: For me all my patients are specials, WE ARE ALL THE SAME.

    why do patients have grandiosity delousions, i dont know but happens all the times, and its annoying.

    when i go to hospital, i dont like to identify as a doctor, i wait sitting, dont demand to be the first, being ill doesnt make you a doctor`s victim, i dont have to kiss you ss, i just have to do my job.

  14. I am a female physician, and I know that patients interact differently with me than they do with my male colleagues. I am not surprised that more women report having difficult patients (with reference to the NYT's article).

    I am deeply pained when I fire a patient, feeling that I have failed. I know that patients come to me at a very stressful time. HOWEVER, the fact that I am a physician does not give others the "right" to abuse either me OR my staff. It does not give patients the right to sexually harass me or try to intimidate me. They do not have the right to impact my care of other patients, either.

    When I fire a patient (which is a very rare occurrence), it is not my obligation to find them another physician. If you think about that dynamic, it doesn't work in any direction (either the receiving physician hates me for the "referral" or, if that relationship fails to work out, the difficult patient might blame me.)

    Because I do not want to get in a "pissing" match, the letter normally states "a failure to establish an appropriate physician-patient relationship." Period.

  15. Slightly Disgruntled, good question. Often I won't tell people off because someone mentally "off" enough to park their black Hummer in a van space illegally is likely to be off in other ways too, and I don't want to risk violence. When I don't need it, I don't use it even if there's no close parking. And at crowded places (drs. offices, some stores) where lots fill up we'll park in the next available nondisability space if I can use it. I've seen other people do this too. My husband never uses my tag and is the only parent at Girl Scouts not to park in disabled parking. The newer hangtags do carry people's initials and an expiration date, though that doesn't help with all the older tags out there. But do be careful--I am mid-30s and got my tags when I had difficulty walking any distance--if people watched, they could quickly tell, but I could see them puff up first and I've had drivers be extremely aggressive with me (pointing at the tag, which I can't lean forward and take down--you have to have this even with plates now). I also have a friend who was shot, young and beautiful, and she has almost no lung capacity and will pass out if she walks far. So I *try* never to judge, though if someone jogs into WalMart I get pretty ticked. I have twice confronted people recently--both at schools where I cannot get in unless I use disabled parking (I can't use the wheelchair lift if I parallel park). I felt pretty safe there that no one was going to go postal on me.

    You know, some drs. may overprescribe tags but I suspect most don't. There is a lot of abuse, inherited tags, etc.

    Thanks for your comments. I have found that most of my doctors are very welcoming of any reading or research; one recently pointed me to a study which explained why he wasn't sure if a procedure would work. I know my doctors have the bigger picture, but also see myself as responsible for my health and feel better when I know what to expect over the long-term. The reason I think most people wouldn't want to be my dr. is that tracking down the zebras has become endless and probably without definite answers, frustrating for everyone. We can see the stripes but not the whole beast or where it's headed.

    Burnout I get, from my own field. My advice from that is to concentrate on the good interactions and emotionally detach as much as possible from situations where people are being unreasonable (which I should probably do too, it works both ways); those people exist with most any job. They're everywhere, mwahahahaha.

  16. Oh, one more thing. If you think people are abusing disability parking at your office or hospital, see if security on your campus can do spot checks. I was told when I got my tag not to keep the proof paperwork in my car in case my tag gets stolen, but mine has my initials and the expiration; these are still often abused. For others who don't carry tags with initials, they can still be asked. Some people will cave under pressure.

    The more people see enforcement, the less people will abuse it. Police can make far more $ in most places on disablity permits than on speeding tickets. Avg. of $300 for first offense, $100 in court fees, time in jail in some states.

    I'd take no offense at being asked if it prevented others' abuse of it.

  17. From the American Medical Assoc:
    "Physicians have an obligation to support continuity of care for their patients. While physicians have the option of withdrawing from a case, they cannot do so without giving notice to the patient, the relatives or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured." (E-8.115 Termination of the Physician-Patient Relationship)

    Given the first sentence of that statement, it certainly does not seem like the AMA is supportive of doctors "firing" patients for no reason. Think about it; if every doctor routinely fired patients for no reason to the same degree that you say that you do (which is certainly not the norm) then at-risk patient populations would have a major problem with continuity of care. Diseases and treatments would be missed because they would constantly be introducing themselves to new doctors before being shoved out the door again.

    And you are 100% wrong in your assertion that the doctor and patient have an equal relationship. The doctor is the professional and his responsibilities are greater to the patient than the other way around. And no, that doesn't mean that doctors should be "slaves" so don't even go there.

    News flash: many people besides doctors have trouble finding time for lunch at work. Get a box of tissues if it bothers you that much. And in the ER? Are you kidding? Did you really think you would be getting leisurely lunches every day when you were starting out? If so, you really got in the wrong line of work.

  18. Anon 5:04.
    You completely misread the AMA ethics statement. The comment regarding continuity of care refers to giving the patient time to find a new provider and providing records to said new provider. There is NO ethical or legal obligation for a physician to continue treating a patient when the physician/patient relationship is no longer functional. Happy's statement "for no reason" implies that both parties have equal rights for ending the relationship. The day I am forced to see patients that I do not want to is the day I quite medicine because the only way that will happen is at the point of a gun.

  19. Anon 5:04.

    News flash: many people besides doctors have trouble finding time for lunch at work. Get a box of tissues if it bothers you that much. And in the ER? Are you kidding? Did you really think you would be getting leisurely lunches every day when you were starting out? If so, you really got in the wrong line of work.

    what are you talking about? do you really think that all that goes to ER are pulmonary edema, IM, stroke, TSV, VT, tension pneumotorax. having a lunch in those situacions are really a leisure.

    If you were a doctor you should know that what you see most on a ER is people that got headache, backpain or fever, an endless amount of people like that, i wouldnt mind to skip my lunch for a critical situacion with no doubt. but remember ER members are still human beings not just robots, if you consider than going to eat or to pee is a leisure, you truly think that doctors nurses and the rest of the staff are slaves.

    geez i dont even sleep and someone say im not qualified to this job.

  20. @Slightly disgruntled doc:

    You know, about your analogy about "I want my lunch for free", because my waiter is "serving" me, but that doesnt happen, I have a couple of points.

    Youre comparing apples to oranges.

    Your patient isnt saying they want their dialysis for free. Theyre saying they want it to be done on time. Theyre still paying for it.

    Suppose your waiter said "Hey, buddy, your meal is going to be 45 minutes late, even though youre paying for it, because, hey, I want to go get lunch!"

    How happy would you be, pal?


  22. What ever happened to treating a patient with dignity and respect? I had an encounter with an ENT physician that has left my head spinning. I am being treated at the facility for allergies and have had an ongoing earache for the last 2 months. When I saw the doctor (first time for the ear) a couple of days ago he was not sure if he wanted to treat the ear problem with antibiotics or steroids. (I am healthy, do not take prescriptions or medication unless it is absolutely necessary). However when the physician decided to prescribe the steroid and said it could possibly keep me awake at night, I suggested the antibiotic might be a better choice (after all it was discussed at the beginning of the exam). The next thing I knew the physician blew. He grabbed/yanked the steroid prescription from my hand, slammed it on the table and had a complete melt down. He started yelling at me and told me if I thought I was the doctor what should he prescribe. He told me I was wasting his time and could find a doctor anywhere to prescribe an antibiotic. He went off for 2-3 minutes (remember the antibiotic was one of his suggestions). I could not even find words to respond to his melt down. I felt totally abused physically by ripping the script from my hand and verbally assaulted. When I left the office, I discretely told the receptionist that I would like to switch doctors, and I don't like being yelled at. They switched me to the other doctor. When I called back later realizing I had a 6 month re-check appt. with the abusive doctor for allergies and needed to switch it to the other one, I was told I was being discharged. (The doctor goes off on the patient and he decides to terminate the patient, lets get real). I have never heard of this happening anywhere (I could see if you don't pay your bills or miss your appts., or did not comply with a treatment plan). The doctor made a big fool of himself by losing it and cannot face the patient again. Funny, I am not the first patient to be fired, according to his staff he has a history of this. I work in a hospital in Human Resources and Training and if a physician talked to a patient this way, he would be suspended or fired. I still cannot believe this temper outburst (I was nice, calm and polite throughout the exam). You think he needs a psych eval?????


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