1. T. Lianne Beck, MD Emory Family Medicine
Patient Abandonment and “The Difficult Patient”
T. Lianne Beck, MD Emory Family Medicine

2. Objectives
Describe the fundamentals of the patient-physician relationship.
Describe the types of “Difficult Patients”
Define indications for terminating the patient relationship.
List the steps that should be taken in terminating a patient relationship.

3. The Physician-Patient Relationship
The relationship is usually established when a physician conducts some form of history or physical examination. It may begin earlier, such as when a physician talks to the patient by phone and agrees to see them.
Once a physician-patient relationship is established, the physician has a responsibility until the relationship is terminated.
The obligation includes providing coverage when the physician is away or treating other patients.

4. Problem Behaviors Multiple symptoms involving multiple body systems
Vague and shifting complaints
Dependent, clinging behavior
Undue concern about minor symptoms
Excessive preoccupation with physical disease
Poor response to usual methods of treatment
Difficult to communicate with

5. Problem Behaviors cont…
Hostile, demanding, dissatisfied
High utilization of health care services
Manipulative, exploitative, controlling
Seductive
Unrealistic expectations of care
Raises new problems as visit ends
Resistant to physician’s recommendations
Noncompliant with treatment program
Rambling, unfocused
Self-destructive

6. Types of “The Difficult Patient”
The “Angry” Patient
The “Manipulative” Patient
Somatoform Disorder (“Frequent Flyers”)
Notorious Non-Compliant
The “Seductive” Patient

8. The “ANGRY Patient”
Pay attention to pre-visit signs: long waits and staff cues.
Is it true anger, or just pain and frustration?
Anticipation of Bad News?
DO NOT GET DRAWN INTO THE CONFLICT
KNOW YOUR TRIGGERS!
Patient anger is uncomfortable for the doctor and can lead to poor communication within the consultation, dis-satisfaction, and therefore patients who are more likely to make a complaint.

9. Strategies to Defuse Anger
Allow the patient to vent their anger.
Acknowledge the anger “I can see you are really angry about this.”
Validate the anger “understandably you are very angry as this is a very frustrating situation you are in.”
Offer to explore the situation in more depth – it is often found that there are many layers to the anger and frustration the patient is experiencing.

10. Strategies to Defuse Anger cont…
During the interchange keep calm
Use a neutral tone of voice, adopt an open body posture
Move back from the patient so there is plenty of space for the patient
Do not become defensive (do not take it personally)
Be aware of the position of the door or any emergency button should you require it.
In a novel study patients undertook to evaluate four different responses (apology, explanation, self-disclosure and acknowledgement) by physicians to patient anger (due to a long wait) by observing video trigger tapes. The approach evaluated as most important and satisfying was an apology combined with a short explanation e.g. ‘I apologise for your long wait. It’s been a hectic morning. Some of the patients have needed extra time.’ Saying ‘I apologise for your long wait’ was ranked higher than ‘I am sorry you have been kept waiting’, because the first response means the doctor is taking more personal responsibility for the situation. Most participant patients preferred the doctor then to move along in the interview by using a follow-up question like ‘shall we get started’ and not utilising questions that explored the patient’s feelings in more depth. Limitations of this study include the fact that videos were used and the anger the patients were observing was only related to the one scenario of being kept waiting by the doctor. Obviously offering an apology for things within the doctor’s control is a helpful strategy.

11. The “MANIPULATIVE” Patient
Play on the GUILT of others.
Impulsive behavior to get what they want.
High % of Borderline Personality Disorder
Be aware of your own EMOTIONAL triggers
Manage expectations and sometimes just say “no”.
These patients often play on the guilt of others, threatening rage, legal action or suicide. They tend to exhibit impulsive behavior directed at obtaining what they want, and it is often difficult to distinguish between borderline personality disorder and manipulative behavior. The keys to managing encounters with manipulative patients are to be aware of your own emotions, attempt to understand the patient's expectations (which may actually be reasonable, even if his or her actions are not) and realize that sometimes you have to say "no."

13. Somatoform Disorder Patients
Doctor Shoppers
Multiple tests, diagnoses, medications and “medication allergies”, and ER visits
Physical manifestation of psychic distress
Symptoms are real, just as your moods and emotions are.
Rx: Regularly scheduled brief office visits, but avoid tests and polypharmacy

14. Responding Clinically to Somatizing Patients
Conduct a straight-forward clinical investigation
Avoid elaborate follow-up and do not repeat tests without a compelling reason
Do not assume that a symptom is produced intentionally just because its psychological function is obvious to you
Many somatizing patients are alexothymic (without words for feelings)
If uncertain whether a symptom is produced intentionally, consult a psychiatrist
Treat the underlying psychological disturbance, not the physical symptom
A strategy for communicating with a new somatizing patient who has "doctor-shopped" might be to address the issue directly at the beginning of the encounter. For example, "I noticed that you have seen several physicians and have had extensive medical tests to try to uncover the cause of your symptoms. I recognize that the symptoms are a real difficulty for you, but I believe that these tests have ruled out any serious medical problems. I have another strategy to suggest that has worked well for patients of mine in similar situations. I would like to make a contract with you to see you every two to four weeks - often enough to see if there is anything truly new going on. If something significant develops that has not already been worked up, we will do more tests. We will meet frequently enough to provide you some assurance that we are not missing anything, and we will avoid uncomfortable and costly tests and procedures unless they are clearly necessary."

15. Clinical Strategies Brief regular appointments (4-6 wks. Max.)
Relapsing course and low morbidity/mortality associated with somatization
Brief physical at each appointment focused on area of patient concern
Avoid hospitalization, diagnostic procedures, surgery and excessive lab
Respect the unconscious processes that give rise to the symptoms and do not tell the patient it is “all in your head” or other variants

17. Non-Compliant Patients Defined
The patient's medical problem is potentially serious and poses a clinically significant risk to length or quality of life
At least one treatment exists that if followed correctly, will markedly reduce this risk
The patient has easy access to the treatment or treatments
The patient deviates significantly from most patients (with similar medical problems) in degree of compliance with medical advice, treatment, or follow-up in a way that directly or potentially jeopardizes the patient's health or quality of life.

18. Multiple Causes for NCB
Failure of Communication and Lack of Comprehension
Cultural Issues
Psychological Issues
Secondary Gain
Psychosocial Stress
Substance Dependency
Underlying psychological and social factors
Feelings of guilt, worthlessness, incompetence, shame
Loneliness, social isolation
Fear of abandonment
Life stress
Concern about personal safety: at home, on the street, other
Survivors of childhood abuse, sexual or other
Rational need for medical information or treatment
Somatoform disorders
Hypochondriasis
Personality disorders: dependent, obsessive or paranoid
Mood disorders: anxiety, panic, depression
Borderline personality disorder
Involvement with tort law or workers' compensation system

19. “The most helpful things I have ever done with noncompliant patients have been to ask questions, not to lecture, and to be willing to listen to what patients say. These activities are often very difficult to do within the time constraints of clinical practice. Sometimes I have to "suspend" the clock and my usual clinical approach and just tell the patient that I'm frustrated and concerned and that I need to know what he or she understands about the disease process and problems being faced. And then I'll just be quiet and listen as nonjudgmentally as possible. “
Quoted from Fred Kleinsinger, MD, Understanding Noncompliant Behavior:
Definitions and Causes |

21. The “Seductive Patient”
Even non-psychiatric care involves “transference” phenomenon
Caring and compassion misinterpreted as sexual suggestion
Innocent flirtations NEVER appropriate
Emphasize that this is a strictly professional relationship 
Utilize chaperone throughout interactions
Obtain consultation/referral if needed
Institute and enforce written office guidelines
Transference=feelings experienced by the patient toward the physician that recapitulate other important relationships within the patient’s life
Counter transference=the analogous emotions experienced by the physician in this relation with the patient

22. Patient Abandonment
Patient abandonment occurs when a physician fails to provide necessary medical care to a current patient without justification.

23. The Elements of Patient Abandonment
The physician duty: an obligation is created when there is an established relationship.
The patient must have had a reasonable expectation that care would be provided.
The physician must have failed to carry out the obligation.
There must be injury or harm to the patient caused by the abandonment.
What must the patient prove? The basic question: Did the patient reasonably believe that the physician would provide the necessary care?

24. Duty to Treat a Patient
Proof of a physician-patient relationship is an essential element in determining abandonment.
Abandoning a patient under care without making reasonable arrangements for the continuation of care is unprofessional conduct.
If no relationship exists, there usually is no duty to treat.

25. Potential Liabilities of Abandonment
Disciplinary action (licensing)
Malpractice
COBRA violations
Punitive damages
Elder abuse (example: neglecting to provide care for patients in SNF)
The physician can be subject to one or several of these for abandoning a patient.

26. Disciplinary Action
Doctors are subject to professional misconduct disciplinary action, including license suspension, for abandoning patients.
The act of abandoning a patient in need of medical attention is so blatantly improper, doctors accused of such conduct may face disciplinary proceedings from licensing boards, in addition to claims for malpractice.

27. Malpractice
It is well established that a doctor who undertakes to examine a patient (thus creating a doctor-patient relationship) and then abandons the patient may be held liable for malpractice.
These instructions, given to jurors in malpractice cades, illustrate the context of a physician’s responsibility.

28. The Idea of Abandonment
When a physician abandons a patient in need of medical attention, the conduct is egregious.
The common sense of laypersons may well be sufficient to suggest that such conduct by a doctor is not compatible with skillful or acceptable treatment.
The abandonment of a patient is something that all people can understand is wrong.
Illustrates that the physician-patient relationship is easy to comprehend, as is abandonment.
From: Moore, Thomas, et al. Abandonment of a Patient: A Physician's Liability. New York Law Journal, March 6, 2001.

29. Punitive Damages
Punitive damages = not to compensate the injured party, but to punish the wrongdoer for egregious conduct and to serve as a deterrent to others.
In contrast to cases with mistaken diagnosis or negligent treatment, abandonment involves acts with a bad motive or reckless indifference to a patient’s welfare.
Often punitive damages are not covered by malpractice insurance.

30. COBRA and Abandonment
Violation of COBRA if emergency treatment and stabilization is not rendered when a patient seeks care.
COBRA was designed to prohibit physicians from limiting the care of emergency patients to only those with financial resources to pay.
Per COBRA: The duty to treat includes a screening evaluation to determine whether the patient has an emergency medical condition. This means screening all patients who present for care to the ER or urgent care. If the physician serves “on-call”, the physician cannot refuse to respond. If the patient subsequently arrives for care in your ER or office after termination, treat the patient until they are stable. Follow-up with another letter that confirms that the relationship is terminated.

31. COBRA and Abandonment
KEY POINT = If a physician does not respond to a patient who seeks emergency care and the case has already been discussed w/ the physician (thus initiating a relationship), the physician may be accused of abandonment.

32. Discrimination and the AMA’s Position
A physician may not decline to accept patients because of “sex, color, creed, race, religion, disability, ethnic origin, sexual orientation, age or any other basis that would constitute obvious willful discrimination.”

33. Discrimination and Patient Care
Physicians cannot refuse to see a patient who is protected by law against discrimination.
If patient is illegally turned away, malpractice insurance may not cover any resulting claims.
Examples that are on the rise include refusal to treat HIV-positive patients without credible medical reasons.
However, a physician is not required to perform a procedure that conflicts with his/her religious beliefs.
If a physician has a religious belief that makes it difficult to treat patient, they should secure other coverage prior to withdrawing from case. Emergency room physicians usually have little discretion in turning away patients because of anti-dumping regulations.

34. Closed Practices
A physician may turn a patient away from the practice if the practice already has too many patients and is closed to new patients.
However, the physician must be consistent (that is, not accept some patients and turn others away).

35. Less Obvious Examples of Abandonment
Failure to transfer patient to appropriate care level.
Failing to respond to calls from hospital regarding inpatient.
Failing to respond to ER when on listed call panel.
Refusing to care for patient after arranging admission.

36. Less Obvious Examples of Abandonment – cont’d
Anesthesiologist leaving a surgical case in progress without coverage.
Failing to continue to treat the patient until coverage or consulting physician is able to assume care.
Failure to make routine visits to a patient in a skilled nursing facility.

37. Methods by which Care may be Terminated
By the patient at any time.
By the physician for specific reasons AFTER providing formal notice AND a reasonable opportunity to find substitute care

38. Reasons for Terminating a Patient Relationship
Breakdown of rapport with patient/family that makes it medically impossible to treat patient
Threatening behavior, abusive behavior or violence
Sexual advances
Repeated no-shows or non-compliance that interferes or jeopardizes patient safety
Refusal of treatment plan recommended by provider after having opportunity to actively participate in decisions.

39. Reasons for Terminating Patient Relationship – cont’d
Failure to pay (consistent) *BEWARE*
Patient misidentification of self
Fraud or theft (but NOT for drug-seeking behavior without first addressing problem)
Other reasons may exist per managed care organization contract

40. Inappropriate Reasons to Terminate Patient
Adverse change in health status
Cost of healthcare needs
High utilization
Drug-seeking behavior that you have not addressed

41. Cautions in Termination
Some situations require extreme caution.
Continued treatment, at least temporarily, may be preferred.
acute stage of chronic illness
final stages of pregnancy or
Situations that may appear to be discrimination

42. Actions to Consider PRIOR to Termination
Advise patient of potential consequences of behavior
Utilize patient care conference
Contract with patient for behavioral changes
Utilize case manager or social worker
For violent or abusive situations: may require a show-of-force or security
Appropriate use of other internal staff: risk manager, psych consult, or medical director
Because of the impact of patient termination, attempts to rectify problems with the relationship may be beneficial. However, these may not be appropriate in all situations.

43. Process of patient termination
Procedure should include:
Written notification
Reasonable notice and period of time for patient to find another practitioner (usually 30 days)
Adequate documentation of rationale for termination
Remain available for E.R. consultation until transition completed
Review managed care contracts

44. Termination letter
Focus the letter on the patient’s long-term benefits
State the reason objectively and briefly. Examples: persistent missed appointments, non-compliance with care
Do not be adversarial or accusatory.
State exact date of termination: e.g., at least 30 days from receipt of letter.
Remain available for emergency care during interim.
Controversy exists regarding amount of detail to include about reason for termination. If you can objectively substantiate reasons and your documentation illustrates this, more specific reason is appropriate. However, state it objectively, and be non-accusatory.

45. Termination letter – cont’d
Give referral resources (e.g., local medical society, patient’s health plan). Do not give specific physician name(s).
Offer to transfer copy of records.
Include authorization form for the patient with the termination letter.
Keep a copy of the letter in the patient’s record.

46. Other Considerations Inform all staff when patents are terminated.
Continuing contact with any staff member may extend the physician-patient relationship.
Examples: Rx Refills on day 28 “resets” the 30-day provision

47. Other Considerations For non-payment of bills:
Go through formal process in writing.
Provide adequate warning that patient will be terminated.
If managed care patient, check with plan first.
Do NOT refuse to copy medical records for subsequent providers if patient does not pay bill.

48. Specific Situations
No appointment for more than a year = does not necessarily terminate the relationship. Patient may be assuming that the physician is available to treat conditions that arise.
If a physician treats a patient who was previously terminated, a new patient-physician relationship is established. The physician has a duty not to abandon the patient until the relationship is again terminated.
Extra burden on physician may exist if there are no other services in the area.
For example, if a physician in the only group available there may be additional burden to treat patient. If the physician terminates the relationship, he/she should be certain there are other physicians available. In providing emergency care to a previously terminated patient, the physician should assess whether a new relationship has been established.

49. Non-compliance When a patient is non-compliant with treatment:
State the behavior that illustrates non-compliance. Labeling patient may give impression that you did not like the patient and therefore gave substandard care.
Document when and why specific treatment was not completed: i.e. “patient did not comply with instructions to take meds…”
If non-compliant, document behavior in chart. This aids in supporting the stated reason for termination in the letter to the patient. Example: “Patient did not take medication (state med ordered) as prescribed in spite of instructions to do so.”

50. Non-compliance
If patient chooses to see another physician, send a note to the subsequent provider with detailed history.
If repeated non-compliance makes it impossible to continue to treat patient, formally terminate relationship via procedure with letter.
Keep a copy in patient’s record.

51. Missed Visits Missed visits are one example of non-compliance.
Document all no shows and ALL resulting attempts to contact patient.
If patient indicates that they do not plan to follow-up, educate them as to the consequences. Document it.
Do not white out the information on the day sheet; indicate “no show.” Keep sheets per record retention policy.

52. Missed Visits
The physician may have some duty to try to contact the patient depending of the nature of the missed visit.
If, for example, vital lab test results have been obtained, it may be necessary to send a certified letter to the patient encouraging them to contact the office

53. Terminating a Managed Care Patient
A physician can be removed from a plan for financially discriminating against a patient.
The contract may have specific requirements for terminating a patient’s care.
If done in a manner that is not in accordance with plan’s requirements, physician could be in violation of the contract.
Some plans require that the plan be notified prior to terminating a patient.

54. Summary
Patient abandonment occurs when a physician fails to provide necessary medical care to a current patient without justification.
Once a physician-patient relationship is established, the physician has a responsibility until the relationship is terminated.
There are situations in which the physician can discontinue patient treatment. However, formal notice must be given and a reasonable opportunity to find substitute care must be provided.

55. Ten Useful Coping Skills for Physicians
Allow patients to vent their feelings.
Strengthen your communication skills.
Become a more effective history taker.
Try not to judge.
Remain calm and confident.
Understand your own strengths and vulnerabilities.
Be patient.
Be proactive.
Avoid becoming an enabler.
Respect your patients.
Ten useful coping skills for physicians
Caring for "problem patients" requires strong interpersonal skills, character and emotional maturity. The following list of skills represents an ideal that few physicians can fully achieve, but with self-understanding and practice most of us can come close enough to serve these patients well.
1. Allow patients to vent their feelings. Listen long enough to show your empathy, but set practical time limits.
2. Strengthen your communication skills. Remember that as a physician, you're also a teacher and a coach. Tailor your explanations and guidance to each patient's needs and ability to absorb information.
3. Become a more effective history taker. Ask the patient what's been happening in his or her life. Ask about the course of the patient's symptoms over time. Answers to questions like these may give you insight into the significance the patient attaches to the symptoms. They may also provide you with clues about what the patient is skipping over or not saying.
4. Try not to judge. Understand the difference between having high personal standards and trying to impose those standards on patients. View patients' disruptive actions as opportunities to learn more about their concerns, beliefs and needs.
There is a proper dosage for empathy, just as there is for digoxin. 5. Remain calm and confident. Stay in control while working with patients who are angry, depressed, manipulative, seductive or overly dependent. Strong, self-confident professionals can tolerate such behavior; others cannot.
6. Understand your own strengths and vulnerabilities. Know when to set limits on patients' demands in order to protect yourself from burnout.
7. Be patient. The problem behaviors you see in patients have taken many years to develop, and human behavior seldom changes quickly.
8. Be proactive. Cultivate the ability to move ahead with patient care in the face of incomplete diagnoses and complex psychosocial problems.
9. Avoid becoming an enabler. It's unhealthy for a patient to be overly dependent on you. There is a proper dosage for empathy, just as there is for digoxin.
10. Respect your patients. Protect patients' confidentiality, keep promises and show that you respect their feelings.

57. Resources
Hull S, Broquet K. How to Manage Difficult Patient Encounters.FPM. June
Haas L, et al. Management of the Difficult Patient. AFP. November
Kleinsinger F. Understanding Noncompliant Behavior: Definitions and Causes. The Permanente Journal. Fall
Gillette R. ‘Problem Patients': A Fresh Look at an Old Vexation. FPM. August

58. Questions?