1. Patient Abandonment and “The Difficult Patient” David E. Kolva, M.D. SJHHC FMRP

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

5. 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! Keep yourself safe in exam room. Use law enforcement if necessary

6. 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.

7. 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/emotions are. Handout articles from AAFP Rx: Regularly scheduled brief office visits but avoid tests and polypharmacy

8. Non-Compliant Patients Often result of illiteracy or hidden family financial problems Cultural Sensitivity devalues prevention (i.e. SE Asian) MD office systems breakdown Poor physician communication with patients = vague expectations

9. The “Seductive Patient” Even non-psychiatric care involves “transference” phenomenon Caring and compassion misinterpreted as sexual suggestion Innocent flirtations NEVER appropriate Strict office policy regarding chaperones and after-hours visits

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

11. 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.

12. 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.

13. Potential liabilities of abandonment Disciplinary action (licensing) Malpractice COBRA violations Punitive damages Elder abuse (example: neglecting to provide care for patients in SNF)

14. Disciplinary action Doctors are subject to professional misconduct disciplinary action, including license suspension, for abandoning patients.

15. 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.

16. 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. From: Moore, Thomas, et al. Abandonment of a Patient: A Physician's Liability. New York Law Journal, March 6, 2001.

17. 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.

18. 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.

19. 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.

20. 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.”

21. 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.

22. 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).

23. 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

24. 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

25. 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

26. 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.

27. 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

28. Inappropriate reasons to terminate patient Adverse change in health status Cost of healthcare needs High utilization Drug-seeking behavior that you have not addressed

29. Cautions in termination Some situations require extreme caution. Continued treatment, at least temporarily, may be preferred. 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

30. 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

31. Process of patient termination Procedure should include: –Written notification (see next slide) –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

32. 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.

33. 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.

34. 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

35. 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.

36. 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.

37. 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…”

38. 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.

39. 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.

40. 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

41. 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.

42. Summary Patient abandonment occurs when a physician fails to provide necessary medical care to a current patient without justification. One 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.