By Clifford Warren Lober, MD, JD, October 01, 2013
As Bryan is about to leave his law office for the day his receptionist enters his office. She tells him that Madison, a dermatologist and longstanding client, is on the telephone and is quite upset. Bryan answers the telephone.
Bryan: Good afternoon, Madison! How are you?
Madison: Not well. I just finished seeing a patient who has repeatedly failed to comply with my treatment recommendations and is now angry with me because he is not getting better. Furthermore, although he has been told that he needs to make an appointment prior to coming to my office, he shows up repeatedly without having done so. I have discussed this situation with him more than once and it has apparently done no good. I am uncomfortable dealing with him!
Bryan: Rather than struggle with a non-compliant patient whose expectations seem unreasonable, it is in your mutual best interest to dismiss him from your practice. It would seem to be difficult if not impossible for you to fulfill your legal and ethical duties to him if you are not comfortable in your relationship with him, especially if either or both of you have already developed negative feelings toward the other. [pagebreak]
Madison: Bryan, I really don’t like dismissing a patient from my practice.
Bryan: Of course you don’t, but it is far better to terminate a bad doctor-patient relationship than to allow problems to escalate. As you have mentioned, the patient is already upset with you.
Madison: What do I need to do to dismiss this patient?
Bryan: You should send him a certified letter, return receipt requested, as well as a copy by regular U.S. mail, letting him know that after 30 days you will no longer be his physician. He should be advised to seek further care from another board-certified dermatologist during this time. Furthermore, let him know that you are available to see him by appointment during the next 30 days if he needs to see you. This avoids the accusation that you abandoned him. It is also wise to advise him in the dismissal letter of the medical consequences, if any, of failing to follow-up with another dermatologist.
Madison: What if he refuses to accept the certified letter?
Bryan: Keep it as part of his medical record. The fact he refused the letter is further evidence of his non-compliance. You do not need to open the letter if it is returned. After all, you know exactly what’s in the envelope since you sent it to him! [pagebreak]
Madison: Do I have to give a complete explanation for dismissing him?
Bryan: No. You do not have to review in explicit detail the events leading to your decision to dismiss him. The intent of a letter dismissing the patient from your practice is not to give him a reason to argue with you, but rather to cleanly and legally terminate the relationship. A general statement indicating that under the present circumstances you do not feel that it is in his best interest for you to continue to provide his medical care is usually sufficient.
You should also be aware that in a few states the Board of Medicine has a form letter available on the Internet that you may use when dismissing a patient.
Madison: Should I give him the name of another colleague?
Bryan: Absolutely not. It is better to refer him to his primary care physician, the county medical society, a local hospital, or to a similar referral facility. You want to make him responsible for selecting the physician who will subsequently treat him. Besides, do really want to send a patient you are dismissing from your practice to a specific colleague? [pagebreak]
Madison: Should I enclose a copy of his medical records with the dismissal letter?
Bryan: This is usually not required by state law. In my opinion, however, it is wise to do so to eliminate the need for either the patient or a subsequent treating physician to have to contact you to request the same. When you enclose medical records you should indicate in the dismissal letter that you are doing so to facilitate his future medical care.
Madison: What should I do if he needs to see me in the next 30 days?
Bryan: He should be given an appointment just like any other patient. If he has a true medical emergency you should either attempt to see him immediately or refer him to the emergency room. It is critical, however, that if he comes to your office you do not see him alone. Remember, this is a patient who you are in the process of formally dismissing from your practice. He will most likely not be in a good mood or regard you kindly, to say the least. Having your nurse or another person present at all times you are with him will lessen the likelihood that he will claim you said or did something inappropriate. [pagebreak]
Madison: What if he makes an appointment and comes to the office or calls to discuss the reason I am dismissing him? What should I do if he apologizes and wants to continue being my patient?
Bryan: You do not want to end up debating the patient. You should strive to end the relationship cleanly. Emphasize that your decision to dismiss him is in your mutual best interest and is final. Although I am aware that other attorneys may view this situation differently, I strongly advise you not to accept someone back into your practice once you have sent a dismissal letter. People in this situation are often resentful, hostile, and may even be physically dangerous. If he feels that you have done anything objectionable after you have taken him back into your practice he may not hesitate to complain to the Board of Medicine, make defamatory comments on the Internet concerning you or your practice, or even consider filing a lawsuit against you. After all, you are the one who, from his point of view, had the audacity to dismiss him from your practice. Why would you allow such a situation to occur?
Madison: Bryan, I understand and will take your advice. Thank you!
If you have any suggestions for topics to be discussed in this column, please e-mail them to me at email@example.com. See the February 2013 issue of Dermatology World for disclaimers.
- When dismissing a patient, send a certified letter, return receipt requested, as well as a copy by U.S. mail, advising that you will no longer be providing his or her medical care 30 days after receipt of the letter.
- Refer the patient to his or her primary care physician, local hospital, or the county medical society to locate another board-certified dermatologist.
- Although not usually legally required, consider enclosing a copy of the relevant medical records to facilitate the patient’s subsequent medical care.
- State the consequences, if any, of the patient’s failure to follow-up with another board-certified dermatologist.
- Should you see the patient within 30 days of his or her receipt of the dismissal letter, have your nurse or someone else present in the room with you to lessen the likelihood that the patient can claim you said or did something inappropriate.