Kevin, M.D. - Medical Weblog

"But noncompliance with treatment is not a reason to fire a patient."

That's nonsense. Non-compliance is a perfectly good reason to terminate a professional relationship. If a non-compliant patient does not wish to follow his doctor's advice, he can and should be told to find a doctor whose advice he wants to follow. Supervising a patient's continuing non-compliance does no one any good, except add to the doctor's revenues, and that isn't exactly puting the patient's interests first.
 

If we fired all of our non-compliant patients, how many patients do you think we'd have left?
 

We ought to dismiss more patients than we do. If we roll our eyes when we see a certain patient on our list, we do that patient a favor by giving him a fresh start with a different physician who may find him charming.
 

This article should be presented as one man's opinion, and only that. It does not represent the general understanding of a physician's right to terminate a doctor-patient relationship, nor does it even represent a model of an ethical understanding of the notion of termination.

A doctor can terminate a physician-patient relationship (unless contractually obligated otherwise) for just about any reason and even for no given reason at all. There are generally-accepted terms by which this usually done, with time allowed to find another doctor, but even those are not carved in stone (e.g., a patient who threatens harm can be terminated forthwith).
 

I did fire a patient once. She had a borderline personality disorder and was calling the office a couple of times a day, cursing the secretary. She refused counseling. Finally, after a month, I gave up. The secretary warned me that she would quit, so I fired the patient.
 

That's nonsense. Non-compliance is a perfectly good reason to terminate a professional relationship. If a non-compliant patient does not wish to follow his doctor's advice, he can and should be told to find a doctor whose advice he wants to follow.
Well, didn't you yourself (maybe not you personally, but doctors here) said that many tests you order are for defensive reasons. So, now you are saying that if a patient doesn't follow your advice on having a defensive test that carries a certain probability of individual harm, you have a right to terminate the relationship? Does this mean that if a patient values you as a good doctor, is polite, doesn't threaten you, but doesn't agree with you on some specific test/treatment (provided that it doesn't threaten public health), the patient has to go look for doctors?
Since most doctors right now practice "defensive medicine" does it mean that a patient that refuses certain "defensive" option shall go without doctors?

What about all the 'preventive' measures? Do we have a right to refuse those or do you only want patients that follow your views of healthy lifestyle? Hey, my then-65 healthy aunt refused to take HRT a few years back; did her doctor have a right to "fire" her?

Does a healthy man have a right to refuse a prostate test? Does a healthy symptomless woman has a right to refuse mammograms if she believes that for her personally a small probability of benefit doesn't outweight the risk of overdiagnosis and is perfectly willing to document her preference in writing?
If we don't have right to refuse treatment this sounds a lot like Soviet-style paternalistic medicine. hey, maybe doctors should "fire" all patients who engage in any kind of activity that threatens their health such as mountain climbing, jumping with a parachutes, figure skating, car driving... Some of these things carry a lot more risks than not following some of doctor's advice.
 

Oh, dear god...not the evil female borderline! Somebody needs to do away with that diagnosis - just say she's behaving like a jerk...because that's what we would call her if she were male.
 

"did her doctor have a right to "fire" her?"

Sure can. She could be fired for no better reason than the doctor simply didn't want to see her any more. Not Soviet paternalism. Free country.
 

Is "fire" the right word here? A patient is not an employee of the doctor, the patient is a paying customer while the doctor is service provider. Am I wrong here?

So, if a doctor can "refuse service" for any reason, does it include race, religion, sexual preference?

Now, if you think there are not enough grounds for lawsuits....
 

Soviet style?! What a moron!
First, nobody wants to imprison non-compiant patients, just dismiss them. Moreover,it would be Soviet-style to compel a doctor to take care of a patient he chooses not to see.
As per race, gender, etc., that's illegal in all other areas of American life as well.
 

Oh, dear god...not the evil female borderline! Somebody needs to do away with that diagnosis - just say she's behaving like a jerk...because that's what we would call her if she were male.

Wow... You made a diagnosis after someone simply anonymously expressed an opinion on the internet. You must be a truly great doctor.

For all you know this could be someone who wants to refuse a specific preventive test/treatment and is terrified that her long-time doctor will refuse service. Or someone who is frustrated by the lack of informed consent in screening similar to that in prescription drugs: there are risks that doctors are aware off that they don't tell the patients about http://www.imagingeconomics.com/library/200411-02.asp.

There are lots of people who believe that preventive medicine is arrogant and intrusive http://www.cmaj.ca/cgi/content/full/167/4/363
Given that most doctors strongly believe in many preventive measures, there may be a situation in which most or all doctors refuse to treat patients who believe that for them personally benefits don't outweight the risks.

In this case, the patients will have a choice of complying and risk harm to them personally or going without a doctor. A doctor's advice then becomes not an advice bu an ultimatum. A patient may then just comply simply not to have to change doctors. Given that some of the good advice of today becomes bad advice tomorrow (vitamin E supplements, HRT for prevention of heart desease, screening children for neurablastoma in Japan), this type of ultimatums are unethical, IMHO. They also will increase lawsuits in future as patients are likely to be very angry if they only complied because a doctor said "if you don't do it, you can look for another doctor". And if this patients decide to stop going to doctors alltogether, there may be a potential risk to public health if they get a communicable desease and don't go to a doctor.

Finding another doctor may not be easy especially if a patient has had a long-term good relationship with his/her doctor and trusts the doctor in most cases e.g. to diagnose/treat illness.

Certainly, there are situations when following doctor's advice is important especially when one is sick and there is only one course of treatment. Certainly, there are situations when a doctor is frustrated because a patient refuses to follow his/her advice. But we are all fallible and the doctor's advice is not always perfect. The benefits may outweight risks when the population is considered as a whole, but this may not be the case for an individual.

Shall the patient who values his/her doctor for many reasons but doesn't agree about what is right for him/her personally be forced to choose between complying or looking for another doctor?
 

anon 1049

I think you are confusing issues. You have every right to refuse a "defensive" test. That is not noncompliance and I think most docs don't have any problem with that. That doesn't hurt my feelings. Depending on the scenario I may have you sign an AMA form.

No one equates that with the borderline personality patient that harasses the office staff daily or the malignantly noncompliant patient.

An example of "noncompliance" is the kidney transplant patient that cost society a million dollars who has decided so replace his anti rejection drugs with recrational drug abuse. Or a million other scenarios.
 

"Shall the patient who values his/her doctor for many reasons but doesn't agree about what is right for him/her personally be forced to choose between complying or looking for another doctor?"

People on this blog are educated enough to use a computer and are interested and informed in their own health. This topic really doesn't concern you. None of you are at risk for being fired because you may not believe in vitamin E or certain screening tests, or whatever. In my observation patients are rarely "fired" unless they are wantonly noncompliant or constanly disruptive to the ofice environment and are adversely affecting staff and other patients.
 

I think you are confusing issues. You have every right to refuse a "defensive" test. That is not noncompliance and I think most docs don't have any problem with that. That doesn't hurt my feelings. Depending on the scenario I may have you sign an AMA form.
You are right I was misunderstanding the term "non-compliant". I thought it meant any kind of refusal to follow doctor's advice whether it dealt with defensive or preventive medicine. I would completely understand doctor's refusal to co continue treating a patient in the case you mentioned.
 

I have to agree that the ideal relationship between patient and doctor is an adviser/client relationship.

"Noncompliance" is too broad a term, and apparently too charged a term, to apply to all forms patient behaviour that include rejecting advice.
 

I am a 66yr old woman, had 2 unsuccesfull stomach surgery's.I am still suffering from this, and put on a anti acid pill dayly for as a lifesaver, after 7 yrs taking it, I have had recently a bowel abstraction,pollups removed, inflamed pancreas and silent gallstones. I have asked help from the College of Surgeons and Phycisians. My doctor and I got into a friction relationship now, and told me for my own interest to find another doctor, it seem they all avoid me like the plaque.Here I am with problems and no help,Please advice!
 

How can I find my answer?
 

I was terminated in July 2004 by an oral surgeon, the stated reason being that I wrote a complaint letter in March 2003 to the clinic Patient Relations office -- which, by the way, promises that any concerns received by them "NEVER" enter the patient's record. I also rescinded and apologized for that letter about a month after sending it. The Patient Relations rep sent me an e-mail after receiving my retraction, assuring me that she'd removed the complaint from the record. After the termination I presented a copy of that e-mail to everyone from the clinic CEO to the Health Information Services director. No one cared. Everyone said that doctors are free to serve whoever they wish. The termination means that I am forbidden to see any other oral surgeon in that physician group (two of whom I never even met) and the nearest other oral surgeon covered by my insurance is a 100-mile round trip away. Oh, did I mention that, prior to being terminated, I had donated over $1,000 to a fund that sponsored sending nurses and residents from that oral surgery department on "Operation Smile"-type missions? Yeah, I was a real threat: a money-giving, apologizing patient whose only crime was trusting an arrogant, idiot doctor who didn't give a rip about how his actions harmed others.
 

I think everyone missed the main point. You have to realize you are sharing your most intimate things with a physician. He or she becomes part of the family. For some they are the only family left. When a doctor fires a patient without trying to work the problem out (which in most ways could be very simple) all he or she does is cause distrust in the community and eventually will get a bad reputation. Remember life isn't perfect. No you don't have to take abuse but you do have to realize that life is precious and throwing someone away like a used tissue will cause harm to both. Try to show compassion. I suggest all physicians watch to awesome movies. One number "The Doctor" and Number two "Patch Adams". Then after watching these movies tell me how much you care for your profession.
 

Good point that the doctor-patient relationship doesn't exist in a vacuum, and that terminations have very wide consequences.
I remain appalled by the physician who flippantly commented, "It's a free world" (or words to that effect). His/her license should be revoked immediately before he/she does any irreversible damage to a patient.
Doctors must understand the tremendous seriousness of a termination. It is not just about you. Many physician groups use "group terminations," meaning that if one doctor can't get along with one patient, that patient loses access to every doctor in that group...whether or not they've even met.
Now consider the further restrictions placed on a patient's ability to choose providers based on health insurance. The doctor who decides to terminate a patient may well leave that patient with NO affordable access to care, period.
I'm not saying doctors shouldn't have the right to "fire" a patient IF they've sincerely made every effort to work through the problem and IF the patient remains willfully uncompliant.
But to say that a doctor should be able to terminate a patient for no reason...absurd, cruel, Machiavellian. If you hold such a belief, you are in the wrong profession.
Further, if you DO terminate a patient, PLEASE tell him or her why, specifically and accurately. I will tell you from experience that when a doctor "fires" a patient and sees no reason to explain that decision, it will make it nearly impossible for that patient to have effective relationships with any physicians in the future.
 

It takes two to tango in every aspect of the life and in doctor-patient relationship as well. There is no involuntary servitude is this country anymore and I as a doctor and a free person should be able to back out of the relatioship in defined circumstances. Remainder to the respected bloggers here is the fact that patient may fire me all the time anytime for whatever reason- they simply call the other practice and schedule the appointment and have they records forwarded. Its a relationship that needs to be productive and useful for the patien- and if it bad (and life is not pefect) perhaps that patient is loosing out on a chance to click with another physician possibly.
 

Patient Non-compliance when looked at on a National Scale amounts to between $75-100,000,000,000 in health care costs. Don't believe me? Do your own due diligence. Examples as you know are the patient who is a brittle diabetic who checks their blood sugars every 4-5 days...there are numerous reasons for this. The solution is to enable the County Health Departments nationally to have dedicated nursing staffs whose sole job is to respond to patient non-compliance lists from Internal Medicine and Family Practices. With even a modest 10-15% improvement in compliance, we can save so much money in our healthcare system that will enable us to allow for Universal healthcare; it will enable us to get rid of the coffee cans in the gas stations to pay for "Little Johnnies brain tumor surgery". The politically incorrect solution is to get Americans to take better care of themselves; it isn't "pretty" for politicians to tell people they are obese, smoke, drink, eat poorly, sleep poorly and don't exercise. THAT is why we don't have Universal Healthcare and THAT is what is getting published in my book...not pretty.
Doc N