How should doctors handle the difficult patient?

by Toni Brayer MD

I am willing to bet that patients do not know that the medical community talks formally about “The Difficult Patient”. Courses are taught on how to handle these patients and there is even an ethics study on Medscape about it. So what is the difficult patient?

Every practice encounters them and they come in many varieties. They are the patients who abuse the staff, miss appointments repeatedly, “lose” their prescriptions for pain medication and then demand instant refills. They may not follow up with important tests or stop taking needed medication and then show up with acute medical problems. Some doctors have a low tolerance for patients who are not “compliant” but even the sainted physicians experience “difficult patients.”

So when the therapeutic relationship is damaged, doctors are taught the ethical ways of firing a patient from the practice. Once a relationship has been established, a physician may not abandon a patient. Medical ethics demand that a physician may discharge a patient from the practice only after attempts to resolve the matter have failed. Adequate replacement care must be available and the patient’s health should not be jeopardized in the process. The physician must ensure that the reasons for discharging a patient are justifiable and ethical.

Once the doctor-patient relationship has broken down, the doctor must make sure:

* She has done everything possible to address the patient’s problems
* She has informed the patient of the consequences of his actions, both for his own health and his relationship with the physician; and
* She must tell the patient that he would better off with another physician and help the patient find another doctor.

Ending a doctor-patient relationship should be a rare event. Like any relationship, there should be discussions that take place openly long before things get bad enough for the doctor to “fire” the patient.

Of course, an unhappy patient needs only to leave a practice and move on. But all physicians know that one disgruntled patient will tell 20 friends about his bad experience.

Tony Brayer is an internal medicine physician who blogs at EverythingHealth.

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  • customer of healthcare

    Thanks for this post. I totally take this on board. On the other side of the fence. I’m tired of sitting in doctor’s office for hours on end while they always run behind. I totally get that you need to see a certain number of patients per day to keep your practice in business and that emergencies happen, but it’s really more of the rule than the exception no matter what type of doctor.

    How do I get get reimbursed for my time as a consultant? How are people that work hourly or have little children and can’t afford a babysitter meant to sit for hours on end? And more of us than not are NOT the nightmare patient.

    As well, the term patient is actually offensive in this day and age. Health care costs are probably in the top three of expenditures any individual incurs. Why is this the only industry where we’re not referred to as customers.

  • Fired.

    Great essay.

    Only part I question is the assumption that a terminated patient will naturally tell 20 friends about the bad experience.
    I continue to recommend the doctor who “fired” me to others — because I recognize that the problem I received treatment for didn’t follow a predictable path, that the complications led to difficulties that no one could have anticipated, that we both reacted as best we could under the circumstances, and that risk management plays a much larger role in these situations than is ever discussed openly.

    Call me a liar, shout that I must have done something abominable, type in all caps that you’d have terminated me too based on these few paragraphs. It’s a free blogosphere and none of us can prove anything within its confines.

    I simply wanted to comment that a doctor who terminates a patient isn’t Satan, and that the patient who’s carrying around a scarlet “T” isn’t always the devil either. It’s a complicated relationship with a lot of external forces involved.

  • Nuclear Fire

    Great. One person is upset they’re a “patient” not a “customer.” Others say medicine shouldn’t be a business but a public service (so citizen instead of customer?). Until society as a whole can agree on even the most basic of things I don’t see how reform will ever be possible.

    Oh, and “doctor” is offensive in this day and age. “Executive” is more appropriate to those who are expected to manage long term, complex issues that affective lives and livelihoods, be cognizant of financial concerns that supposedly are brining down the economy, and have conflict of interest standards more stringent than our politicians.

  • christophil M.D.

    How should doctors handle the difficult patient? Well fire them of course. Difficult patients are dangerous patients (i.e. more likely to sue). They also harm office morale and consume time and energy. Cut them loose.
    There really is no down side to firing disgruntled patients. Yes, the fired patients tells 20 like-minded friends. And yes, some of the friends may change doctors but the ones that change doctors did not have a solid Doctor-Patient relationship to begin with, or they wouldn’t change. Think of it as a thinning of the herd. Weed out the weak relationships.
    I’ll take your bet. You write “I am willing to bet that patients do not know that the medical community talks formally about “The Difficult Patient”. Of course they know, medicine is big business. All businesses use and teach public (patient, customer, client) relations. Do you mean to imply that patients will find it taboo to discuss the difficult among them? Are doctors to be “above” that discussion? Get off the pedestal.
    Final thought, do you think patients talk formally about the “difficult doctor”? Remember, the squeaky patient gets the doctors time.

  • JPB

    Interesting… We were ultimately “fired” because we changed to a better insurance plan and he lost his monthly capitation payment. No recommendations for a new doctor were made. I don’t think that this was very professional behavior! (We never cancelled appointments, abused the staff or demanded special treatment. However, we did disagree with the doctor on some points and politely told him about our concerns. He seemed to handle that just fine but not the loss of the capitation.)

  • http://advancedmediterraneandiet.com/blog/ Steve Parker, M.D.

    When I had an office-based practice, I fired a patient every two months. It was always a relief for me and my staff. Once a patient has been fired by 5-6 doctors, he just might start to think he should examine and change his behavior.

    -Steve

  • Paul MD

    I am a private, for profit subspecialist health care provider.

    I routinely fire patients. If 2% of your patient base is 90% of your patient problems, cut them loose. There are many reasons for it.

    Not paying the bill is one. There are those who cannot pay and or make every percieved effort to pay or they just need a break. If their care is not hurting us/me we extend ourselves and often write off their debt and continue to treat them. It seems right, it feels good and it is OUR decision which feels empowering. It is charity care as it was meant to be.

    Folks that refuse to pay their bills and have resources to do so, I cut loose and report them to credit agencies. People that are rude, abuse my staff or other patients are shown the door as well. The addage, “the patient is always right” is parallel crap to, “the customer is always right”. The only truth is that the patient is always the patient and customer is always the customer. That is it.

    The patient is entitled to express their opinions to me and my partners and question what the plan is. I feel this inconvenience is healthy and an important part of patient participation in their own care. Candid and sometime spirited discussion occurs, and it is most often OK.

    Non-compliance to any of the agreed upon plan indicates a lack of interest and or respect and poses poor or grave outcomes for all parties concerned and our relationship with these folks is terminated as well.

    With EMTALA, mandated non-reimbursed hospital call and abandonment constraints, I/we execise our will within the confines of ever constricting public policy. Other than the sometimes long waits at our office, we, as I’m sure most providers, have nothing to apologize for.

  • Disgruntled

    “But all physicians know that one disgruntled patient will tell 20 friends about his bad experience.”

    After my bad experience with my former doctor, I went to every MD review site and left a less than stellar review. I was not the only one.

  • Fired.

    I don’t agree with posting negative reviews, including of doctors who’ve “fired” you. There are many more patients than doctors, with choices further restricted by insurance plans. It doesn’t help the next patient to be handed my baggage before they’ve even met the physician.

    Imagine what it would be like if doctors could post negative reviews of patients they didn’t like. Seems fair under the circumstances, but a lot of us would cringe at the notion.

    Sorry for the “Oprah” moment, but I think if a doc/pt. relationship isn’t working for either party, providing there really isn’t some outrageous or criminal act involved, you do just have to move along without poisoning the well…even if you feel somewhat justified in your frustration.

  • Medical Student

    Customer of Health Care,
    I wonder what you’re getting at when you say that patients should be renamed “customers”. Do you want to replace the doctor-patient relationship with a customer relationship? Like the one you have at Home Depot?

    The article spells out above the restrictions that physicians face when “firing” their patients. They have to: 1) have done everything that they can 2) have to counseled the patient on the consequences of their actions, and 3) have to helped them find a new physician.

    These relate to the doctor-patient relationship which is legally as strong as the bond between parent and child (called a fiduciary relationship, definitely not what you get when you’re shopping at Walmart). You want to exchange all of that for the rights of a customer?

  • Fired.

    Medical student: Those three “restrictions” that you list (assuming I understand the letters that my clinic’s risk management JD sent) apply only to terminations that occur when removing the patient from treatment could at that moment have serious consequences to the patient. Without those safeguards, the doctor could face charges of patient abandonment.

    However, the restrictions are apparently much less strict if the patient is not in any immediate danger. In my case, there was no advance warning, no “second chance”, no explanation beyond “due to past interactions”, and no help finding another doctor — unless you consider “call your insurance provider” help.

    I don’t want to get into any debates over whether I did or did not deserve termination. I’m saying I support the doctors’ right to have some choice in who they treat, but I also appreciate the article’s premise that decisions not to treat should be handed down with some grace and not taken lightly.

    Which no doubt 99.9% of you all do, and thank you for that.

  • Doc Stone

    The original article makes two points that, if taken at face value, I must disagree with:

    “Once the doctor-patient relationship has broken down, the doctor must make sure:

    * She has done everything possible to address the patient’s problems
    . . .
    * She must tell the patient that he would better off with another physician and help the patient find another doctor.”

    I don’t think that the writer really means “everything possible”. It is possible to go outside your scope of practice? It is possible to break the law. It is possible to move in with the patient? It is possible to treat all the non-payers for free–even to skip out on your own bills. It is possible to let the rude patient stress and run off your staff and you continually replace them. It is possible to let them destroy your joy in medicine and drive you to see a therapist or get on handfulls of meds. And so forth . . .

    I don’t think that the author meant this literally but that is how some readers will take it.

    It is also not necessary to determine that the “patient will be better off with another doctor” although that is almost always in fact the case.

    The bottom line is that the doctor-patient relationship is a reciprocal relationship and each have the right to terminate it for whatever reason suits them. The doctors professional obligations are in how he fulfills his duty while he maintains the relationship and the time and manner of termination. The only clear hard fast and long-standing ethical prohibition is that you can not do so in the midst of an emergency without ensuring continuation of care.

    There are plenty of circumstances in which a doctor does not have any meaningful obligation to ensure continuity of care. If the doctor accepts that as an unwavering obligation, some of the most destructive patients will frustrate efforts to do so and thereby entrap the doctor in a dangerous situation. The common idea of “30 days notice” is spelled out by some medical boards but is not a universal standard accepted by all. The basic concept of abandonment could require more or less. It is the same with “on call”. Some states demand it. Others, “including mine thankfull” recognize that as a boundary of the practice that the physician is free to set individually according to what fits his practice.

    Most patients that I have discharged have not been with 30 days notice as there was generally no immediacy to the medical complaint at that point. In some cases I have given 120 days as that is what I knew it would take for them to arrange proper long-term care. The degree of availability and for how long is something that I think ethically best crafted to each situation, even if fixed policies are more easily defended legally.

    Doctors don’t like to fire patients and do so very reluctantly. Even when another patient’s firing is the result in my eyes of that particular doc having a hangup with a particular patient–in fact especially then–I think it the best for all concerned. Far more errors of omission are made in this matter than errors of commission. As a patient, I note a reluctance to fire doctors also. Perhaps some of the discharges are provoked by patients who cannot themselves break it off.

    I have also noted that on many occasions the discharged patient will not replicate the offending or obstructing behavior with the new doctor, making it in fact a therapeutic experience.

  • Anonymous

    I’ve never been fired by a physician – but, after tolerating some truly outrageous behavior on the part of a physician, I fired her. I’m convinced that the only reason she continued to see me after her medical error (confirmed unequivocally by testing done by another physician) was to conceal the fact she had erred and, perhaps more importantly, placate me. It didn’t work. I didn’t start to ask questions until her behavior changed to CYA-mode. If she’d had the integrity to admit her mistake I’d still be her patient, by the way.

    In my experience, many difficult patients are made so by negative encounters with physicians. Every medical professional I’ll encounter for the rest of my life will likely have the pleasure of dealing with the minimal trust I now have in the medical profession. I’m no longer a nice, “compliant” patient… in my experience it’s not in my best interest, unfortunately.

  • AnonymousQ

    Why are sick people expected to be normal, cheerful, and civil? Aren’t personality traits normally considered annoying often a sign, or clue, of disease process?

  • Nuclear Fire

    Are people who are ill expected to be normal and cheerful? No.
    Civil? Absolutely.
    Abusive? Never.

  • Overworked/underpaid MD

    Easy question to answer: Fire first, ask questions later.

  • Paul MD

    Nuclear Fire,
    Well put. Thank you. The “biopsychosocial model” has no provisions for people being as%ho@es whether they are the caregiver or the patient.

  • Evinx

    Never been fired by a dr but know 2 who have. In both cases, it had nothing to do with abusive behavior, or chronic lateness, etc. It had to do with questioning the dr. Too many (not all) are on their 6 minute/patient schedule and really dislike patients who ask lots of questions. And the dirty little secret is if you question about type of testing and if really necessary, many drs feel threatened and vulnerable. Let’s be honest – many times there are referrals involved for testing, + these referrals translate to favors, dinners + drinks, and cross-referrals. So if you continually question against tests that are “routine” (and not for any symptom), drs get upset. You are taking too much of their time and perceived as the type who may cause legal trouble. The most effiicent patient from a dr’s view, is the one who is relatively compliant and does not question anything – the patient-automoton. Break out of the automoton mode and you risk getting fired.

    Of course, this is not all cases but with the tremendous fear of litigation, it is becoming an increasing by-product of the lack of some kind of tort reform.

  • AnonymousQ

    Nuclear, but truculence and stubborness and lack of internal “screening” of impulses is a feature of many diseases. It’s wonderful to have nice healthy patients who are never cross or impatient…but the ill ones are the ones that need care the most.

  • AnonymousQ

    If You reduce the patient’s affect to “psychosocial” factors, you may be misinterpreting a sign of illness.

  • Nuclear Fire

    @AnonymousQ
    I believe your argument is not addressing the issue of this post and is quite unfortunately hindering the dialogue.

    Specifically, the author is talking about “the medical community [talking] formally about “The Difficult Patient”. This formally defined patient is specifically not someone whose behavior is disruptive due to underlying organic disease such as stroke, Alzhiemer’s etc. or non-organic illness such as Bipolar, ADHD etc. Obviously (I would hope), this is not what we mean by disruptive or abusive patients but rather those without underlying pathology. Thank you for reminding us that some diseases can alter behavior and personalities. I accept your point as well taken, but do not think it germane to the specified topic.

  • Paul MD

    #1 “At first he called me an incompetent boob”
    #2 “Ouch!”
    #1 “Then he threatened to sue me and harm me and my family”
    #2 “You’re kidding?”
    #1 “Then he DID sue me”
    #2 “For real?”
    #1 “Yeah”
    #2 “What are you going to do now?”
    #1 “At first I was angry, then depressed and well, you know all of the stages….”
    #2 “What ever happened to him?”
    #1 “Oh…I’m still seeing him as a patient”
    #2 “Tell me you’re kidding”
    #1 “No, not at all. I found out that he was just being truculent”
    #2 “Ohhhh….”

  • Heart Patient

    In response to “customer of heathcare”, “As well, the term patient is actually offensive in this day and age.”:

    I don’t find the term Patient offsensive at all. I’ve worked in health care finance 30+ years, and our hospital system staff was trained to refer to the “patients” as “customers”. I find that demeaning myself. I AM a Patient. To me a “customer” is a person that shops in a retail environment, etc. I have a very special relationship with my physicians; and they certainly don’t treat their patients with the lack of care that “customers” seem to receive.

  • AnonymousQ

    Nuclear, since discussion has tapered off, I feel confident that my point in full will not distract from “what do do with a patient you have already decided you don’t want anymore”.

    I think it’s relevent. I think many physicians take the disturbed affect of their patients personally, when disease is actually changing the way the patient interacts with the world.

    If you have not yet diagnosed parkinsons, will you notice the tell tale personality changes? Cumulative damage from diabetes or poorly controlled blood sugar can result in personality changes, as can thyroid disease, complications of liver disease, other endocrine disease – a host of common problems. Even chronic pain has been determined to cause changes to brain, and therefore personality.

    Why did you distinguish bi-polar disorder as “non-organic”? It have an organic cause, and a chemical treatment.

    It makes me suspect that the affect of the patient due to disease may be assumed to be something under the patient’s control, with the patient blamed for non-conforming behaviour and removed from the physicians care, when it is directly related to a need for medical management.

  • http://www.medicaltranscriptionsservice.com patient health records storage

    How should doctors handle the difficult patient?
    First the doctor and the patient relationship has to be re-defined, the truth is that the doctors are service-providers and patients the customers, it is a commercial tie-up between a doctor and a patient. The doctor is not going to provide his services to a patient without receiving his fees. Similarly, a patient will not use the services of a doctor who fires his patients, instead will look for a health care provider that do not fire their customers.

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