Why doctors should be allowed to fire patients

A recent article in the Wall Street Journal is getting a lot of attention: More Doctors ‘Fire’ Vaccine Refusers. The article discussing the increasing frequency of pediatricians who are “firing” patients/families from their practices because they refuse to take recommended vaccines for fear of autism or other concerns (rampant on the internet, but all proven untrue).

It is important to note that not only should physicians be able to fire patients, they must be able to fire patients. Physicians are allowed to choose which patients they accept (unless they work in the emergency room). This happens every day, when a physician refuses to accept a patient that does not have an insurance they contract with. However, it would not be illegal (or even unprofessional) for a physician to for example, not accept any patients who currently smoke. Many primary care physicians will not accept a new patient who is a chronic opioid user (or will only accept them under the circumstances that another provider manages their narcotic prescriptions).

However, once a physician sees a patient, she has established a doctor-patient relationship. This is a legal and binding contract that comes with rights and responsibilities, such as confidentiality. In addition, if a doctor-patient relationship starts to sour, the physician cannot simply one day refuse to see the patient. This is called “abandonment” and is subject to legal action. Thus, physicians need to have a process to “fire” (terminate is the technical term) a patient from their practice, or they would become indentured to their patients indefinitely. The process of terminating a patient usually involves timeliness of notifying the patient, provision of care until a new provider is found in a reasonable amount of time, and assistance with finding a new provider (such as providing recommendations).

The issue of pediatricians firing vaccine refusers is an interesting one, since the typical splits between doctors and patients are usually related to disruptive patients, unhappy patients or patients inability to pay. The issue of vaccine refusal is more of a philosophical one, though concern for the health and safety of other patients and staff is certainly a reasonable concern.

However, another twist to this issue involves new models of health care where providers are rewarded for improvements in quality of care. Known as “pay for performance,” physicians get a bonus if they can deliver better quality. These bonuses are generally delivered on patient population data. For example, a target might be having 90% of diabetic patients getting annual eye exams or checking blood sugar control. Would it be reasonable for a physician to “fire” a patient who refuses to follow the recommendation that the physician is being measured on?

Patient satisfaction is also becoming a popular measure. Would it be reasonable for a physician to “fire” a patient who is constantly unhappy and likely to give the physician a poor satisfaction rating that he or she is being measured on? Should there be laws against physicians firing non-adherent or unhappy patients? If not, and assuming most physicians will wind up incentivized by such measures, which physician would accept a known unhappy or non-adherent patient?

Matthew Mintz is an internal medicine physician and blogs at Dr. Mintz’ Blog.

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  • http://twitter.com/SocialDentalNet SocialDentalNetwork

    Doctors should wholeheartedly have the right to fire patients at will!

    • Anonymous

      MDs claim superiority to RNs because they don’t strike.  However, the real question will come when the boomer docs retire and the health care crisis really hits.  Since the AMA has ceded all of its responsibility and power in the healthcare reform and impending Medicare, we younger providers are going to have to organize ourselves.  Firing patients is going to be the least of our problems.  Surviving the onslaught of new Medicaid and Medicare patients with our student loan debts is going to be our problem.  We can only bring about that major shift in finances by demanding a livable wage.  We paid for the education; we must be paid for the work.  That can only be done together.

      • http://www.facebook.com/people/Blake-Duckworth/100000709998441 Blake Duckworth

        Maybe we should see an article of patients firing doctors. doctors are not in it to help people. The medical profession is a business , doctors are in it to make money. I have suffered from a disease for 2 years, and have tried to tell many different doctors what is going on but none of them listen to me and all come up with a bunch of wacky theories that turn out to be false after the tests the schedule are wrong. Make biggest complaint is doctors never listen to their patients.
        The physicians I have dealt with think they know it all and that they are never wrong.Thousands of people die each year because of medical malpractice and misdiagnosis.

        When a dog is suffering from severe chronic pain, the master will take him out and put him down so he can suffer no more. Humans are not given that option, the medical community tells the individual who is suffering from the illness that he must grin and bear the pain. And if the patient even hints at suicide he can be arrested and placed in a Psychiatric hospital / metal ward.This has happened to many individuals who had chronic pain and were refused medical treatment and became suicidal. But all you wanna here is how nice and pleasant doctors are and how they are always correct and never make a mistake. Doctors are humans and they commit malpractice and make mistakes on a daily basis. some of which cost people their lives

  • Anonymous

    If they have the right to fire patients.. then I think we should also be able to deny admission to a patient who repeatedly gets admitted because of noncompliance with a chronic illness.

  • http://pulse.yahoo.com/_KCL4AO3HM6GTZ2X4RD3BQD5JPI GPZ

    The issue of firing patients who refuse to follow the vaccination guidelines could be as simple as requiring parents to sign a contract at the origination of the doctor-patient relationship that informs the patient that the waiting room is a vaccination-only zone due to the risk of non-vaccinated patients passing diseases to very young patients (that are too young to be vaccinated) or to patients that have been vaccinated but did not develop sufficient immunity. 

    The policy needs to be verbally reinforced and clearly stated in order to avoid any “it was small print” arguments. 

    Vaccination only protects everyone with ‘herd immunity’ when everyone is vaccinated because if the vast majority react positively to the vaccine, then the minority that do not respond to the vaccine are still safe. If you introduce non-vaccinated people into that mix, you put some vaccinated children at risk. 

  • http://www.facebook.com/profile.php?id=558041620 Vikas Desai

    you are indulging hypothetical situations with questionable practicality. The fact is few of these pay for performance objectives will lead to any significant increase in income. I for one don’t have any clue how that even works. Its been discussed to death but no one talks real numbers. Just how much money comes from these pay for performance objectives? 1000 dollars, 100 dollars, 1% increase in a 99213 payment of 45 bucks?? The bottom line is the more people in the door the more revenue. Physicians should not complain about declining reimbursement when they are actively turning business away. I think its weak to “fire” a patient for non-compliance. If they refuse treatment in a respectful manor simply document clearly that treatment was offered and refused.  I’ve inhertied with bilateral carotid stents and they still would refuse insulin, until a year in and i was able to slowly break them down. If non-compliant patients keep coming to you(especially in a competitive market) they trust your opinion even if they don’t always follow thru. To let these people go is a lost opportunity to make a real difference. In the case of peds, parents may initially refuse vaccines but that’s because of media “hype”, and what the latest celeb is talking about. Once the 5 o clock news talks about measles outbreaks/ pertussis outbreaks those same people will come running back. During the swine flu “epidemic” i ran out flu shots so quickly i was reprimanded by patients, the next year i made sure i had enough vaccines, and then was reprimanded for forcing the “dangerous” flu vaccine on people. Point is no reason to lose patients(and MONEY) just because of recent trends, there is an ebb and flow to medicine, the constant is always the MD/patient relationship. 

    • Matthew Mintz

      “The fact is few of these pay for performance objectives will lead to any significant increase in income.””The bottom line is the more people in the door the more revenue.”

      No one knows how P4P will work out. Primary care operates on the margins. It may be that meeting P4P criteria allows a PCP to keep the relatively low reimbursement they are getting now. PCP’s can not afford to lose anything more.  The demand for primary care docs is so high, that if a doc “fires” a non-adherent patient for fear of not meeting P4P benchmarks, a new (potentially more adherent) patient will be there to fill that patient’s shoes.  I also agree that it is “weak” to “fire” a patient for non-adherence.  The point of this post was not that docs should be firing their patients, but rather, because in our current system where physicians have certain legal obligations mandated by an established doctor-patient relationship, where we have a broken malpractice system, and where the possibilty exists that meeting P4P targets could substantially impact physician income; doctors must be able to terminate the doctor patient relationship.

    • Anonymous

      We now have a wealth of excellent studies proving conclusively that P4P programs do not improve quality of care or decrease spending. Their only justification is to allow yet another group of parasites to get their cut of health care spending. One has to assume, therefore, that in our anti-evidence based health care system, they will become increasingly important in the future.

  • Anonymous

    Not a physician, but I agree doctors should be able to fire patients in many circumstances. If a patient refuses to stick with a medically necessary diet and is endangering their own life, fine, whatever. It would be infuriating and a waste of a doctor’s limited time which could be spent on patients who are accepting treatment and need medical attention. But, sometimes trying to tolerate the annoying patient and attempting to educate them isn’t a terrible thing. I work in mental health, and there are certainly those folks who refuse medications for whatever reason. Listening to their objections, offering empathy, and being willing to see them should they hit rock bottom is part of the game. Frustrating? Yes. Heartbreaking? Yes. Would I fire these clients? Not if they want to keep seeing me. Sometimes patients have a mental block that needs a bit of prodding, and they eventually see the light.

    Now, if it comes to issues of spreading life-threatening diseases, fire. Fire. Fire. Those anti-vaccine folks are ignorant, and their refusal to vaccinate their children borders in child abuse. If their kids get sick, which is happening in various parts of the country, they can spread illnesses that kill. It annoys me greatly. Ever met someone who survived polio? No? The vaccines are against diseases that are disfiguring, disabling, and/or deadly. These people have no idea. NONE. It makes me ill. 

  • Ruth Ann Artz

    As an RN, I do not have the right to deny a patient care. I was not required to take the Hippocratic Oath, either. Take a look at the current version of the Hippocratic Oath that all physicians should be following.
    Let me tell you a rather disturbing event:
    One evening, a physician left the clinic while there were still patient’s in the building requiring care. A knock on the window and we found a man in acute distress outside.
    Had I left the clinic to attend to the man, the ANA would not have supported me because I would have abandoned my existing patient’s.  The man was not able to get into the building unassisted.
    We called 911 because we had no physician (he had walked out the back door without telling us) and I was called on the carpet for not going outside to attend to the man. Fortunately, the ANA was sensible in supporting that calling 911 was the only viable option we had.
    COBRA law does not allow a facility to turn away a patient. I do not agree that a physician should turn away a patient.
    The rest of the healthcare team cannot turn away a patient. Can an x-ray tech refuse to perform a procedure because the patient has body odor? Can a respiratory therapist decide not to give a nebulizer treatment because the patient still smokes?
    Since when are physicians above the rest of the healthcare team? 

    • Matthew Mintz

      Ruth,
      There is a big difference between “firing” a patient, abandoning a patient, and turning away a patient. Firing or terminating a patient is more like a divorce. It means the physician believes that the relationship is no longer therapeutic. Similar to a divorce, there is also a process which includes documentation and providing care until a suitable replacement can be found within a reasonable period of time.  The situation you describe when a doctor left before providing needed care to an established patient would be considered abandonment, which which is not only unethical, but also illegal/malpractice. “Turning away” a patient is also different, because a doctor patient relationship was never established. If a patient is in the hospital the X-ray tech or respiratory therapist can not turn away a patient for smoking status, body odor, or any other reason because the patient has already established a relationship as a patient in the hospital. If, on the other hand, the outpatient doctor referred a patient to an outpatient radiology suite, the radiology suite could turn the patient away.  For example, if they did not accept the patient’s insurance they could turn the patient away unless the patient refused to pay up front.  They could also turn the patient away if the patient was morbidly obese and their  equipment was not capbable of imagining a morbidly obese patient.  On the other hand, turning away can get tricky if it becomes discrimination.   A physician or radiology suite can not  turn a patient away based on skin color for example.

    • http://twitter.com/#!/CloseCall_MD Close Call

      Do a quick google search for “nurses strike”… then do a search for “doctors strike”.  

      I can think of one member of the healthcare team that LOVES to walk out on patients.

      • Ruth Ann Artz

        Close Call, my goodness, not to be flippant, the first thing that came up when I googled “doctor’s strike” talked about the death rate dropping when doctors went on strike. 
        http://www.qcc.cuny.edu/socialsciences/ppecorino/MEDICAL_ETHICS_TEXT/Chapter_3_Moral_Climate_of_Health_Care/Reading-Death-Rate-Doctor-Strike.htm
        I have been a nurse for over 30 years.I am proud to be an RN. I do not know any nurse who “loved” to walk out on patient’s. Never having been part of a union, perhaps there are those who felt that way. There are bad apples in any profession. I have seen the best of physicians and the worst. Same goes for any other healthcare team member. 
        In my career, without exception, those under my care were treated without prejudice: The developmentally delayed child who bit me, the head injured patient who kicked me in the chest, sending me sailing into a wall, the drug addict who was cared for while handcuffed to the bed by the police. 
        Nursing has been a personally rewarding career, even when I made $6.00 as an ICU CCRN  as the lead RN for the unit and my fiance, who just started as a trainee in the copier business made $6.50. 
        Matthew, I appreciate your explanation; however, where will the “fired” patient go in a small community? Wouldn’t some type of arbitration be more beneficial to both parties? In this litigious society, “firing” a patient just seems to be a recipe for more litigation, especially when dealing with personalities that already are feeling at odds with their physician. 
        As for terminating a patient…well, that seems rather final!  (please folks, double entendre!)

  • Anonymous

    As a pediatrician, I deal with the vaccine issue every day.  I see families that refuse all vaccines (not too many of those folks) and many that want to spread them out.  The AAP does not recommend turning patients away that refuse or slow down their immunization schedule and that’s what we’ve done at my office.  I find that 90% of the time if you work with them, explain that the vaccines are safe, and remind them of the potential risks of not vaccinating, they turn around and finish the schedule.  As far as the pay-for-performace issue goes, I make sure that I use the ICD-9 code V64.05 (Vaccination not carried out because of caregiver refusal) – that way the insurance company knows the vaccine wasn’t given because of my decision.

    That being said, if any patient is belligerent to me or my staff, is stealing items from my office (it’s happened a few times), or begins to threaten they will sue us if we don’t give them what they want, you’d better believe they’ll be getting a termination letter in the mail. As many of us are small business owners we have a right to do that at any time.

    Adam Falik, MD

    P.S. Matt  - I graduated a year behind you at GW Med School and I enjoy all of your posts on here.

    • Frank Butera

      As another pediatrician, I also found the requirement that you find the “fired” patient (i.e., vaccine refuser) another pediatrician to be the stop point.  There were no other pediatricians in my community that agreed with vaccine refusal.  Even though most did not fire such patients, I felt it unfair to foist these patents on my colleagues.

  • Payne Hertz

    So long as society grants the medical porfession a monopoly on medicine, no doctor should ever be permitted to “fire” a patient except under extraordinary circumstances. If we give doctors this right, and we do, they will abuse it to deny treatment to patients they would rather not deal with, like chronic pain patients, which they do that regularly. Where does this leave those patients who, because of the monopoly exercised by doctors, cannot get their pain treated outside the system? If patients are denied the right to freely associate with anyone other than a doctor to obtain their medications and treatments, why should doctors have the right to  deny them that treatment on a whim?

    If we are going to force patients into dealing with the medical profession to protect that profession’s profits, we as a society should expect something in return, like that doctors will responsibly deal with public health issues in a way that benefits the public rather than their own convenience. Even at the VA where doctors are paid with taxpayer dollars those same taxpayers can be denied treatment by any doctor.

    Let me give a real world example. A few years back, a doctor in my area lost his license for 6 months for killing two patients. He was also a notorious drug dealer who sold scripts out of his car, though this had nothing to do with his losing his license. Doctors in my area immediately panicked and started “firing” all their chronic pain patients and refusing to see people who had any kind of chronic pain condition. It was patient abandonment on a massive scale, but let’s not pretend a doctor can’t always find some excuse for getting rid of patients, even en masse.

    “However, it would not be illegal (or even unprofessional) for a
    physician to for example, not accept any patients who currently smoke.
    Many primary care physicians will not accept a new patient who is a
    chronic opioid user…”

    It isn’t unprofessional to deny medical care to people? How about minorities? Should doctors be allowed to deny treatment to minorities? How about overweight people or liberals or atheists or any other group the doctor doesn’t like? If not, why not?

    • Matthew Mintz

      “It isn’t unprofessional to deny medical care to people? How about minorities? Should doctors be allowed to deny treatment to minorities? How about overweight people or liberals or atheists or any other group the doctor doesn’t like?”  
      This is not what I am saying.  Not only is this not ethical, it is discrimination and likely illegal.
      Chronic opiod users (in most cases for no fault of their own) are very challenging for a primary care physician to manage, just as a dialysis patient might too complicated  for a primary care physician to manage.  It is perfectly OK for a PCP to tell a chronic opiod patient, “I can not manage your narcotic pain medications.  You will need to see a pain specialist for that.”  Smoking is somewhat different, and more similar to the vaccine issue.  It would be perfectly OK for a PCP to state that “we take all insurances, but will not see patients who smoke unless they are interested in quitting.” This is in a sense stating up front that it is unlikely that doctor-patient relationship will be therapeutic, so you (the patient) would be better off seeing another doctor who is more willing to work with patients that refuse to quit cigarettes.  

      • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

         Doctors don’t have a monopoly on the practice of medicine, and haven’t for some time. Nurses can practice independently, including controlled drugs, over most of the country.

        • Payne Hertz

          My point is that a patient can’t get treatment for pain and other problems outside of the medical system. Nurses are still part of the system but the discussion here is on doctors firing patients, not nurses.

          • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

            You said doctors have a monopoly on the practice of medicine. They don’t.

            The premise of your point is wrong.

            As usual, you don’t know what you’re talking about.

            Payne. So much mouth, so little knowledge.

          • Payne Hertz

             I said:

            “So long as society grants the medical porfession a monopoly on medicine…”

            Which clearly includes nurses. But since we are talking about doctors firing patients, I limited the focus to that. I am a patient advocate for over 18 years. Do you seriously think I am unaware NPs can write scripts (particularly when the person at my local VA who treats pain and writes the scripts is an NP?)

            The premise of your usual strained attempts at ad hominem attack is wrong.

            Ninguem, so many cheap insults, so little reasoned argument.

          • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

             Do you seriously think I am unaware NPs can write scripts (particularly
            when the person at my local VA who treats pain and writes the scripts is
            an NP?)

            Actually, that’s precisely what I think. You don’t have a clue.

          • Payne Hertz

            I could care less what you think. I know what you are.

          • Payne Hertz

             My comment was a duplicate of what Ninguem wrote, but predictably you censored my comment and left his. It would be nice to see a consistent standard to all the ad hominem attacks and patient bashing in the comments section here.

          • http://www.kevinmd.com kevinmd

            I don’t censor comments, they are community-moderated. Comments are automatically deleted by the system after it receives a certain number of flags from readers.

            Thanks,
            Kevin

      • Payne Hertz

         Treating pain is now part of the standard of care, and most long term opiate therapy is administered by primary care doctors, not pain specialists. Indeed, most so-called “pain specialists” don’t prescribe opiates at all but only administer shots and other financially renumerative therapies. Treating pain with opiates is not rocket science, and there is no compariosn between opiate therapy and dialysis, since the latter requires specialized equipment while the former requires only minimal training.

        Refusing to see a patient because that patient has an illness you’d rather not deal with is discrimination. Of course, it is far easier to excuse that discrimination than it is to explain why a doctor might refuse to see black people, but that doesn’t alter the fact. It all comes back to whether the medical system should be allowed to deny treatment to those who have no other option but to use the system.

        “t would be perfectly OK for a PCP to state that “we take all insurances,
        but will not see patients who smoke unless they are interested in
        quitting”

        So if a person lacks the willpower to quit smoking, it is okay to deprive them of medical care and possibly see them die as a result? How is that ethical?

        I once went to see a doctor who smoked during the examination. I never went back. Should doctors who meet the definition of obesity or who refuse to quit smoking, drinking, taking drugs, having unsafe sex, overeating or engaging in any other unhealthy behavior be prohibited from practicing medicine? I can certainly see far more rationalization for that than refusing treatment to patients who indulge in these vices.

        • Matthew Mintz

          “Treating pain with opiates is not rocket science, and there is no compariosn between opiate therapy and dialysis.”

          You have a patient and advocacy perspective, and I completely appreciate that.  However, management of chronic pain is extremely challenging.  (I could write an entirely separate post on why it actually is more complicated than dialysis). On what appears to be your blog, it states “The mission of Payne Hertz is to educate and inform the public of the continuing abuse and maltreatment of people with chronic pain, and to advocate for civilized and humane treatment based on our highest conceptions of individual liberty, human rights, and morality.”

          You are absolutely correct that many patients with chronic pain are not treated in a caring, compassionate and respectful way.  Part of the problem is the health care system that as you correctly point out gives an anesthesiologist a substantial amount of money to inject something and a primary care physician who works with a patient less than what most people pay for a hair cut. The other, likely greater part of the problem is the current state of pain management itself.  Essentially, when we use narcotics to treat chronic pain, we essentially (by no fault of the patient) turn patients into drug addicts. Addiction, regardless of the cause, is extremely risky. Thus is chronic pain management must be managed very carefully. 

          I have over 15 years of experience managing chronic pain.  I probably prescribe more narcotics than any of my 20+ primary care colleagues in the large academic medical center I work at (some of whom, because of the complexity and challenges will not write for chronic narcotics).  I believe my patients have been satisfied with their treatment. I have ever only “fired” one chronic pain patient, and this was after she was caught in a lie, having just filled a narcotic script and then claiming she lost the script and asking for another one. 

          The FDA has cracked down on narcotic prescription writing because narcotic prescriptions are the single most abused drug in the country. Doctors who write narcotic prescriptions must be extremely careful and are at risk of losing their license.  Despite the need for good caring doctors to manage so many patients with chronic pain, it is not fair to compel doctors to do so, especially under the current environment that mandates they do so much, reimburses virtually none of this, and locks them up (not joking here) if they fail to comply. 

          Because addiction is so tricky, there also must be strict rules when managing narcotic prescriptions and patients must follow these rules. I am very clear with my patients regarding how I believe their pain should be managed and how we must go about writing prescriptions. I try to treat them as caring and respectful as I can, but if they stray from this (getting narcotics from other doctors, asking for early refills, forging my signature, lying about lost prescriptions, etc.), then I believe I should have the right to fire these patients. 

          • Payne Hertz

             Only a small minority of people who are treated with opiates become addicted to them. Even then, it is still possible to continue treating addicted  pain patients with opiates, just as it is possible to treat hard core drug addicts with methadone and heroin (as is done in some European countries). Untreated chronic pain is always destructive 100 percent of the time. The slight risk of addiction seems a fair trade off to the certainty of the destruction of body, mind and life caused by chronic pain.

            If you have only fired one patient in 15 years of prescribing pain meds, it doesn’t seem like chronic pain patients are as much of a problem as they’re made out to be.

            The argument for compelling doctors to treat pain is that people in pain have no alternative but to see doctors (or nurses). This gives doctors enormous power over pain patients that is routinely and brutally abused. We are forced to see you to get pain treatment, but you have no obligation whatsover to provide it. How is that fair or equitable? Name one business where you are forced to give money to someone who isn’t required to do something in return for it.

            You complain about reimbursement. How much money do you expect to make for writing a script once a month? Ever think of what it’s like to be a pain patient and forced to pay for thousands of dollars of therapies and treatments you know from experience are useless just to get a doctor to give you the thing that you know from experience works? Ever wonder what it’s like to go through years of this crap before you find a doctor willing to treat pain, only to find you have to agree to some totalitarian infringement on your personal liberties including allowing the doctor to interrogate members of your family to ensure you’re taking the meds as prescribed?

            You might consider that in the US, the punishment for annoying a doctor is swift and draconian. In essence, doctors have the power to sentence people with chronic pain to torture without a judge, jury, a system of laws or any legal protections whatsoever. They can do this on their whim, and few doctors are ever disciplined for refusing pain treatment. You can argue that a patient can always find another doctor to treat him, but that can often take years and if you ask too many doctors for treatment, you are officially a doctor shopper which is illegal.

            You say that doctors are imprisoned for prescribing pain meds. I hear this all the time and of course every doctor believes this. What I have never seen is any evidence to back this assertion. I mean, an actual study that clearly shows doctors were imprisoned for the legitimate practice of medicine and not for outright drug dealing or endangering the lives of patients.

            Of course the ultimate solution is not to force doctors to treat pain, but to give patients the right to treat themselves, which the human race has enjoyed for the entirety of its history until the modern era. Until we have that right, there should be some obligation on the medical system to exercise their monopoly to our benefit, and not just for personal enrichment or at their conenience.

          • Anonymous

            I spent 6 months during medical school working in the ER and Urgent Care Clinic of a big inner-city hospital, screening every patient for drug and alcohol abuse, as part of an initiation by SAMHSA (Substance Abuse and Mental Health Services Administration); if patients screened positive, I would use motivational interviewing techniques to encourage them to take advantage of the treatment options I had to offer. As a med student, I spent my Family Medicine clerkship working one-on-one with a primary care doc who had many patients either on chronic pain med regimens (including narcotics), and/or with chronic pain syndromes that were difficult to manage (ie, fibromyalgia, lower back pain, etc). Finally, on a personal note, my brother, with whom I am very close, struggled for years with addiction before finally getting help; he is now 2 years sober.

            The reason this background info is important is that I feel that, while my level of experience and expertise is of course limited, I have also had the opportunity to see this issue from all sides, and I have learned a couple of things from the experienced practitioners I’ve had the pleasure of training under.

            1. Drug addicts come in all shapes and sizes, be they scammers doing a weekly shopping trip through the local EDs to score narcotics, or the housewife who was started on narcotics for fibromyalgia and now can’t stop without facing withdrawal symptoms.

            2. Drug addicts are annoying. They have extremely low tolerances for pain and frustration. This not only makes them high-maintenance patients, but can complicate their treatment for pain in the future. They hate being kept waiting, every bump and bruise is “10/10 pain,” they believe they NEED pain meds and become angry when they have to take “no” as an answer.

            3. Differentiating between patients in legitimate pain and those with addiction issues is EXTREMELY difficult.  As I said before, they come in all shapes in sizes. Not only that, but addiction is an extremely powerful motivator, and leads people to do things out of character for them, like lying or stealing. When a person is no longer in control of their behavior and has a powerful incentive to be less than truthful, they can be extremely good liars and expert manipulators. This is not meant to be pejorative, but it is true, I’ve seen it in my own family member. My brother told me AA has an expression for this concept of addicts being such amazing liars, they sometimes even believe themselves: “An alcoholic will steal your wallet and lie about it. A drug addict with steal your wallet and then help you look for it.” In a similar fashion, an NP once told me, “When you’re in a room with a patient considering whether to prescribe pain meds, the second you think to yourself, ‘No there is no way this person is drug-seeking, this person is not a drug addict,’ that is the instant you should realize that they probably are.” It can be so hard to tell what kind of patient you’re dealing with, what the actual nature of their REAL problem is, and what is the best course of action…combine that with most doctors WANTING to believe their patients and not wanting an unpleasant confrontation, that even good doctors sometimes cave and give narcotics, even when they are doubtful that they are appropriate or necessary.

            4. One of the last tools doctors have to try to separate the real pain patients from the addicts is having patients sign a “Prescription Contract” or something of that nature. It outlines the rules of the practice that, if broken, will result in termination. They usually involve a promise from the patient that their PCP will be the only provider who prescribes them any meds, that they will only use one pharmacy to fill said prescriptions, that they will come to the office face-to-face to obtain further prescriptions/refills, that they will only take what is prescribed and will not request early refills or extra prescriptions because they “lost” any meds, etc. This is the last way doctors can try to get a grip on the issue of wanting to treat patients’ needs but not wanting to feed into a substance abuse habit. The real chronic pain patients have no problem with this; the addicted patients always do. These are simple, easy rules and do not deprive patients of their “individual liberties,” in fact, they are simply asking for the basic level of compliance expected from all patients, including a promise not to break the law.

            5. There is considerable overlap between “real” chronic pain patients and those with addiction issues. Patients with legitimate pain issues often develop addiction to narcotics after chronic pain med prescriptions get them hooked. This is why most doctors do not go straight for the narcotics when you complain of chronic pain. They will want you to try exercise, good sleep hygiene, Flexeril and an antidepressant for your fibromyalgia, before they give you Oxy. They will want you to try to lose weight and get exercise to help your lower back pain, before handing over the Percocet. They are not being stingy. They are doing you a favor.

            And judging by the angry, insistent tone you have used throughout this comments section, the persistent arguments you use as to why you should be able to “treat yourself” for pain without being “subjected” to a pain contract; your obvious anger about the PCPs who stand in the way of the drugs you need; the way you have totally convinced yourself with all of these arguments…I don’t know you and I don’t know your story. But it sounds at least POSSIBLE that you may have developed an addiction issue. I would strongly encourage you to consider this possibility, and if necessary, reach out to a provider who can give you the help you need.

        • Anonymous

          “I once went to see a doctor who smoked during the examination. I never went back.”
          So you think the patient has the right to sever the doctor-patient relationship, but the doctor doesn’t? 

          Interesting.

          • Payne Hertz

            I never said the doctor shouldn’t have the right to sever services, just only in the most extreme circumstances, not as a matter for whatever trivial reason he likes.

            I’m sad a doctor can’t see the difference between a patient refusing your services and you refusing a patient treatment. If I walk out my doctor’s door, there are 10,000 patients to replace me. The doctor is not going to suffer or die because of me and he is under no obligation to enter into a doctor patient relationship with me.

            If the medical system refuses to treat certain types of patients, like the obese, smokers, people with fibromyaglia, chronic painers or anyone else they prefer not to deal with, that can lead to suffering, injury and even death for those patients, because they have no alternative but to deal with you as you have a monopoly on drugs, treatments and even most testing.

            You freely enter into an association with us, we do not freely enter into an association with you. As a chronic pain patient, I HAVE TO  go to you as you’re the only game in town. Yet you take my money, humiliate me, defame my character, try to scam me into useless treatments,  and usually give me nothing in return. Why the hell do millions of patients with chronic pain have to subject ourselves to this crap while you can just kick us out the door on a whim? You think the system is unfair to YOU? Give me a break.

            That doctors don’t understand the implications of denying treatment to patients or just prefer to pretend they don’t exist is really appalling, but not in the least surprising to anyone who understands just how self-serving this system is and how little the rights and health of patients matter within it.

  • Anonymous

    I agree with other comments that there is a big difference between refusing a patient with a certain insurance plan and “firing” a patient midway through treatment. Firing a patient opens doors for medical malpractice suits. Not taking action can be just as bad or worse than taking the wrong medical action. I would imagine that most doctors are not willing to fire a patient. On the other hand, patients fire their doctors often and might seek second opinions.

    The pay-for-performance reimbursement model creates an interesting twist to this firing issue. A patient’s negligence can decrease the doctor’s performance measures and cause financial punishment or missed bonus opportunity. If a doctor can’t or does not want to fire a patient, the doctor should at least be able to report patients that are taking ill-advised actions that would cause the doctor’s performance score to drop. These patient’s outcomes should not be included in the doctor’s performance measures. However, enforcing policies like this would be difficult and expensive. A major concern of P4P programs that goes beyond “firing” is that doctors will refuse to treat higher risk patients that will decrease their performance scores.

  • Anonymous

    the fact that this is even controversial shows what a general anti-physician sentiment there is among the lay public, and is especially alarming coming from other members of the healthcare “team”.  Generally the first to lay blame on physicians are the ones who’d much rather do any number of things before caring for patients e.g. complaining about staffing ratios, spending hours during a shift “on break” or dealing with vacation / sick time scheduling, etc.

    Since when does ANYONE (even MDs) not have the right to end a relationship that is nonproductive? happens in every business every day. The only difference with physicians is that we can be mandated to continue to field liability and harrasment for no reimbursement, for a month, eg.

  • Anonymous

    I worked in a busy private practice group that routinely (1-2 per month) fired patients and received legal counsel that they should be firing  more than they did. Some examples 1. Abusive patients- to staff, nurses etc. Physically threatening, throwing things (clipboards at a secretary in one instance) or expressing specific threats .(.”If this is not done, I will bring a gun in the office tomorrow morning… I will wait till the office closes and follow you to your car..), screaming profanities in the waiting room., etc.2 .Patients clearly abusing narcotic medication and lying about their use and refusing any attempt at addressing the issue or attempting rehab. That being said, we had a local pain clinic that was very good and it was easy to refer them get them seen quickly.These were the most common examples. No firing of smokers or vaccine refusers. The actual letter than receiving firing them was very tactfully written and there were plenty of other local offices for them to be seen.

  • Anonymous

    Really, what you are saying is that doctors should be able to fire patients that don’t agree with them, from treatment options to philosophical issues to lifestyle. I reallyneed to be careful of what I tell my doctor. 

    Maybe I will be fired if I tell him about that drunken orgy I went to last weekend.

    Or maybe I will be fired when he finds out I voted for Obama.

  • Payne Hertz

    sorry this post went to wrong spot so i deleted it

  • http://twitter.com/#!/CloseCall_MD Close Call

    I think point being is that as an RN, you have a right to deny a patient care.  Either by quitting or by striking (which is the ultimate “firing” of a patient).  

    Perusing the 32 million other search results of doctors and nurses strikes I come up with 2 conclusions:  

    1. Nurses strikes happen like every other day in the U.S.  
    2. Doctors strikes happen on a regular occurrence everywhere BUT the U.S.  (and what’s up with India? 10k doctors going on strike?)

    I want each member of the healthcare team to be treated equally.  An RN is just as important in the healthcare team as a physician.  So if an NP or RN join a union and strike, then in fairness, so should a physician. If an NP or RN can choose to walk out on a patient because of safety concerns, a doctor can similarly walk out due to safety concerns.  

    But doctors in the U.S. don’t.  Instead of wreaking havoc (or “disrupting care”) on a large scale… it happens in a contained environment… like their medical office… with an individual person.  That’s why most physicians are so adamant about the ability to fire a patient when they feel threatened or the safety of their patients is threatened – as in the case with unvaccinated kids in the waiting room.

  • Daniel H Beegan

    I have fired physicians in my adult life and have been fired by a few. Currently, the two doctors I see regularly and I have good relationships, and my last general internist cared for me well for 15 years before I moved 1000 miles away and couldn’t see him any more. One of the two doctors I see now was recommended by a retired doctor friend who had been his patient. He’s family.

  • Anonymous

     Many of the comments here miss a few points, and the most concerning that Dr Mintz alludes to in his comments below as well as the article: who will look after the anti-vax patients, the “non-compliant” ones, the dissatisfied patients?  They will still need health care….

  • Anonymous

    I have a complicated condition associated with a tethered spinal cord.  The tethered cord was not found until I was 42.  From the time I was 7 years old I had misdiagnosis(s) at least 20 times, a good diagnosis would have caught the condition early.  However, my parents and I did not question the physicians involved.  We trusted them.   After 2 surgeries and now suffering from Caudia Equina Syndrome, losing my 30 year job to disability, losing my wife, home, and suffering chronically, I have to worry about asking questions and receiving treatment.   I have to ask questions!  Look at what trusting my physicians has produced.  Now you say, I should be able to be fired if I ask the wrong question, or become to much of a pain due to the complications of my case.  I have had enough pain in my life and it continues!  I do not need more trouble with physicians.   This is a form of discrimination against the disabled white male (and I am sure other ethnic group males as well).  I get turned down regularly from doctors who do not want to help me.  I should say “good” I don’t want them anyway, but when it gets to a point no one wants to help, then I get frustrated.   I think doctors should not be able to just fire their patients, they need to give the patient some good reason and help to find someone who could help them (really help).

    The entire situation with physicians/medical insurance is becoming a nightmare and it is getting worse fast.

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