Docs to Disruptive Patients: 'You're Fired'

A California physicians organization is finding that more doctors are dismissing patients because they are uncooperative, refuse to comply with treatment, exhibit drug-seeking behaviors, and increasingly threaten the safety of care providers.

Disruptive physicians get a lot of attention. Remember the story about the surgeon who feeling, "pushed beyond my limits" slammed down an incorrectly loaded device and accidently broke a surgical technician's finger?

Last week I wrote about toxic docs, but this week, I'm turning my attention to the disruptive patient in physician practices.

Years ago, physicians would be concerned about patients who consistently were late for appointments or simply didn't show up. Then, doctors would inform patients that they would be better off seeing someone else for care.

Essentially, the patients would be "fired." Those dismissals still go on, but most of the reasons have nothing to do with the calendar or schedule. Now, most terminations involve disruptive and threatening behavior often linked to drug abuse, says Ann Whitehead, RN, JD, the vice president of Risk Management and Patient Safety at The Cooperative of American Physicians.

Doctors own CAP, a California organization that assists physicians in risk management and other services, including dealing with disruptive patients.

See Also: Physicians Aren't the Only Problem

Doctors are dismissing patients because of "drug-seeking behavior, a request for multiple prescriptions, or a doctor identifying schedule 2 narcotics from different providers," Whitehead explains. "It's progressively getting worse, at least from looking at our call volumes. We also see more physicians being threatened than in the past."

"It has become quite important to discharge patients because they are mad for a lot of different reasons, and disruptive for a lot of different reasons," she adds. "The number of calls hasn't increased, but the reasons have totally changed. Before, patients would be discharged if they missed appointments a lot, if they came in late a lot, or disrupted the flow of the office. It wasn't efficient, because they didn't show."

Now, they are "going from one doctor to another, going down the line to get a number of prescriptions," Whitehead says.

Over a six-month period, from January 1 to June 30 this year, CAP fielded 210 calls from physicians in California, who sought advice in dealing with unwelcome patients. After a consultation with the organization, most of the physician callers took steps to fire the patients, Whitehead says. Overall, in 2012, there were 440 calls.

Sometimes the calls are alarming from worried doctors: The patient vows to come to the office to cause trouble. Their threats are credible and unsettling. CAP runs a hotline to offer specific advice to physicians about dismissing patients.

Doctors have an ethical obligation to maintain a relationship with patients once it is established, and cannot just abandon a patient. Abandonment is withdrawal from a patient without enough notice to the patient, or giving reasonable notice before care is discontinued. But certain patients are simply uncooperative, refuse to comply with treatment, and are abusive.

Some patients are tapping into the Internet and bringing in reams of documents, arguing against their care plan. Others aren't paying their bills, either. And increasingly, there are the drug issues, Whitehead says.

Under those circumstances, a physician is not required to continue treatment of these patients, but must take steps to get another physician for continuation of care, including alerting the patient about the risk of not continuing treatment, and giving the patient reasonable notice before care is discontinued.

Still, the drug issue has catapulted itself to be among the chief concerns of physicians who eventually seek to "fire" patients. While most patients seek legitimate prescriptions, others are demanding more drugs for their conditions, such as seeking pain relief. Physicians must straddle a fine line in patient care, as well as facing increasing scrutiny from law enforcement, particularly over prescriptions for opioids.

"We're sitting in the middle of a minefield," says Arnold Feldman, a pain management specialist who runs the Feldman Institute in Baton Rouge, LA.

"We have to treat in terms of ethics aligned with our oath as a professional. But we're reluctant to treat people with opioids. We won't give them to patients who look suspicious, or if they've smoked marijuana. They are banging on the door, looking for treatment."

Although, pain management physicians often have patients who are prescribed powerful drugs, they are not the doctors who most often fire patients, Whitehead says. "They are pretty well organized in their practices, and do drug testing," she says. "We are seeing more of the prescribing abuses [originating in] the general practice and specialties."

California runs databases known as Controlled Substance Utilization Reviews and Education System (CURES) and the California Prescription Drug Monitoring Program (PDMP) to help physicians monitor the drug use of patients who may visit several physician practices. "We are educating physicians to query the database when they are prescribing. If they see a large number of prescriptions out of the ordinary, they can see if their patients are getting them from other sources," Whitehead says.

While this resource is helpful, Whitehead concedes that the database isn't used by physicians as often as it should be. California's budget problems undermined the efficiency of the database at one point, she says: "That has turned some doctors off. They can't get the information they want and don't go back to it."

The potential for physical harm to physicians and other healthcare employees remains a constant concern about disruptive patients. Whether in physician practices or in the hospitals, "healthcare institutions today are confronting steadily increasing rates of crime, including violent crimes, such as assault, rape and homicide," according to a 2010 report from the Joint Commission Sentinel Alert.

"If there is acting out or threatening behavior, or if an allegation of threats is made over the phone, there is good reason to fire the patient," Whitehead says, referring to any healthcare facility. "If there are threats in person, 911 must be called."

While hospitals may have security staff, that's rarely the case for physicians. In July 2011, a psychiatrist in McLean, VA, had lunch with a friend, another psychiatrist, and expressed his concern about one of his patients, whom he said was getting paranoid and blaming all her problems on the doctor.

If that was the case, she should see someone else, his friend recalled. The doctor agreed, but the dismissal of the patient came too late: the next day he was shot dead by the 62-year-old woman, who later turned the gun on herself. That doctor didn't have a chance to fire the patient.

Second-guessing a patient's motives might not be wise, Whitehead says.

Sure, some physicians may feel a patient "didn't mean what they said, and feel I'm going to give them a second chance." That would be a mistake, she says.

"I don't think there's a second chance in this world because people carry guns."