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How to fire problem patients


To fire a problem patient, an expert recommends remaining cordial, and communicating your intent in a letter that details why you're firing them, where else they can seek follow-up treatment and what could happen medically if they don't.

Aspen, Colo. – Dismissing a troublesome patient requires a firm stance and a soft touch, said an expert at The Cosmetic Boot Camp, held here.

"It's an honor and a privilege to be a physician," said Jeanine Downie, M.D., a Montclair, New Jersey-based dermatologist. Accordingly, she said, "Be respectful and professional when firing a patient. Understand that feelings may be hurt. And you don't want the patient to Internet-bomb you, which has happened to me. Try to exude positivity. I always tell them, 'It's not really you – it's me.'"

Because she appears regularly on TV, said Dr. Downie, she occasionally encounters patients who seem to believe she is a magician. "And I'm not – I'm simply a doctor who is trying to work on their image, their acne, or whatever their skin issues are."

If she can tell that a prospective patient is not mentally stable, Dr. Downie said, she politely refuses to treat the person in the first place. "Some patients are flat-out difficult from the beginning," apparently on purpose. Conversely, Dr. Downie said she'll gladly treat a patient who has psychiatric issues if the patient is receiving proper mental health care, participating in a dialogue with her and following treatment recommendations.

When dismissing a patient, on the other hand, "You must send a certified letter, return receipt requested, as well as a copy by U.S. Mail. Photocopy both items and put them in the patient's chart, after they're stamped and before they're sent." Often, she said, patients will not sign the certified letter. "So they still get a copy in the mail."

The letter should detail the incident and date of inappropriate behavior by the patient, Dr. Downie said. It also should advise the patient that within 30 days of their receiving the letter, you will no longer be providing their medical care. "That's critical – you cannot abandon them right away" without facing possible legal repercussions.

Because many problem patients are quite confrontational, Dr. Downie said, they may show up at one's practice within the 30-day window, demanding to see the dermatologist. If this happens, "Do not see the patient alone in a room. Have your nurse, assistant or other staff member present in the room to lessen the likelihood that the patient can claim you did something inappropriate."

Even if the patient says he or she does not want another person in the room, Dr. Downie emphasized, "Don't listen to them. As far as I'm concerned, you can still talk to them in a semi-private area and have somebody standing by." She added that a colleague who failed to take such precautions had to settle with a patient who had completely fabricated a claim of impropriety.

Somewhat similarly, "If a patient comes in and debates you, tell them as you would tell a child – but not in a pejorative tone – that your decision is final, and it's in both of your best interests. You might have to repeat yourself three or four times. Then the bottom line is, if you feel threatened in any way, don't hesitate to call the police."

Also in the letter, "Refer the patient to his or her primary care physician, insurance company, local hospital or the county medical society to locate another board-certified dermatologist. Keep it distant and cordial – inform the patient that there are many other competent practitioners in the area." However, said Dr. Downie, "You do not want to send this patient to another dermatologist in your area with whom you maybe don't get along, because that dermatologist will do it back to you."

Additionally, the letter should spell out the medical consequences of failing to follow up with another board-certified dermatologist. "You don't want to be in court later with the patient saying you abandoned him or her, and there's no paperwork regarding what their sequelae would be" without further treatment.

Although it's not legally required, she added, "You can enclose a copy of the medically relevant records to assist the patient in their exit from your practice and facilitate their subsequent medical care."

Less urgent, but still problematic, said Dr. Downie, is the no-show patient, who wreaks havoc with a practice's schedule and patient flow. Before taking action, "Always listen to what their circumstances happen to be." For example, she said, having chemotherapy trumps "The dog ate my appointment card."

Ultimately, "If it's more than three no-shows, and you feel you're not connecting with the patient, absolutely fire them. Explain in your letter to them that it's due to their failure to present or cancel in an appropriate amount of time before their scheduled appointments. Tell the patient that you will make their medical records available to them when they pick another dermatologist." With your letter, "Enclose an authorization form saying that you need a signed medical release to ship the records out. And always extend your best wishes to the patient."

Dr. Downie reports no relevant financial interests.

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