Home Forums Discussions General Discussion Angry patient

I have a patient whom I inherited who is a chronic pain patient who recently wrote me a 4 page letter saying that I did not understand her and that she did not appreciate my "threatening" her by not refilling her full month's prescription of Lortab after she repeatedly rescheduled her MRI that I had ordered. She gets migraines and is unable to leave the house. I ordered the MRI in advance of a pain clinic referral which cannot be scheduled until her MRI is complete. Her 4 page rant clearly demonstrated dissatisfaction of my treatment of her. She mentioned she was going to get an Attorney to write a letter to the xray facility who also told her they would not reschedule her if she missed another appointment. Can I fire a patient like this who is clearly high risk? I really feel like the doctor patient relationship is compromised.

Well, you obviously need to. But...... I'm not sure. You may actually need to spend money on an attorney to find out if/how. Probably worth it if you can. Guess she isn't taking anything to try and prevent the migranes either.

NM has a "Prescription Monitoring Program" like the one in my state (Virginia). URL: http://www.rld.state.nm.us/pharmacy/monitoring.html This NM practitioner manual on narcotic dispensing is also very helpful: http://www.rld.state.nm.us/pharmacy/PDFs/practitionermanual.pdf

In Virginia, a quick call usually produces a listing of all the narcotic prescriptions which have been filled by the patient over the past year from all providers. It's very helpful, since most of the time the patient has a history of doctor shopping, seeing many physicians for similar narcotic medication prescriptions.

If she has a rap sheet of abuse, simply show the patient the "proof" of the abuse, and then you can immediately cut the relationship without any fear of legal retaliation. Nowadays you can have the listing of narcotic prescriptions in within minutes of calling!

Al

I would send a standard discharge letter, certified mail, return receipt and same by regular mail. To avoid charges of abandonment, however misguided, I would prescribe at least 30 days of Lortab. This way the patient will feel a small victory and hopefully move on and not harass you in future. Good luck.

Yall need help. I hate to see docs have stress from pain patients. I'm an invasive and non-invasive pain doc. I hate the distinction b/c pain docs should do it all and not pick and choose.
Anyway, simple things I do that work, are legal, ethical, and the dea is happy with.
1. you do not have to prescribe narcotics if you think they are NOT the best for the patient. Would you prescribe a beta-blocker to a patient with a hr of 45 just b/c they want it.
2. Even for legitimate pain etiologies, if patients can not be compliant with clinic rules, can't keep their bill paid, keep scheduled appts, not run out of meds, not loose meds or Rxs, or fail random urine drug screens,then potent narcotic analgesics are not in their best health interest.
3. if patients don't get other treatments, studies, or other recommended modalities and just want pain meds, their pain is not driving their behavior, but their med seeking is.
4. I would not recommend actively firing a pt. If you do not prescribe the meds they want b/c you think them inappropriate, give them all the naprosyn they can carry only and they will fire themselves.
I'd be happy to answer any pain med questions.

Well, I have to say that over a lot of years our practice has on quite a number of occasions fired patients for a variety of reasons and with no repercussions. We don't get into long winded explanations ("Never wrestle with pigs; you only get dirty and the pig enjoys it.") We just send a registered letter that says roughly "We regret that we will be unable to provide further care beyond (30 days hence). We will be available for emergency care during that time. Please arrange to have your records transferred, etc." I have never been sorry that I did so when necessary.

We want to do the best job we can. We can't do that when we dread to see someone on the schedule, are chronically angry with them, or feel manipulated. Medical care is a relationship. Sometimes it just doesn't work. Best to be upfront about it and move on.

And, if your big concern is legal repercussions, then call the risk manager at your malpractice carrier and have them help you through this. I doubt you are at more legal risk from firing this patient than in keeping them.

I would definitely fire her immediately. As Akbeth said, you will find it difficult to be able to provide this patient unbiased health care. Doctors are humans and we are not immune to harboring ill-feelings toward patients. I would send the certified letter stating that you feel your doctor/patient relationship has been compromised and that it would be in her best interest to find another doctor with whom she feels more comfortable. I would give her 30 days of Lortab and end it there.

As primary care odcs, we can be charged with abandoning a patient if we deny them care. This can result in a variety of penalties including loosing your license.

Sometimes the aggrevation of a drug seeking or even just non-compliant or beligerant patient is NOT worth the mental energy. It is simmpler and cleaner to "divorce" them when there are "irreconsilable differences." Then there can be no legal repercussions.

You do not need a reason to "fire" a patient as I understand it. You do have to give them time to find another physician. This may vary by state, but here in IL it is 30 days and you need to give them resources to find another doc (county medical society, their insurance company) so they cannot complain they could not find another MD.

I was on the board of a state-operated malpractice carrier for about 15 years. To my knowledge, we NEVER told anyone to hang on to a patient who was threatening or non-compliant. We did suggest they do it right if they wanted out, give the patient ample opportunity to find a new physician, provide full interim coverage, etc. but there is nothing in the physician/patient contract that implies the physician, regardless of specialty, has sold themselves into eternal bondage by accepting a patient.

Thank you all for your thoughtful responses. You have eased my mind.

OK people I'll state it in a different way. I prescribe a great deal of narcotics I believe appropriate and The DEA and I have an ongoing good relationship.
You do NOT have to prescribe narcotics to any patient that you deem in your medical opinion that class of drugs are not in the patients best health interests.
What are yall afraid of? Please don't forget, your DEA license also includes the responsibilty of do diligence to keep controlled drugs from being diverted illegaly. That aspect should bug you more than patient complaints or fear of the regulators picking on you b/c you didn't prescribe a narcotic to some patient.
Also, not prescribing a narcotic is NOT abandoning a patient. If you deem it inappropriate DON'T do it.
Actively firing a patient will sooner have you standing in front of a judge than not prescribing narcotics.

I received a call from the state Board of Professional Regulation regarding a patient complaint that I refused to see her. They were trying to find out if it qualified as patient abandonment.
The patient had missed multiple appointments,had not been seen in about 2 years, walked in and demanded to be seen late in the day. She was told that we could try to get her in an urgent care slot tomorrow and that she would be charged missed appointment fees.

The bureaucrat agreed that we did not abandon the patient and said the case would be unfounded.

Just that headache makes me very careful about:
1) getting rid of troublesome patients
2) making sure I have CMA in paper documentation that they are no longer associated with me.

Maybe it is not that serious, but I don't need the headache of troublesome patients.

I just called my risk adjuster at the insurance company. The questions was 15 or 30 days on termination. There is apparently no standard and she said some do 15, but 30 would be safer. I'd let the patient go if they have violated their contract and start the 30 d clock.

I generally use some random number like 17 just so they know there is no standard. There are times I use none, if they have no pressing medical issue. They can go to the ED if they can't find a physician.

Patients that fire me don't give me 30 days.

But don't you feel abandoned!?

Completely. Heartbroken. Devastated.

But, when I fire a patient, I don't just send a certified letter that says, "Hey, I fired you."

No, I would at least say, "I know everything seemed great, and you paid your bills and we seemed to have a good rapport and you gave great histories and all, but I am firing you for no good reason. Actually, confused patient, I am firing you for a reason, but I am not going to tell you. I will let you sit around and try to figure it out. Hey, maybe you didn't do anything to me. Maybe you looked funny at one of my staff. Oh, I know we had 100 good visits. Great visits actually. But, it was just that one visit where you kind of rolled your eyes."

I am so happy to hear you guys fire patients also. When I opined that view at the start of this thread, I came away feeling like the worst doctor since Josef Mengele. Oh, well. It wouldn't be the first time.

I know this is OT, but we have had a couple of very difficult clients that loved our work, but were a constant headache to keep functional.

After a very difficult contract phase , we were asked to bid a contract mod; we didn't want to work with them any longer, but even after we kicked the price up 50%, they still took the mod. After that, we kept upping the price of each following mod further. Eventually they took a lower bidder, and we all (including our insurer) slept easier.

Bootom line - I'd agree with Bert, sometimes it's easier to part ways without having to explain why.

We would not hesitate to dismiss a patient like this.

We're a PCP clinic and have discharged patients from care for a variety of reasons over the years. There haven't been any problems with it, but we're very careful to maintain documentation of events that led up to the firing (drug seeking, violation of narcotic contracts, abusive & threatening behavior, and chronic no-show for appointments.) Our treatment period is normally 30 days depending on the reason for the discharge. Even if we send someone to collections (resulting in a dismissal) the letters emphasize our assumption they are withdrawing care by refusing to pay their bill or respond to our calls etc.