One question I get from time to time is how a doctor may discharge “problem patients” and end the physician-patient relationship. Doctors who terminate the relationship improperly can face disciplinary charges for patient abandonment or worse. Medical Board complaints for patient abandonment are generally the result of poor communication and typically are the product of a doctor moving to a new practice group; the closing of a medical practice; or a physician moving to a new city. I’ll deal with closing and departing from a medical practice in another post. The issue today is the “problem patient” — one who is disruptive, non-compliant, delinquent or simply has a personality clash with the physician or staff. Discharging these patients should be done with care.
The physician-patient relationship is not a life-long commitment for either the doctor or the patient. With the exception of certain requirements of EMTALA (the Emergency Medical Treatment and Active Labor Act of 1986), physicians are not obligated to accept every patient who seeks his or her services. Once the doctor-patient relationship is established, however, a doctor must follow certain guidelines when discharging a patient to avoid abandoning the patient. Colorado Medical Board policy 40-02 sets out the procedural guidelines for discharging a patient. The Medical Board recommends that:
- Any discharge be in writing and sent to the patient via certified mail;
- In the discharge letter, the doctor agrees to provide 15-30 days of provisions coverage while the patient finds a new doctor;
- The physician provide information for referral to new physicians, if possible; and
- The letter notify the patient that the patients’ records will be sent to the new physician upon receipt of a written authorization from the patient.
Keeping in mind that problem patients are being discharged for a reason, care should be taken to make sure that a physician minimizes the risk of being charged with abandonment or worse by virtue of the discharge. Even where procedural guidelines are followed, physicians must take care that all discharges are for non-discriminatory reasons, not in violation of anti-discrimination laws such as the Americans with Disabilities Act, and do not jeopardize the welfare of the patient. Thus, a discharge letter should also explain the reasons for discharge in clear and concise language, taking care to spell out the non-discriminatory basis for ending the relationship. A properly prepared discharge letter can eliminate many headaches for the doctor down the road.
The ever-increasing popularity of social media sites like Twitter, Facebook and others, can create issues for doctors and other health care providers. A few weeks ago, I posted about the Rhode Island physician who lost her job and was reprimanded by the Medical Board for inadvertently identifying a patient on Facebook. Other than the HIPAA and physician-patient privilege issues, social media can present other issues for doctors. For example, last year, CNN.com ran a story about physicians on a humanitarian mission to Haiti posting photos on Facebook. The article, which can be read here, indicates that the Puerto Rican Medical Board investigated the posting of photos of doctors drinking, posing with guns and partying. Ultimately, Medical Board exonerated the physicians, but the incident itself highlights the risks of social media for doctors.
A major concern for health care providers with an online presence is maintaining professional and personal boundaries. The AMA has issued a policy on professionalism in the use of social media for physicians that should be required reading for all healthcare professionals. The AMA Policy can be viewed here.
Doctors and other healthcare providers who choose to have a social media presence should keep a couple of things in mind:
- Nothing about the Internet is Private. The physician-patient privilege and HIPAA prohibit disclosure of any information that would identify a patient. The more unique a case is, the more likely a description would identify the patient. Don’t discuss patients or cases, no matter how interesting. Here’s what can happen.
- Boundaries become Blurred Online. As with the physicians in Haiti discussed above, the lines between private and professional life can be difficult to discern. An April 2007 article in the AMA Journal Of Ethics, cautions against physician’s disclosure of personal issues to patients, such as similar medical conditions, in an attempt to empathize with the patient. Allowing patients “behind the curtain” into a physician’s personal life is a situation ripe for problems. Although patients may feel a greater connection to the physician, they can also start to view the relationship as something more. Most commenters recommend avoiding “friending” patients on Facebook. See”A Doctor’s Request: Please Don’t Friend Me” from USA Today; and “Practicing Medicine in the Age of Facebook” from the New England Journal of Medicine. Because of the unique nature of the physician-patient relationship, keep your personal and professional life separate.
- The Same Rules Apply Online as Off. If physicians or practices choose to have Facebook or other social media presence, keep in mind that all of the rules that apply in the real world apply online. This means that poor advice, poor decisions, and poor communication online can have the same affect as that given in person.
One of the primary reasons doctors receive Medical Board complaints is communication with patients, but also with hospital and office staff as well. Although many believe that treatment of hospital staff cannot result in discipline or privileging issues, a recent Wyoming case illustrates otherwise.
On February 24, 2001, the Wyoming Supreme Court upheld the St. John’s Medical Center’s revocation of medical staff privileges of a physician described as “disruptive.” Significantly, both sides agreed that only the doctor’s behavior toward staff, not the quality of care to patients was at issue. The case illustrates the high standards placed on physician behavior.
The physician, an orthopedic surgeon, was described to have “repeated instances of behavioral issues” with hospital staff. When the doctor applied for reappointment to the staff, he entered into a “Medical Staff Reappointment Agreement” that identified behavioral concerns and placed conditions on reappointment. Several months after reappointment, the entire operating room staff signed a petition refusing to work with the surgeon. Subsequently, the Medical Executive Committee summarily suspended and ultimately terminated the surgeon’s privileges. The physician challenged the revocation of his privileges on several grounds, including his right to due process, and the hospital’s decision to bypass its “Disruptive Practitioner Policy.” The Wyoming Supreme Court ultimately upheld the hospital’s decision. In reaching its decision, the Court quoted the Oregon Supreme Court’s holding in Huffaker v. Baily, 540 P.2d 1398 (Ore. 1975):
The factor of ability to work smoothly with others is reasonably related to the hospital’s object of ensuring patient welfare. This conclusion seems justified for, in the modern hospital, staff members are frequently required to work together or in teams, and a member who, because of personality or otherwise, is incapable of getting along, could severely hinder the effective treatment of patients…. Hospitals uniformly consider cooperativeness an important factor, and in these circumstances it seems questionable whether this court should gainsay the hospitals’ experience and judgment in this matter.