Wednesday, February 15, 2012

Your Fired! Can Doctors Fire Their Patients?

In today’s Wall Street Journal, and article that is getting a lot of attention is 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). Many have started to blog or tweet about this. Richard Meyer at World of DTC Marketing.com poses the question Should doctors be able to fire patients ? This is an interesting question that I will attempt to answer.


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 acceptable/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 acceptable/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?

17 comments:

Rich Meyer said...

Great post. Given that so many people are intent to slowly kill themselves through bad diet and lifestyles I think that doctors should be able to tell them "either we work together to get you healthy or you're going to have to find another doctor". I guess it comes down to whether physicians want to treat the condition or the person and just prescribe a pill for high cholesterol while his patient goes out and has another burger and order of fries

Dr. Matthew Mintz said...

Rich, thanks for your original post on this that got me thinking.
Ideally, even when a patient didn't make the lifestyle changes I recommended (which is not uncommon) I would still want to work with them. Ultimately, if the patient refused to make any effort, we could agree that our relationship was not therapeutic, and maybe another doctor would be better. However, this is more of a "break up" then a "firing." The real issue with patient termination is that standards and measures used to evaluate physicians and potentially reimburse them. In the new health care models (whether from government or private sector), physicians are getting incentivized by providing quality care at lower costs. This is another way of saying pay for performance or P4P. It is one thing to try to continue to work with a patient to try to move forward. It is entirely different if a P4P system rewards me for meeting goals. These means non-adherent patients hurt my bottom line. If that's the case 1) it may not be fair if physicians can't "fire" patients and 2) if physicians can't "fire" patients, they may start to cherry pick those patients with more acheiveable goals rather than less than healthy patients with other barriers that are likely to "hurt" the physician's bottom line.
In the vaccine article, the pediatrician's "firing" of patients is discussed as a philosophical conflict. However, in a P4P model, pediatricians will be certainly measured on vaccine adherence. In addition, there are potential liability issues in regards to harming staff and other patients.

Maurice Bernstein, M.D. said...

Doctors and other healthcare providers are also presenting mixed messages with regard to allowing themselves to be vaccinated. For example,one study residents registered at the University of Toronto were surveyed after the 1999-2000 influenza season. "Influenza-like illnesses were reported by 36% of house staff. The vaccination rate was 51% among respondents, being highest for community and occupational medicine and pediatric staff (77% and 75%) and lowest for psychiatry, surgery, and radiology staff (32%, 36%, and 36%). Vaccinees reported significantly fewer episodes of illness (42 vs 54 per 100 subjects; P = .03) and fewer days of illness (272 vs 374 per 100 subjects; P = .02); absenteeism was not different (63 vs 69 per 100 subjects; P = .69). Self-protection was the most common reason for vaccination. Vaccinees believed the vaccine was more effective than did non-vaccinees (P < .01). Non-vaccinees considered influenza-like symptoms the most important side effect of the vaccine. Busy schedules and inconvenience were the most common reasons for not getting vaccinated. Overall, 44% of house staff believed the influenza vaccine should be mandatory."

Should doctors be fired for not accepting vaccination? ..Maurice.

Dr. Matthew Mintz said...

Dr. Bernstein,
There is no question that physicians are not the best patients and are often guilty of "do what I say not what I do."
That said, not getting an annual flu shot and refusing vaccines is not the same thing. Not sure what the process is for your students, residents, faculty and staff; but at our institutions there are usually special "flu shot" clinics that health care workers are supposed to go to (and in the clinic, faculty are instructed to get the flu shot from the nursing staff in their clinic). This is different from seeing a doctor (doctor-patient relationship) be told they need to get a flu shot, and then refusing.
However, your point is well taken that we ought to practice what we preach.

Anonymous said...

I am disturbed by this ability to fire, because it takes the freedom of choosing how to deal with my health away. Just becuase I have a conflicting opinion, doesnt make it ok for my doctor to "fire" me. I go to my doctor for assistance in dealing with my health- sometimes medicine or advice- but it is my body and I should ultimately have the last say in my healthcare. Doctors are to be teachers and a resource for knowledge and skill, not as professionals who force their belief system on a patient. People know their bodies best and are often time looked over as the experts on it; not everyone has the same "normal" and cant be put on the same general baseline. Sounds to me from the comments posted it comes down to money- if that was your motivation to practice medicine, and do well at it, I am afraid you failed every patient you have ever cared for.

Anonymous said...

Doesnt this 'firing' for complications already happen to some extent? I know a PCP who refers all his complicated diabetics to an endocrinologist to follow because not only do they get better care... it makes his numbers look better since he has one less A1c of 10 in his practice.

Dr. Matthew Mintz said...

Firing and referring might seem like the same thing to a patient, but it's not the same thing. As a generalist, though I am trained to take care of most things, there are somethings I have greater comfort and interest in and some things I do not. Some internists might refer their diabetic patients, which is something I rarely do. Conversely, urologic issues are something I am not as up to date on, and will refer many patients with these issues to a urologist. Regardless of where I refer a patient, I am not "firing" them. I am simply asking them to get some advice on the management or diagnosis of a specific disease. I assume full responsibility of that patient's care and will work with the specialist (and patient) to manage the disorder I referred the patient for.

Nurse and Hospital Stories said...

These are good points on the issue of doctors firing a patient, Dr. Matthew. Though, I oppose the word "fired" since this word is use for employee-employer relationship, not doctor to patient. Doctors can only agree or disagree to cure a patient but not "fire" him. btw, do nurses have the same authority too?

Thanks,
Peny@lab coats

el emer said...

I was just fired by my dr's OFFICE MGR! (Office Mgr hung up on me-- when Dr. apologized to me, telling me she, the Dr, had fine relationship with me, but several of the staff complained...I was 'abrupt' & 'rude'. Yes, really--so transferred me to office mgr, Dr. saying, if OM & I could work it out, Dr would continue my care.) Guess OM & I can't work it out--Next day came certified mail 'firing' me SIGNED BY THE OFFICE MGR. Before She had hung up, she referred to another OM in a practice years ago who 'also had a problem with' me.

Think there's an OM old girls' network? You bet.

Think I'm going to sue & try to go for class action. You can bet on that, too.

So, calling for all patients abused in this way, please comment or e-m me at boomerbabe128@gmail.com. Attys & other advocates for patients welcome,too.

This is my 1st post her, Dr. Mintz, hoping to hear your pov. Would love your support. I'm willing to give many details of difficulties with old OM & recent one (who I never met!), but who says staff complaints=my firing.

I'm really upset, so call me crazy; just constructively comment, please--& ignore typos.

I hope you've the integrity to post this, Dr. Mintz. I--& commenter Anonymous here, I think--really do want doctors we can respect.

Dr. Matthew Mintz said...

el emer,
Sorry to hear about your situation. Sounds pretty bad. The point of the original post was that if the doctor-patient relationship is a contract, then both doctors and patients, under reasonable circumstances, should be able to get out. When a patient continues not to show up/breaks appointments, at some point (three times, four times, etc.) the doctor should be able to "fire" that patient.
However, the office manageer should NOT be able to "fire" the patient without the doctor's permission. The doctor's staff is a direct extension of the doctor. Just as it would seem ridiculous for a secretary to prescribe a medication for a patient, an office manager can not dismiss a patient from the practice unless he or she is acting on behalf of the doctor. Even in a practice where the doctor is not the boss, there needs to be a clear policy in place when a patient can be terminated. For example, if a patient shows in a waiting room an threatens to blow it up or set it on fire, it is pretty reasonable that the office staff might be able to terminate that patient assuming there is a policy in place stating that any patient who threatens office staff will be immediately termintated.
This does not appear what happened to you. I would not recommend suing, because the only person you can probably sue is the doctor, and if you like the doctor, then you will only be hurting him or her.
I would recommend setting up a face to face meeting with the doctor expressing your desire to continue to see them as a patient as well as your concerns about staying in a practice where the office manager seems to be treating you inappropriately

el emer said...

Sorry Dr. M., but the Dr. in this case, rather than 'do no harm' did indeed hurt me. A lawsuit would 'hurt' the doctor? I should request to meet & continue to see a dr that, rather than fire her incompetent staff, directs the patient, not exactly an employee, to ask the OM 'can't we all get along?'

Seriously?

When, still before dr transfers me to OM who hangs up, I asked dr. if she hires staff, she says no. When I ask if she knows that 'more than one' who complained were incompetent...Dr's response='But I can;t continue as your dr if staff is bothered & it affects practice.'

How about if it 'affects' her patient?

My brief research shows there is something called 'blackballing' a patient. Since I've been shamed into silence by this 'firing' (by office managers, not doctors) more than once AND one incompetent yelled out (yes) that she didn't like my politics (nor my NY accent=ethnicity) here in really red Indiana, AND previous drs. kept referring to my (mild) bipolar disability as 'probably' my behavior being the cause of discord--including this most recent dr...

Well, Dr. M, it will be just a such terrible shame that the dr will be 'hurt' by a lawsuit.

At least she'll have company, as I plan include some of her peers. I just hope I won'tbe alone, and will have the support of other patients...and a really, really good law practice where their clentss come first--and can't be fired by their office staff!

If you care to actually help, there is much more 'bad' treatment by the associated hospital staff here, too, that is relevant. You are welcome to e-mail me or give my e-mail to someone who will help.

If there were an alternative to a law suit, I would try it. However, my concern is my hurt and to prevent office staff & irresponsible drs from hurting future patients in this way.

This silence must be broken; patients should not be...

(again, pardon typos, please.)

Dr. Matthew Mintz said...

el elmer,
my understanding from the original post was that you were upset with the office manager and not the doctor. In addition, it seemed like the physician still wanted to see you. From your follow up posts, it appears that is not correct.
If in fact you are upset with both the doctor and his/her staff, then your only recourse is to sue the doctor for malpractice. In other words, you have no real legal way to "punish" the office staff. Even if "black balling" occurred, this would be a very difficult case to win. On the other hand, a physician has certain responsibilities when it comes to "firing" patients. This includes proper notification, agreeing to provide care until a replacement doctor can be found, and assistance in finding a new physician. If you doctor did not do this, this is called "abandoment" and may be considered malpractice.
Again, if you wish to continue your care at this physician's office, then I would not recommend a legal route. However, if you do not wish to receive care at that office, and want some sort of legal recourse, then I would suggest that you contact a lawyer in your area.

el emer said...

Attorneys, here I come!

Attorneys, here I am!

And Dr. M: Though I appreciate your posting my comment (& replying), truly no offense, but: Your choice to be silent about the doctor giving 'complaints' of staff priority over care of patient...speaks volumes.

My silence over their pettiness was in the service of preserving precious time & words here. My patience knew no bounds with some of these staff members. All I did was actually remind them and ask questions...to protect my own health.

I lost a very technically competent doctor last week because she presumed my difficulties with her office workers, OM & previous practices just had to be my fault, since I was the common denominator.

Even though she had not one moment of difficulty with me.

I could hear in her voice the last time on the phone she told me she couldn't continue as my doctor unless,maybe, I could work things out with this OM she transferred me to...(deep breath)... I heard in her voice that it was my obligation to beg the OM to allow me to see her, the dr.

Had I gone down the rabbit hole AND through the looking glass?!Sure feels that way as I describe this; felt that wayin, er, spades while it was happening.

I'd already said that I'd meet with everyone who 'complained' about me to resolve misconceptions...That was refused twice previously; once by the OM underling who said she'd consult the DOCTOR. But then the dr tells me it's up to my 'resolution' with the OM...er? When did I become the employee here?

Therefore, the dr lost all my respect. And why would I run the gauntlet through this office that sees an empowered patient as a threat to their jobs?

At the risk of being redundant:

ATTORNEYS, PLEASE CALL ME MAYBE!

Thanks, Dr. M for the, um, forum. I know the topic's circumstances of firing were very different.I wish my weird experience were less weird & more consonant with your examples, like refusing to give my child a vaccine.

But very little is available on the subject of firing patients at all--except malpractice insurers & attys defending doctors.

But I think you might know that.

BTW, why does this post 3 hrs earlier time difference than mine if you're in NY (your bio)? Just curious--don't FIRE me!:-)

el emer said...

PS just re-read your reply to my previous (2nd) post--Yes, the dr did say she'd be happy to continue seeing me...if I made the OM happy 1st...

Anonymous said...

If anyone can make sense out of this , I'd appreciate it . My pc told me that she would no longer work with me on a specific health issue . I said that I understood and would find another Dr. Then my Dr. said if I did that it would be firing her . How could it be firing her when she told me that she wouldn't see me for that health issue anymore ? That just didn't make sense to me . I am wondering if she wanted me to fire her ?

Anonymous said...

What about firing a patient from an entire practice of many doctors? Around here if one doctor fires you, you can not use any doctor in the practice. And the practices are huge - many specialists in different specialties, primary care docs, etc. Each of the three major hospitals here have nearly all the doctors, regardless of speciality, with privileges in one giant practice. It seems to me that this is unethical except under rare circumstance. Frequently these practices not only fire the patent, but then their entire family from the entire practice.

Dr. Matthew Mintz said...

That's are really good point. I think it really depends on why the patient was fired. We have a process here where we discharge a patient from our practice. This rarely occurs but is most often a result of frequently broken appointments or failure to pay despite multiple, multiple warnings. It would also include patients who threaten a physician or staff member. I think if a patient threatened to kill one doctor in a practice, it would be fair for the group to fire that patient from the entire practice, regardless of the practice size. On the other hand, a poor working relationship might be a "fireable" offense for one doc, but unfair for the whole group.