Resources & Information

Board Members and staff often observe how valuable it might be for licensees to be a “fly on the wall” during Disciplinary Committee meetings.

Of course, these meetings – during which Board Members review cases, tease out questions and concerns, and, finally, make recommendations for how to resolve each case – are held in closed session. What’s more most of the cases reviewed are closed without public action, because the Committee determines that the facts and circumstances do not warrant it.

What a shame, our Board Members thought, for all those potential lessons to go unheard and unheeded by licensees.

With that sentiment in mind, NCMB is establishing a new recurring feature in the Forum newsletter. Through fictional case studies that are inspired by actual cases that have come before the Board over the years, we will regularly present lessons that might otherwise never see the light of day. Our hope is to illuminate choices and circumstances that may help other licensed physicians and PAs avoid similar situations in future.

First up: Meeting professional obligations to patients when ending the clinician-patient relationship.

Case study: Severing ties with a “disruptive” patient

Patient is a 57-year-old male with a history of high blood pressure, high cholesterol and moderate obesity. He has been a patient with Do Right Internal Medicine for approximately nine years. In that time, patient has overall been compliant with his treatment plan, excepting his physician’s recommendation to lose weight. The patient is taking medication daily to manage high blood pressure and cholesterol levels and is currently being seen quarterly to monitor his progress with implementing lifestyle changes to lose weight.

The patient arrives at the practice to be seen for a quarterly appointment. When he approaches the front desk, the staff person who greets him tells him that his appointment has been cancelled due to his physician being out of town. The staff person indicates that the practice called to notify the patient of the cancellation earlier that week and left a voicemail asking him to reschedule. The patient indicates that he was working when the call came in and, when he saw that it was the medical practice, he assumed it was a routine confirmation of his appointment. He did not listen to the voicemail and, as such, did not get word that the appointment was cancelled. The patient explains that he took time off work to be seen that day and asks if someone else with the practice could see him in place of his regular physician. The staff person says that no one is available to see the patient just then but indicates that she can reschedule the appointment for another time.

When it becomes clear that the practice cannot accommodate his wishes, the patient becomes angry. He loudly complains that it is “effing ridiculous” for the practice to turn him away. He slams his hand on the front desk and exclaims, “This is no way to treat people!” He says that he has recommended the practice to numerous friends, neighbors and coworkers over the years and now wishes he had not done so, “if this is the thanks I get.” Finally, the practice administrator approaches the window to reiterate that he cannot be seen that day. She asks the patient to leave, which he does.

The following week the patient receives a letter from the medical practice indicating that he is being dismissed as a patient. The patient accepts this decision but seeing no reference in the letter to prescription refills, he contacts the practice to request that his blood pressure and cholesterol medication be refilled so he can remain on them while he seeks to establish with a new practice. He is abruptly refused by the staff person who answers the telephone. “You are no longer a patient with this practice,” the patient is told. Unsure where else to turn, the patient files a complaint with the medical board against his physician.

Discussion

Just as patients have the right to choose the physicians or PAs they entrust their health to, licensees have the right to decide who they choose as patients. This right includes the discretion to terminate a patient for any reason. That said, terminating the licensee-patient relationship can be a difficult and delicate task – and there is an appropriate way to do it.

NCMB provides guidance to licensees regarding professional obligations to patients upon dismissal in the position statement entitled, The Licensee-Patient Relationship. Put simply, the Board’s view is that patient dismissals should be handled in a way that reinforces the licensee’s underlying obligation to support continuity of care. Licensees should ensure that administrative staff understand these obligations.

At a minimum, a licensee should meet the following obligations to patients who are being terminated:

• Notify the patient of the decision to terminate sufficiently in advance (generally, 30 days’ notice is considered the minimum) to secure alternate care. Ideally, notice of termination should be presented in writing to the patient and a copy included in the medical record. In the example provided, the licensee/practice did provide written notice to the patient.

• Provide ongoing care to the patient during a limited period following notice of termination. Again, 30 days is considered the minimum standard “wind-down” period. In some situations, it may be appropriate to set limits on what type of care will be provided (e.g., ongoing treatment for established conditions and new, acute illnesses, for example). In extreme situations, where the licensee is concerned that a patient may become violent, it may be appropriate, upon termination, to direct the patient to the nearest urgent care or emergency room for care. In the example provided, the licensee failed to meet the professional obligation to address continuity of care/access.

• Provide refill prescriptions (generally, a 30-day supply for maintenance medications) to bridge the patient until he or she establishes with a new medical provider. In the example provided, the licensee/practice failed to support continuity of care by refusing to provide any refill prescriptions to the patient.

• Provide copies of medical records to patients or to their new medical providers following termination in a timely manner when requested. In the example presented, no issues with medical records arose. However, if the patient or his new medical provider requested copies of medical records, the practice would be obligated, both ethically and professionally and under federal HIPAA laws, to fulfill this request.

Avoiding missteps when terminating patients

Although inappropriate patient dismissals do not often result in public action, it is nonetheless important for licensees to ensure that they take steps to meet their obligations to patients even when severing ties. Clear and consistent policies regarding dismissal can help avoid conflicts with terminated patients, prevent complaints and ensure that patients have the opportunity to establish elsewhere with minimal disruption.

NCMB offers the following guidance to support appropriate dismissal procedures:

• Review the NCMB position statement on The Licensee-Patient Relationship and assess current practice policies to ensure that they align with the principles outlined therein. Make sure the administrative staff who are charged with implementing and enforcing such policies are aware of medical professionals’ obligations to patients.

• Consider developing a form letter for patient dismissals that clearly states how refills and medical records requests will be handled. The letter should state whether the dismissal is from a single physician or PA or from the medical practice as a whole. Don’t forget to address how urgent medical needs will be handled immediately following notice of termination and for how long (e.g., 30 days from the date of the termination).

• Ensure that policies are implemented fairly and consistently. Although no licensee or medical practice is obligated to tolerate rude or disruptive behavior by a patient, bad behavior is not an excuse to deny a patient access to medication or medical records.

Send questions and feedback to forum@ncmedboard.org.