Lessons from NCMB’s Disciplinary CommitteeComments: 12 comments Print Friendly Version | Share this item
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.
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 firstname.lastname@example.org.
Comments on this article:
The only issue that I thought could have been managed differently is that the staff could have asked the physicians that day if they would have been willing to see the patient for a brief visit as a favor to the patient. Maybe he had something vital to say. I do not think that refusing to see a patient who shows up unexpectedly is good medical practice . Patients have taken the refusal to harm themselves and or others . A screening questionnaire for all patients like the PHQ 9 modified would have been helpful.Also the staff attitude sounded pretty hostile to me, and therefore helped provoke this situation.By kim j masters on Dec 22, 2022 at 12:18pm
Thank you for this. What a wonderful educational endeavor to help us learn how to deal with real world issues in today’s complicated medical environment, for which we received little formal education during our training. What a great idea!By John Latz, MD, MS on Dec 22, 2022 at 12:27pm
This was a well presented case.By Harold Zeltner on Dec 22, 2022 at 12:57pm
Yeah, my only comment is that it appears that the staff member refused to refill the patient’s medication without checking with the provider.
I feel that in questions of this nature, the staff should always check with the provider, who most probably would’ve known about the 30 day rule.
A refusal to renew medication should always be made by the provider, in my opinion.
clearly, they were problems from both parties, but the office staff was absolutely in error in many ways. The patient had some legitimate concerns and should not have been turned away regardless. He was there for a basic follow up and medication refill so at the least, he should have been seen by a staff member as a courtesy. If he had other problems that needed work up, that would be another process altogether. Rigidity by office staff is not acceptable. If the staff member is new and unsure, he/she should discuss with the supervisor or office manager. The patient’s response was not the best, but losing time off from work is a serious issue for many. I speak from 40 years of experience in private practice, both solo and a group.By Ray Sullivan MD on Dec 22, 2022 at 1:09pm
My thanks to the Board for deciding to share anonymized lessons to improve physician care and compliance. Having done various forms of QA over my career, disseminating lessons and having them incorporated into practice routines is an important goal.
In the case discussed, accommodating a working man (who has been a good patient for years) due to a miscommunication would, at the very least, have been a kindness, especially as it was merely a quarterly check-in. Some education on conflict resolution may also be useful for the staff, especially when the consequences of tempers running hot may be serious.By Anthony P Borzotta, MD on Dec 22, 2022 at 1:10pm
“licensees have the right to decide who they choose as patients”
A distinction must be drawn that under EMTALA obligations, licensees do *not* have discretion regarding their patient panel unless/until those screening and stabilizing requirements are satisfied
Nice value added education NCMB featureBy Elizabeth Dunbar, MD, MBA, FACEP on Dec 22, 2022 at 7:16pm
Great new feature! Will look forward to reading future ones. In this case, it seems to me the practice terminated the patient unnecessarily. I think a brief private conversation between the patient and the office manager would have calmed the patient on the day of the appointment. Ending this conversation with a quick rescheduling of the appointment would probably have ended the issue. At the rescheduled appointment the physician would have had an opportunity to support his/her staff by discussing the inappropriateness of the patient’s interaction with the staff. One slip-up by a long term, mostly compliant patient should not end in termination.By Arthur Kelley, MD on Dec 23, 2022 at 10:26am
The 30-day refill suggestion does not take into consideration the fact that the waiting time for a “new patient” appointment may be three MONTHS, as it was for me (although there was no urgency in my case). I would suggest that if the medication in question is a “maintenance medication”, is one the patient has been taking for at least a few months, and is not one which requires frequent monitoring, 90 days would be a more appropriate duration.
If the old practice says “Sorry, we only give 30 days, tough luck if that’s not enough”; and the new practice says “Sorry, your case doesn’t meet our definition of an emergency”; and the patient has been terminated specifically for being disruptive; what do you think the outcome will be? This might be dismissed as an example of The Law of “Unintended” Consequences; but these consequences are entirely PREDICTABLE, and therefore could generate significant liability.By Barry M. Lamont on Dec 23, 2022 at 2:37pm
I think the practice should make at least 2 attempts to contact a patient. That way, it would have prompted action on behalf of the patient to listen to their voice mail &/or call the office to find out why they were being contacted. And yes, kindness is also good medically. So the least the staff could have done is see if the patient could be accommodated by another provider, and if yes, the patient may willingly waited and that way everyone would be happy.By M on Dec 23, 2022 at 3:21pm
These anonymized cases are a fantastic idea to give us insight into the kind of complaints that come to the medical board and what the best course of action should be, from both an ethical and medicolegal perspective. Looking forward to reading more in the future.By Mitchell Mimier, DO on Dec 23, 2022 at 10:22pm
I feel sorry for the patient. In this day and age, patients are under so much stress - remember that thing we all have been dealing with for 35.5 months. He was upset and felt betrayed by someone he thought he could trust. It’s too bad he didn’t listen to his VM but I also totally understand his thinking that it was just a confirmatory call.
Anyway, thanks for posting these. We can all learn to be kinder to our patients every day.By Claus Hecht, MD on Dec 23, 2022 at 11:55pm
Sharing these true stories is a great way to remind and educate docs about best practices and practices to avoid or improve on. Thanks for this!By Robert Patterson on Jan 07, 2023 at 4:19pm