The Situation:  A solo physician periodically encounters a patient who is belligerent and frankly rude to her staff. One particular patient disrupts the office at each visit, and it starts even before the patient arrives at the office. The staff anticipates what will happen. Most importantly, the physician does not like how the patient treats the staff. She tried talking with the patient, but the patient’s behavior did not change. What can she do? Does she have to keep seeing this patient?

The Potential Issues: Patient abandonment; lack of continuity of care; state board complaint; and medical malpractice claim.

The Solution:  The short answer is no; she does not need to keep seeing this patient; however, to minimize liability risk for her, there are certain steps she should take before discharging the patient from the practice. Physicians have an ethical responsibility to assure continuity of care for their patient (see AMA Code of Medical Ethics Opinion 1.1.5). Here is a practical way to handle the situation:

1. Discussion with the patient. Tell the patient that if his behavior does not change, that he will be discharged from the practice. This gives the patient an opportunity to change his behavior while understanding the ramifications if he does not do so.
2. Document patient discussions. Document the conversations with the patient about his behavior. Include in that documentation that the patient was notified that he will be discharged from the practice if his behavior does not change and that despite discussion with the patient, the patient’s belligerent and rude behavior continued.
3. Send a confirming letter. Send the patient a letter that outlines the discussions, the nature of his negative behavior, and how the patient can get things back on track. Again, include that the patient will be discharged from the practice if things do not change. This serves as evidence.

Then, when the patient again does not behave, discharge him from the practice. Notify the patient in writing and include information on what the patient needs to do to continue with his healthcare treatment, recommendations on obtaining a new provider, and giving the patient thirty days to find a new healthcare provider. Why all of this? So that the risk of a claim of patient abandonment or a report to the state board of medicine is low. If either of those occur, the physician will have documented well the evidence needed to support her actions and show that she did not abandon the patient.

A good risk mitigation strategy is to have in advance prepared template letters that can be customized for each situation.