How to Effectively Treat the Difficult Patient, Part 2

Written by Donnaline Richman, Esq., and Marilyn Schatz, Esq., of the MLMIC Legal Department and Kathleen Harth of MLMIC Insurance Company, this was originally printed in our Fourth Quarter 2022 issue of The Scope: Medical Edition.

In this second installment of “How to Effectively Treat the Difficult Patient,” we examine other situations that arise when treating patients who present challenges beyond their medical conditions. Read Part 1 here.

Patients Who Complain about Treatment

Patients who lodge complaints about their care and treatment with a third party, such as a hospital, insurance company or governmental agency (e.g., Medicaid or the Office of Professional Medical Conduct [OPMC]), create an awkward situation. The patient may have chosen not to discuss their concerns about treatment with the physician and, instead, decided to write a formal complaint letter. Sometimes, it is not the patient who makes the complaint, but rather a spouse, adult child or other family member.

No matter where it originates, receipt of a complaint letter places the physician in an uncomfortable and defensive position. It may not be wise to continue to treat the patient if they are dissatisfied. Consciously or unconsciously, the physician may be inclined to order additional, or even unnecessary, testing or procedures merely to satisfy the patient’s demands or protect themself from litigation or government investigation.

If a physician does receive a complaint letter that alleges substandard quality of care received and requests compensation for an injury (i.e., a claim letter), the physician should contact MLMIC Insurance Company. MLMIC will investigate the patient’s claim and develop an appropriate response and/or resolution to the complaint. If the patient’s letter does not ask for monetary compensation but simply raises concerns about the quality of care, the MLMIC Legal Department is available to assist the physician in preparing a written response.

Patients Who Fail to Pay Bills

Physicians often ask whether they may discharge a patient who fails to pay for services rendered. The answer is yes, as long as there is no medical reason that would preclude discharge. These patients may also fail to keep their appointments due to their inability to pay. If the patient misses an appointment and their medical condition warrants follow-up care, appropriate steps must be taken to ensure that the patient is counseled about receiving the required care and the consequences of the failure to obtain it. Warning letters should be sent about missed appointments that describe the patient’s condition, the need for continued treatment and what could happen if treatment is not received.

Only after such steps have been taken may the patient be discharged from the practice. Note that the physician-patient relationship does not automatically end when a patient’s bill is sent to an agency for collection. The physician’s responsibility for the patient’s care only ends when the patient has been formally discharged.

Patients Who Threaten to Sue or Consult an Attorney

If the patient not only complains about treatment but threatens to bring a lawsuit, or if the patient has consulted an attorney, clearly, the physician-patient relationship has been seriously disrupted. The physician’s first awareness of attorney involvement may occur when they receive a request for a copy of the patient’s medical record. Since it is not always clear why an attorney is requesting a copy of the record, many physicians rely upon instinct to alert them to a potential liability issue. If there is any inkling that the patient is contemplating a malpractice lawsuit, it may make it uncomfortable for the physician to continue to treat the patient.

Surprisingly, some patients wish to continue seeing a physician they have sued, but it is not in the best interests of either the patient or the physician to continue the relationship. Patients who have sued, or who have consulted an attorney with the intention of commencing a lawsuit, often cancel or fail to keep scheduled appointments, particularly after their attorneys have requested a copy of their medical records. They may be noncompliant with treatment recommendations or fail to communicate about medical issues. Physicians may feel compelled to practice “defensive” medicine, ordering inappropriate tests and procedures. The physician may believe that continuing the relationship will help them “look better to the jury,” which, generally, is not true.

Once a patient has commenced a malpractice suit, the physician-patient relationship, based upon mutual trust, has been seriously compromised. The patient should be discharged from care, or, if their condition requires it, the patient may be transferred to another practice. If the patient’s physician is in a group practice, the patient should be discharged from the care of all medical providers in the group.

Intoxicated/Impaired Patients

When a patient or family member comes to the office drunk or otherwise intoxicated, they may be uncooperative and disruptive and can be asked to leave the premises. The physician may be concerned about the patient’s ability to drive and may question whether they should call the police to prevent an accident. These same questions arise when a patient who has received an anesthetic or sedative in the office insists on driving home, despite clear warnings not to do so. Regrettably, a physician’s office should not call the police to stop a patient from driving, since this would be a breach of the patient’s right of confidentiality.

Handling these situations involves skillful persuasion. First, the patient should be assessed to determine whether there is another cause for the behavior that can be treated, or if the patient has recovered sufficiently to drive safely. If the physician feels the patient is unable to drive safely, the physician should attempt to persuade the patient to remain until they are safe to drive, offer to send the patient home in a taxi or car service, or call a family member of the patient to provide transportation. The counseling efforts and actions taken must be documented in the patient’s medical record. If clinically appropriate, the patient may be discharged from the practice.

Patients Who Lack Capacity

Patients with decreased cognition, dementia, or those who reside in an Office of Mental Retardation and Developmental Disability (OMRDD) facility can be difficult to treat. Concerns may include cooperation, safety and informed consent. When dealing with patients who lack capacity, proper staffing and allocating adequate time are important so that these patients may be treated safely. It can also be difficult to discern if such patients have a legal guardian or other person who has the right to provide consent. A patient may have multiple family members who disagree about the patient’s care but do not have the legal authority to make healthcare decisions. Individuals entitled to make healthcare decisions, such as providing consent for treatment, include healthcare proxy agents, legal guardians, or, for a patient from an OMRDD-regulated facility, an involved family member.

Patients who lack capacity pose special legal issues involving appropriate delegation and documentation of decision-making authority. If you have a situation that requires evaluation of such authority, you should contact legal counsel.

Patients Who Act in a Seductive Manner

Some patients send love letters, exhibit unusual or flirtatious behavior or use sexual innuendos when speaking to their physician. In some instances, the patient may not even be aware that this behavior is inappropriate.

A physician should have a chaperone present in the room when it is appropriate. The presence of the chaperone must be documented in the patient’s medical record. (The MLMIC Legal Department can provide sample language that can be used to document the presence of a chaperone.) This is particularly important for patients who act in a seductive manner.

A patient who acts inappropriately toward their physician may have underlying emotional or psychological issues. There is a very real risk that the patient may make allegations of sexual misconduct when their advances are rebuffed by the physician. Such allegations can destroy a physician’s career and result in disciplinary action by the OPMC. The use of a chaperone can help a physician avoid such allegations. If a patient alleges that sexual misconduct has occurred, the patient must be discharged immediately, if appropriate, to protect the physician’s license and reputation.

Discharging a Patient from Care

As pointed out in this discussion, a physician is not required to continue caring for a patient whose behavior makes the physician uncomfortable. A patient may be discharged from care if he does not have an urgent or emergent medical condition or does not require continuous care without a gap.

In some situations, the physician may find that the patient cannot be discharged, or that the physician must first arrange for a seamless transition to another provider. The physician must consider the patient’s ability to obtain the same type of care in a timely manner within a reasonable geographic distance. In some specialties, 30 days’ notice may be insufficient.

If the patient can be discharged, any existing appointments must first be canceled. The physician must then promptly send a certified letter to the patient stating that he is discharged from the entire practice. If the patient refuses to accept a certified letter, a copy of the letter should be sent by certificate of mailing.  Once the discharge letter has been sent, all office staff must be made aware of that fact, so that the patient is not inadvertently given a new appointment.

The wording of the discharge letter may be important. In cases where the patient has failed to pay for treatment, it is usual for the letter to state nonpayment as the reason for discharge. In other cases, especially when the discharge is due to the patient’s disruptive behavior, or if there is a potential lawsuit against the physician, the discharge letter may be more general and may state simply that there has been a disruption in the physician-patient relationship. This general, noncommittal statement may help avoid or minimize an unpleasant confrontation. If further evaluation, care, and treatment are indicated, the discharge letter must emphasize the importance of seeking such care from another provider and state the consequences for failing to obtain it.

Conclusion

Interactions between medical practitioners and patients can sometimes present challenging dilemmas. Angry, rude, unhappy, and anxious patients can be disruptive to the office. The ability to positively address patients’ concerns is an essential component of a successful medical practice.

It is strongly recommended that physicians implement appropriate strategies to manage difficult patient encounters in order to reach amicable resolutions. Successful communication and listening skills are required to avoid and defuse strained relations. Anxieties can be reduced by empathizing with patients in a calm and understanding manner. Physicians should acknowledge grievances, frustrations, and concerns by demonstrating understanding without being dismissive or disrespectful, know when to compromise and always maintain professionalism.

Effective skills are essential to address stressful relations between physicians and patients. MLMIC professionals have the experience and requisite expertise to assist in the management of these uncomfortable circumstances. Please do not hesitate to contact MLMIC should the need arise. By properly managing these situations, physicians can maintain good relationships with their patients, provide effective care, and protect their reputation.