How to Deal with Problem Patients

September 16, 2011
J. Scott Litton, Jr, MD

The doctor-patient relationship is built upon a foundation of trust. What do we do when a patient compromises or starts to bend the trust?

In the practice setting, we have all had our fair share of patients who have caused us to bear a certain amount of undue stress. Certainly the doctor-patient relationship is built upon a foundation of trust between the two parties. What do we do when a patient compromises or starts to bend the trust?

Patients being treated with controlled-substance medications in my practice are all required to sign a medication-use agreement. Such an agreement, which is not a legal document by the way, states in plain terms my expectations of the patient and also describes what the patient must do in order to comply. Such expectations range from presenting for random pill counts and urine drug screens, informing me of seeing another physician and receiving a controlled substance (dentist, ER physician, etc.), and not utilizing multiple providers or pharmacies. When patients do not follow these well-defined rules, I meet with them in the office and explain to them in a face-to-face encounter that I will be unable to continue to provide the controlled medication to them; however, I will continue to provide primary care for them. In 99 percent of these cases, the patient chooses to remove themselves from the practice.

We have a well-written policy regarding failure to show for scheduled appointments and showing up late for a scheduled appointment. Each situation is reviewed and patients are asked to be more responsible at the first violation. Repeated no shows results in the patient receiving a certified letter informing them that they are being discharged from the practice. Generally the first warning to the patient that repeated no shows will result in dismissal from the practice has helped to reduce greatly our no show appointments. Further, I utilize a telephone reminder service that calls patients two days prior to their appointment, reminding them of the date and time.

The above examples are typical of the problems encountered in a medical practice setting. I am very blessed to have a wonderful patient population to care for, however there have been two patients that have been informed that they will be dismissed on the spot after verbally insulting or assaulting my staff with profanity. I am the only male employee in my practice and the other employees are female. It is understood that I expect each of my patients to treat them with the same respect that the patients show to me. For the two patients that have used profanity directed toward my staff, they were asked to leave the office and a certified letter was sent to them that day.

As physicians we have a great deal of responsibility to treat our patients appropriately, both medically and professionally. For a very large percentage of our patients, this is certainly our privilege and gives us all a tremendous amount of both personal and professional satisfaction. Being disciplinarians was not taught in medical school, however in a medical practice it must be carried out when necessary. A good practice to remember is to treat each patient equally and fairly, and if disciplinary actions are to be made, make sure that you are consistent for each patient as well.

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