Wednesday, June 11, 2008

Dear Patient, You're fired!

This is a really intriguing article, from yesterday's New York Times. Do you agree with this doctor that he has the right to dismiss a child as patient because the patient's parent has a dramatically different care philosophy from his own?

Here's the heart of the argument:

The physician-patient compact basically states that a doctor will care for a patient in exchange for compensation and that the patient will heed the doctor’s advice. Patients who disagree with their physicians, or just dislike them, are free to go elsewhere.

By the same token, this mutual contract gives a doctor the right to dismiss a patient. The most obvious reasons are failing to pay or missing multiple appointments. Refusing to adhere to treatments can lead to dismissal. So can being abusive to the medical staff.

Of course, we need to exercise this option sensibly. Doctors cannot fire a patient in dire straits like severe pain, bleeding or a life-threatening situation. And of course, we cannot refuse to see patients because of their race, age, sexual orientation and so on.

But could I fire a patient because I didn’t like his mother? Colleagues who had studied the ethics and legal issues told me that the answer wasn’t clear-cut. Obviously, I couldn’t just abandon them. Yet like a lot of legal jargon, the word “abandonment” is open to interpretation. I decided it meant that as long as I wasn’t leaving anyone out to dry with a serious, immediate medical problem, that I gave a patient reasonable notice and provided options about where to continue getting care, I was within my rights.


janemariemd said...

I agree completely also. I think it is possible to care for patients who have a relative who is disagreeable or unpleasant, but this mom was more than that, in my opinion. It ultimately can interfere with your care of the patient, so I think the doc is completely justified. There is also an outside chance the woman might learn something, and behave better with the next doctor (but then again, she probably won't!)

Anonymous said...

I was in agreement until he described the letter he sent. It was inappropriate and he certainly knew that the child was of reading age. That he then published the story is really crossing a line. He should have handled the "dismissal" in a much more humane fashion and then kept the whole thing to himself. Word travels fast and I'm quite sure the son and the mother both recognize their story. Shame on this doctor.

Anonymous said...

I agree with nasov about keeping it to himself and not in the NYT, but the boy will learn an important lesson; that adults are not always right, even if they are your mother. For me, the scales were tipped when she said "I'll treat him for tetanus if he needs it." She clearly hasn't the faintest idea that this disease is frequently fatal and there is no effective treatment except supportive care and prayer. She is allowing her global hostility to overcome her responsibility as a parent; I would have fired her too.

nonlocal MD

Anonymous said...

To carry the thread more broadly, should physicians be able to refuse treatment of children whose parents refuse vaccination for deadly diseases or those with great public health risk? It reminds me of the cartoon where a doctor asks his patient if he would like to be treated according to germ theory or creation theory. Can you end a relationship based on ignorance or only abuse?

Roanne Weisman said...

This doctor is doing his patient a favor. He obviously cannot work in partnership with this family, which is what we need our doctors to do. As I wrote in "Triumph Over Diagnosis,"
We need our doctors to recognize that their words and attitudes are powerful influences on our bodies, minds and spirits. If they cannot be our partners in hope, the relationship should end. Thirteen years ago, when my neurologist told me I'd probably remain disabled after a stroke, I ended the relationship and found those who helped me achieve a full recovery.

Anonymous said...

A true doctor will strive to restore the health of another human being always, and such subjective issues as philosophy or religion are not in the equation. If a doctor allows his subjective state to be an element of patient care, than that person should not be a doctor.

Furthermore, and what might be considered an exception, is refusing those seeking cosmetic surgery or lifestyle treatment of an otherwise healthy person. Any doctor who enhances the appearance of another human being does not deserve the title of a doctor. Perhaps the title of asthetic molder would be more appropriate. Remember Dr. Kervorkian? He does not deserve the title of a doctor, although many believe he was relieving suffering. By killing others, that is causing harm. Maybe Kervorkian deserves the title of executioner.

I digress. If a doctor is not restoring the health of another human, or potentially harming them, they should not be doctors.

The simple fact that someone asked such a question illustrates the state of this health care system, containing doctors understandably demoralized and vexed because of others not allowing them to be true doctors. I'd be cynical as well. Why they are deprived of being true doctors is a topic for future debate.

Dan Abshear

Anonymous said...

This woman was rude, disrespectful, and bordering on abusive to this physician who was trying to do his best for her son. Every person has the right to be treated with respect, EVEN physicians (!) and we also have the right to remove ourselves from abusive situations, which is what this physician did.
As an anesthesiologist, I am obligated to take care of everyone who comes in the door, but I am fortunate NOT to have to establish long-term relationships with unpleasant people. I enjoy and cherish my interactions with 99.9% of my patients, but that 0.1% is probably the reason I am not a PCP.
By the way---in 20+ years of practice, there has been ONE patient who I politely excused myself from caring for (totally elective procedure---25 year old woman having wisdom teeth removed) because as soon as I met her she began swearing at me and threatening to sue me. The surgeon looked at me with disbelief when I calmly told him that his case would be delayed while another anesthesiologist was arranged. I hope (but of course will never know) that this patient got a clue about how to treat other people---I have a deep empathy for EVERYONE who has to deal with the public, and I go out of my way to be nice to bank tellers, grocery store cashiers, receptionists, etc. etc. who I am sure must put up with more than I do.

e-Patient Dave said...

I think the boy could learn an even more important lesson than "adults aren't always right": sometimes a relationship between two people simply is not working and it makes no sense to continue it, and there's nothing wrong with that.

It takes a healthy person to recognize, without blamecasting, that a relationship isn't working. It also takes a healthy person to communicate that clearly, again without make-wrong.

If we patients want to be full partners with our providers, I assert we ought to act like responsible partners. And I'd never have a problem with a partner (whom I've chosen for his/her competence or good fit for me) telling me that it's not working.

e-Patient Dave said...

Two follow-up comments. (Thanks to those above for their thought-provoking words.)

First, I take Dan's point about the doctor's responsibility, but I humbly propose that patients have a responsibility, too. It's one thing for a patient to demand good care (and I won't get into the spectrum of ways that might be accomplished). It's another entirely to simply bitch about what's going on and expect the world to adjust.

Mind you, I don't know whether the patient in the article did that - I'm just pointing the flashlight to that aspect of the issue.

Second, reconsidering this story reminds me of the horrific (imo) story recounted by Scott Haig MD in November in Time, "When the Patient is a Googler." Dr. Haig's interpretation of that nasty individual gave all empowered / participating patients a bad name. I reframed it:


There seems to be a binariness to the conversation: some think patients should just mind their own business (i.e. stick to the listening side of the desk), others think patients have every right to mind their own business: be actively involved in researching and knowing their condition, and bringing things to the table.

What's missing is the aspect of building an effective partnership. As a living specimen of the patient side of things, I have a couple of observations.

1. How dare anyone tell me not to try to find out what's going on inside my body? I wouldn't tolerate that from a car mechanic and I won't tolerate it from a doctor. That attitude is obsolete.

2. At the same time, if I want partnership, I get a responsibility too. At the core are two-way respect and open communication: freedom to express, freedom to bring things up, freedom to be heard - and responsibility to listen and not abuse the privilege.

When you look at it that way, it becomes clear: the patient in Haig's article would have been a nightmare with or without Google. The real title should have been "When the Patient is a Yahoo."

Daniel Sullivan said...

Firing a patient is a big deal.

While I certainly agree doctors have the right to do this, this right should be exercised rarely and only after considerable thought.

I don't think the doc in this case did enough to try to figure out why the patient's mother was acting the way she was. Maybe the relationship was not salvageable, but I'm not convinced.

Some people are very difficult to deal with, but they still need doctors.