It’s not me, it’s you...how to withdraw a patient from your practice

It’s 4 pm on a Friday and Dr Sam is about to see his twentieth patient. It has been a tiring day, with several complicated cases, including an elderly gentleman who required an ambulance transfer, along with the winter influx of cough, sore throats and flu. Dr Sam feels his heart sink as he reads the name of the next patient on his list: Jacob. He has previously had difficult interactions with this patient, who is often argumentative and not accepting of medical advice. Dr Sam has spoken to some of his other colleagues who have dealt with Jacob, and all had experienced similar behaviour.

Dr Sam greets the patient in the waiting room and invites him into the consultation room. After an introductory chat and some basic questions, Dr Sam establishes that Jacob is seeking time off work for a back injury. Dr Sam had observed Jacob walking to the room and had not noticed any impediment or obvious signs of pain. He asks Jacob to stand so he can begin to examine his back; Jacob refuses and demands a medical certificate based on the symptoms he has listed. Dr Sam tries to explain to Jacob that he needs to examine him and make his own diagnosis, and assessment of fitness to work, based on the history and examination findings. Jacob will not answer any questions about his injury and makes a disparaging remark about Dr Sam’s training.

Dr Sam is feeling stressed and starting to get angry, but he attempts once more to gain consent for examination. Jacob leaps up from his chair and aggressively leans over Dr Sam, pointing his finger and shouting at him, demanding that he gives him what he wants “or else...”. Dr Sam immediately leaves his consultation room, feeling intimidated and threatened. Jacob follows him, shouting as he enters the reception area, where other patients are waiting. Jacob continues to yell and use profanities at Dr Sam, who in the heat of the moment shouts back at him and tells him to leave. Jacob sweeps a pamphlet display off the reception desk, which shatters on the floor, and with a slam of the door, leaves the clinic. Dr Sam turns to the reception staff and tells them to ban Jacob from the practice.

Can a practice refuse to treat a patient? Can you un-enrol a patient from your register? Is there anything that Dr Sam could have done differently in this situation?

Let’s analyse this scenario, one point at a time. Firstly, was it ok that the patient left the clinic without receiving medical attention? Should another doctor have followed Jacob and offered him treatment? The Medical Council of New Zealand (MCNZ) states that when ending a doctor-patient relationship, you must be satisfied that the patient does not require urgent medical care. In Jacob's case, he demonstrated that he could move freely and independently and did not appear acutely unwell. Therefore, it was reasonable for the practice to not offer him immediate medical care.

Can, and should, Jacob be excluded from the practice due to this incident? The MCNZ says that either a doctor or a patient may make the decision to end the professional relationship. Dr Sam has a right to decline to see this patient again. The question is, does Jacob pose a safety risk to all the clinic staff, or has the relationship just broken down between him and Dr Sam? Jacob has a history of disruptive behaviour with other staff, and he acted aggressively at the reception desk. The practice should debrief about the incident including how it affected each staff member, whether there were any identifiable triggers and if there are any safeguards that could be put in place for the future. If appropriate, a staff member should also check in with the patients in the waiting room who were present during the event, to ensure their wellbeing. An incident report should be completed and added to the practice’s register.

The other clinical staff can be asked if they are willing to take on Jacob as their patient, if he wishes to continue coming to the practice. However, this arrangement is not tenable if the practice decides that it is a safety risk to have Jacob on the premises or if there are times when Dr Sam is the only clinician rostered.

The MCNZ offers the following points when considering ending a doctor-patient relationship:

• Seek advice from colleagues, your medical indemnity insurer or your professional college/association
• Attempt to find a solution and resolve the situation if possible
• The decision should be fair and professional, and communicated respectfully to the patient (in person or in writing), explaining the concerns and reasons why they cannot consult with a particular doctor or attend the practice
• Consider how the decision will impact the patient’s access to medical care (and that of their family/whānau), e.g. is there another practice nearby they can attend?
• Consider how the decision will affect any ongoing treatment the patient may be receiving, e.g. regular monitoring for a chronic health condition
• If appropriate, assist the patient in transferring their care to another provider

After this assessment, actions may include giving the patient a formal warning, placing them on an acceptable behaviour agreement or requesting that they leave the practice. The incident, and any decisions made as a result, should be documented in the patient’s record with separate documentation kept for the practice. If the doctor-patient relationship is terminated, this should be entered into the clinical record, along with a brief, clinically relevant account of the events, including the patient’s concerns. If the patient is concerned about what will be transferred to another doctor, give them the opportunity to review their records first. If the patient has additional concerns not contained in the notes, these can be detailed separately in a letter to the new provider. If a patient is excluded from a practice, all staff should be informed, and the patient file flagged. These measures are to help prevent the patient from making another appointment. The practice should also devise a response plan that can be activated if the patient turns up in person.

So, is there anything that Dr Sam could have done differently that may have resulted in an alternative outcome with Jacob? Sam was fatigued after his long day and upset by Jacob’s behaviour towards him, but he conducted the consultation in a professional manner. Dr Sam let his guard down when he shouted at Jacob in the reception area, but it was a very stressful and emotionally charged situation. Dr Sam has continued to replay the unsettling experience in his mind since it occurred. He is upset with himself that he got angry and that he could not defuse the situation with Jacob. Resolving to do better, he has found it useful to talk to other colleagues so that he can put some strategies in place if a similar situation arises in the future.

The Royal Australian College of General Practitioners (RACGP) has a guide for general practices on preventing and managing patient aggression or violence, that is useful to consider in this situation. It states that patient aggression or violence may occur in many forms, which in the case of Jacob, included verbal aggression (rudeness, yelling, swearing), intimidation and threats, threatening or inappropriate body language and destruction of property or possessions. Jacob also displayed several warning signs of escalating aggression including irritability, refusal to communicate and verbal abuse, along with his history of argumentative behaviour. Other warning signs may include pacing, repetitive movements, avoiding eye contact or intensely staring, aggressive gestures (e.g. pointing, slamming objects), veiled or overt threats.

If you detect early signs of aggression in a patient, the RACGP offers some strategies that may help to de-escalate the situation:

• Communicate in a calm, controlled, confident and respectful manner, e.g. I understand that this is making you feel upset, but I need to ask you these questions, so I know how to help you.
• Use reflective questioning - repeat back what the patient has told you and frame it as a question, e.g. you have injured your back and don’t think you will be able to work, is that correct?
• Use clear, direct language and simple explanations, e.g. I would like to examine your back to see where it hurts the most.
• Be aware of your body language, e.g. turn towards the patient when speaking to them, keep your arms at your sides or in a neutral position, maintain regular eye contact without staring.
• Explain that your actions are focused on providing the best care for them, e.g. I would like to examine you so I can see if there is anything we can do to make this pain better (as opposed to focusing on the “paperwork”, e.g. the ACC work certificate, or proving that they have no injury).
• Ask questions that are likely to be answered affirmatively, e.g. this back pain is making it hard to do your normal tasks, is that right? There is no specific part of your back that is sore, but just generally sore all over, is that what you mean? Answering a series of questions with “yes” can help a patient to perceive you as being sympathetic to their problem or “on their side”.
• Engage the patient in finding solutions to their problem, e.g. you say you are too sore to drive yourself to work, is that right? Can you think of some other ways you could get to work?

If none of these strategies are successful, and a patient becomes aggressive or violent, the RACGP recommends in the first instance, that you calmly ask the patient to leave. There are some learning points for Dr Sam here: ideally, he should not have left the consulting room first without asking Jacob to leave, at which point he could have followed Jacob to reception to ensure he exited the practice. Leaving a patient unattended in the consulting room poses several risks such as access to the computer and patient files, access to medicines (although usually not in the room) and equipment, risk of tampering or breakage of items, along with access to personal belongings. Although Dr Sam was unable to maintain his composure, he was ultimately successful in getting Jacob to leave. If Jacob had continued to be aggressive and violent, it would have been appropriate to alert the police, and if possible, to move the patients in the waiting room to a safe location, along with Dr Sam, his colleagues and their patients. As the practice did not have a specific plan in place for this, they have since incorporated it into their safety protocols.