A plastic surgeon called me recently. He routinely examines his female patients with a female chaperone in the room. This is a good idea. Make that – a great idea. While it’s not common to be accused of inappropriate sexual contact, the accusation does occasionally happen. Then, it’s he said, she said. Write a big check.
This patient said she did NOT want any such chaperone in the room as it would create “negative female energy.” Huh?
The doctor explained the rationale for the chaperone. Still she refused.
To accommodate this patient, the doctor still saw the patient. He left the door cracked; and the female chaperone was in the next room.
After a one hour discussion and examination, the doctor said he had other patients waiting and he had to leave.
Patient said, ”So, you’re kicking me out?”
“No, I’ve given you an hour of my time. We’ve discussed your substantive issues. I have other patients who are waiting.”
“Well, I’m not finished.”
“I am.”
OK. It’s clear this was not going to be a long-lasting doctor-patient relationship. And, it’s good the doctor did not operate on the patient, where the stakes would have been raised significantly.
The first red flag was the patient’s demand to break a standard protocol. While THIS patient may have had honest intentions, there’s a chance this was a setup. If so, the patient would claim the doctor fondled her, and there’d be no witness. Sure, the doctor could pull out the medical record stating the patient explicitly refused to have a female chaperone present. Her retort would be that’s a little too convenient. Nothing of the sort happened. And the doctor “doctored’ the medical record to suit his perversion.
The next red flag, which was picked up correctly, was the patient’s belligerence at the end of the consultation. The doctor terminated the relationship. If the patient had become excessively belligerent and created an office ruckus, there might have been reason to call security or police. In this case, that would have been overkill. But, in other cases, making sure other patients in the office as well as staff are protected from harm must be among the highest priorities.
In sum, many protocol are in place and practiced day after day for good reason. If the protocols are broken, they must be for compelling reasons. Requests to break protocol for anything less should be treated as a red flag until proven otherwise. What do YOU think? Let us know.
I agree with all of the above. Typically I will leave my examination door wide open during my neurologic discussions and examination. I do not have patients remove their clothing. If a patient were to ask to have the door closed, which most of the patients don’t say anything, I would definitely have a female employee in the room with me; no exceptions. With my door wide open I have occasionally wondered about a HIPAA violation. However, patients are in a common waiting room which makes me believe that in my examination room it would be no different if another patient were to see patients in my examination room or in the lobby. Maybe I’m wrong? It’s a crazy and difficult world and we cannot protect ourselves enough.
I agree with the above. We require staff chaperones for all patient examinations, male or female. This patient would have been politely dismissed at the first request to be examined without another female in the room due to “negative energy”. Out the door. Many more problems that concerns with her breast. I have never had a patient make such a request. Most are relieved that I have a chaperone in place. Our chaperones are quite, respectful and stand in the corner of the examination room. Just saying.
I am a plastic surgeon and I always have a female chaperone with both male and female patients.
If a patient refused this request, that is certainly a red flag and I would not see the patient
We mandate a chaperone and have video and audio CCV with recording of all patient interactions. In OK, it is legal for all patients to record audio or video without physician knowledge or approval. Inexpensive and very valuable protection in every room and outside the office, 24 cameras!
When you have a patient who sends you bad signals, you are getting an unwrapped gift ahead of Christmas. Many physicians don’t have that “opportunity,” especially when the patient is seen in the ER or if you are on call for an emergency surgery. Under those circumstances you proceed and just hold your breath.
You might consider going to seminars and learning what your state regulatory board’s rules are on refusing to see patients, and patient abandonment. There are probably similarities with most, but some states may be more restrictive and specific than others. I recall that during the height of the (untreatable) AIDs epidemic, physicians were calling their boards all over the US to find out what they could or could not do.
Sometimes your State will set you up with drug seeking “patients” to test your response. I once had a drug seeking patient offer me sexual favors for drugs. Ironically my wife was also working at my office then, and was just outside the room. I was never certain if she was a “plant” or for real, but she was escorted out of the office by my staff, with a list of other podiatrists we copied off the Yellow Pages.
If you prescribe a lot of drugs in any category that could be considered “frequently abused,” you never really know if the patient is a plant or for real. All one can do is just take them (or rather refuse them) for what they are.
No physician, even a psychiatrist should conduct a physical examination or invasive treatment without a proctor right in the room with you. You would do well to rehearse with your staff on how you will get together to escort a patient out. Every encounter must be handled professionally, with dignity the person doesn’t really deserve and expedited out of your office ASAP. When you do this, you are also sending a message to their drug seeking and suit-prone cohorts waiting on the wings to see if you are a sucker.
There is also the issue of truly unstable patients who may be prone to violence if they feel “disrespected.” The trick is to be really nice to them and get rid of them at the same time. You are acting of course, and the Oscar you win is not getting shot a week later.
Michael M. Rosenblatt, DPM
All very depressing to be sure.
As I plastic surgeon, I spent a lifetime working to learn the skills to help people. I have suffered my share of abusive patients who on first blush seem “normal”, and then turn out to have hidden agendas. One secretly audio taped me.
I agree that chaperones are important, but only for MY protection. I wonder if I were to be nefarious and lie, why wouldn’t I have an assistant who is of like mind with me to really be effective with the charade?
This distracts from, and adds to the cost of being a great doctor.
Scott E. Kasden, M.D.
Tough call. Some patients desire to be alone with their physician to discuss personal issues and have no malefic intentions. After five minutes, if the consultation appears atypical or uncomfortable, demand the chaparone to come. At that point, if the patient is still objectionable, there is now a third party to witness the brief and harmless encounter and escort the patient out the door after giving a refund. 🙂
To the subject of Dr. Rosenblatt’s issue of patient abandonment: I’m not sure when a doctor-patient relationship begins or ends. When I was still doing surgery, I refused to treat elective aneurysm patients who were smokers until they had not smoked for a month and had committed to stay non-smokers for life.* (The complication risks for smokers is somewhere between 10 and 100 times higher than for non-smokers. I have no idea why this should be the case, but empirically this is what we see.) I always offered to refer to another doctor who didn’t set the bar where I did, but no patient ever took me up on that.
So if I declined to treat a patient, was I abandoning that patient? I don’t think I was. What I was doing was refusing to take the patient into harm’s way when the deck was stacked against him. I’m not sure–and perhaps Dr. Segal can tell us–when the doctor-patient relationship would have begun in these instances. I believe that it began each time the patient proved that he was a member of the team treating him, i.e., after he had stopped smoking so I could treat him as safely as possible–at the end of the month of no smoking.
But maybe I’m wrong. Maybe it begins whenever we interact with patients, and the hiatus between first interaction and treatment is a probationary period. The question then becomes what the nature of the relationship is during that time interval. Is there a D-P relationship then? What about the times a patient doesn’t follow through and continues smoking (which means I don’t treat him)? Is/was there an imputed relationship during that trial period? What would have been my liability had a patient had a subarachnoid hemorrhage during that period? Fortunately it didn’t ever happen, but what if…?
*Clearly there was no way to enforce this req after surgery had been done, and I don’t know how often patients backslid. But for at least a month they didn’t, and that seemed to bring the complication rate back to a baseline level.
One of my long standing guidelines is that any patient who appears aggressive or inappropriate in the pre-operative area is canceled. I feel that anyone who says something like, “Doc, if this doesn’t work out I am going to sue you,” may be kidding around but I take this very seriously, I carefully explain that bad things happen and if they are willing to say such things before surgery it is my right to cancel their “elective” eye surgery as it gives me an idea of what they might do if their result is not what they expected. This recently really proved to be of great import.
I was having a really long day with some poor scheduling issues and surgical delays. I usually go to the reception area and give the patients and families a little pep talk or “this is your captain” discussion about the delays and apologize, usually saying something like, “if it was you or a family member you would like me to spend more time with them to get things right, no?” One wife (patient) and husband stood up and said they thought it was terrible. I had our staff put them in an isolated room and spoke with them. The husband raised his voice and started accusing me of total disorganization and disrespect for a patient’s time. Not wanting to spend too much time with this family as I was already behind I told them my policy and explained to them that the patient’s surgery would be canceled. He stormed out through the reception area screaming that I was an “arrogant son of a bitch” in front of everyone. Two weeks later we got a call from an attorney asking for $750.00 for the husband’s and wife’s time. Dodged bullet the way I see it. But for sure I am going to think about whether to sue them for defamation of character or just pay the extortion. I value patient’s time. Do people actually sue bus companies for breakdowns and this degree of entitlement is a bit disturbing at best, and a sign that as surgeons we are truly exposed to risks that pale when compared to the normal workplace.
Dr. Horton is correct. Patient abandonment/acceptance is a complex issue that is not easily answered. He correctly points out that it is even difficult to formulate the questions around this. Some of these issues even point past your practice years into your retirement. At our retirement community I once observed an acquaintance who started showing signs of ALS and ataxia. His girlfriend came to me with questions about his gait. After a brief examination I actually witnessed a fasciculation and he was showing signs of progressive muscle weakness, by both history and examination.
I was retired. There is no way a podiatrist can treat ALS, even if they are licensed, except for bracing, shoe gear and advice to help them avoid falling. I should not have examined him. I was acknowledging a patient/doctor relationship and I was no longer a licensed podiatrist. It turned out, tragically that my diagnosis was correct, but I never divulged it to the patient, although I strongly advised him to see a real doctor, a licensed neurologist. Fortunately I kept my mouth shut, but I’m sure they read my demeanor and the shock on my face.
I won’t make that mistake again. But you folks still practice medicine, and patient abandonment is a serious medical board offense. I think this is why it is very important to try to establish the guidelines in the state where you practice. It is likely that more patients you see will be using cannabis in its various forms than ever before. We are now heading into a new realm of generalized cannabis use among your patient populations, when it is legalized, which I predict will soon happen in many states. And you will likely get requests for prescriptions for “medical” pot. Fore-warned is fore-armed.
Michael M. Rosenblatt, DPM
Agree with Drs. Rosenblatt and Horton–the doctor-paitent relationship and abandonment are complex issues. For myself I have decided that the initial consultation is a two-way interview. The patient is deciding whether he/she wants me to treat them and I am trying to determine whether or not I can help them or in some cases if I should decline to take them on as patients. Without any doubt my threshold for terminating the relationship or declining to initiate treatment has decreased in recent years as my “threat-indicator” has become more acute. Call it paranoia if you will but we all know that some patients have hidden agendas; some have personality disorders and some are even planning to take advantage of patient protection laws for financial gain. Any aggressive or drug-seeking behavior at the outset is a deal-breaker, especially given the increase in violence against health care workers.
A plastic surgeon may refuse to initiate care and treatment after a single consultation without concerns of a abandonment. The State Board of Medical Examiners should not be negatively judgmental about the rights of a physician not to treat because it is not in the best interest of the patient or doctor. Dr. Horton hit the nail on the head:)
The worst a patient could do if you abruptly terminate or fail to initiate elective care is slam you on the internet with a negative review. We’ve been there. This is one of the most favorable negative reviews you could have: “He refused to operate on my nose and told me to see a psychiatrist.” You’re in a bad space treating a problematic patient and then having to deal with the fallout. Once you treat or operate, they’re yours, and the relationship is tight. I’ve never regretted not treating or operating on a patient.
If patients won’t sign consents on our intake form, that’s a deal-breaker for us, and the doctor-patient relationship is never initiated.
If routine chaperones are part of your practice and if you wish to avoid a predicament like this, consider having your patients sign “consent for chaperone” while they’re in the waiting room. If they don’t sign, the front desk is the last stop.
Eric 🙂
Here’s my general rule of thumb: If you don’t like a patient in the exam room you will definitely not like them when they have pus coming from their incision.
I practice in the law-suite friendly state: Florida..specifically Miami
I have 16 cameras in my office and often feel they are not sufficient. Just last week I had a patient “kneel” down on the floor with me in front of her with zero injury to only have her mother state the pt fractured her coccyx because of that. Luckily everything was on video.
We always have a female present in the room when performing a pap and/or breast exam and document whom the chaperone was, but simply can’t afford to have a chaperone present during all female non-gyn exams.
I am thus considering installing cameras in patients rooms…the cca metas would be pointing towards the back of the exam table..ie..the patients back.
Is this legal?
Where can I research this?
What sort of an attorney would be able to give an opinion regarding this?
It’s usually before and after photos in my office that patients on rare occasion will refuse. In this case- I review with the patient, their value in assessment both now and in the future as things change. Additionally – I explain how as we treat- we change anatamy ( i.e. fillers, botox, etc) and it is impossible to evaluate accurately what was, once we change it if we have no photos. If they still refuse, then I apologize and say that I am required by the Medical board to accurately assess patients before I treat them. I respect their wish to not have the photos, and it’s fine to defer the treatment. I support them in their decision but politely send them on their way without treatment. Most of the time, they return and are willing to cooperate, but if not- I am ok with the idea that one patient is not worth the risk in loosing out on the tools and protocols I have in place to protect both them and me.
I am sure there are better ways, but this has been what I have done.
Celia.