Medical Justice provides free consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. We also provide counsel specific to COVID-19. If you are navigating a medico-legal obstacle, visit our booking page to schedule a free consultation – or use the tool shared below.

The Voyager satellites launched in the 1970s. Depending upon how one defines “solar system”, both have left our solar system. Data is still being sent back to earth. They are powered by a simple form of nuclear power.

A brick of radioactive material surrounded by layers of thermocouples, which use the temperature contrast between the hot radioactive brick and cold space to produce electrical power.

On Voyager 1 and 2, that thermocouple is powered by plutonium 238. The plutonium decays by producing alpha particles.

The spacecraft were designed to have sufficient power to last 12 years. Both made it to Jupiter and Saturn.

After Voyager 2’s successful Saturn encounter, it was shown that Voyager 2 would likely be able to fly on to Uranus with all instruments operating. NASA provided additional funding to continue operating the two spacecraft and authorized JPL to conduct a Uranus flyby. Subsequently, NASA also authorized the Neptune leg of the mission, which was renamed the Voyager Neptune Interstellar Mission.

Voyager 2 encountered Uranus on January 24, 1986.

Both Voyagers are still running on residual power.

[T]here are several other fields and particle instruments that can continue to send back data as long as the spacecraft stay alive. They include: the cosmic ray subsystem, the low-energy charge particle instrument, the magnetometer, the plasma subsystem, the plasma wave subsystem and the planetary radio astronomy instrument. Barring any catastrophic events, [Jet Propulsion Laboratory] should be able to retrieve this information for at least the next 20 and perhaps even the next 30 years.

Plutonium is a compact, long-lived power source.

So, it’s not surprising that some medical device companies dabbled with nuclear powered pacemakers. What is surprising is that some patients are still walking around with these devices in place.

In the 1970s, Medtronic worked with Alcatel, a French company, to design a pacemaker powered by plutonium.

Medtronic’s nuclear battery contained a small 2.5 Ci slug of Plutonium 238 (Pu-238). Pu-238’s radiation struck the walls of its container, generating heat that a thermophile (a stack of thermocouples) converted into the electric current that simulates the heart.

Cordis and Coratomic, Inc. made its own nuclear-powered pacemaker.

Dose rates at the pacemaker’s surface are about 5 to 15 mrem per hour. Whole body exposure for the wearer is about 0.1 rem (or 1,000 mrem) per year for the patient—and 7.5 mrem per year to the spouse of a patient. Not a lot.

According to US Nuclear Regulatory Commission, this is how much radiation you expect from the following activities:

620 mrem/year = the average level of radiation per person in the US

1 mrem = two hours in a jet plane

7 mrem/year = from living in a brick house

72 mrem = breast mammogram

60 mrem = abdominal x-ray

700 mrem = Chest CT

One patient, Laurie DiBari received her nuclear-powered pacemaker 30 years ago (when she was 25 years old). That device is still working.

She gets it checked every three months from home through a transmitter affixed to a landline receiver that reads signals from bracelets placed on her moistened arms.

Ms. DiBari said, “I’ve never had a problem with it, so I’m not going to touch it.”

Due to the extremely long battery life, nuclear pacemakers tended to outlive their users, and posed challenges with burial. Not surprisingly, the US Nuclear Regulatory Commission wants all plutonium accounted for.

Should you encounter a radioactive pacemaker, contact Los Alamos’ Laboratory’s Off-Site Recovery Project (OSRP). Call them toll-free at 877-676-1749. They will provide shipping and disposal instructions.

Who knew?

Medical Justice provides free consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. We also provide counsel specific to COVID-19. If you are navigating a medico-legal obstacle, visit our booking page to schedule a free consultation – or use the tool shared below.

Jeffrey Segal, MD, JD

Chief Executive Officer and Founder

Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.

Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2021 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.

A medical practice is no battleground. But sometimes it feels like one. Patient conflict is one of the many occupational hazards of practicing medicine. It is critical doctors and nurses (and all staff) understand how to de-escalate patient conflict before there is a bad outcome. And “bad outcome” is a big umbrella. You want to prevent acts of violence, obviously, but hostile patients, left unchecked, can make your staff resent working for you. You don’t want to lose valuable employees because you just don’t know how to de-escalate a conflict with a difficult patient.  

To pile on, patient conflict often signals that another occupational hazard of medicine is forthcoming. Patients in conflict with their doctors frequently sue their doctors.  

This article will describe broadly best practices specific to identifying and de-escalating patient conflict. We’re answering two important questions… 

• How can doctors and their staff learn to recognize patient conflict before there’s an outburst? 
• And in the event conflict is already ongoing, what can doctors do to put a stop to it without making the situation worse? 

Before we begin, here’s some background about our organization – and why we are qualified to solve these problems. 

Medical Justice exists to protect doctors from medico-legal threats. Frequently, these threats originate from conflicts with patients. We’ve devised solutions to every patient conflict situation you can imagine – we’ve been at it for 20+ years, and we’ve seen everything. Nothing surprises us. Our methods prioritize de-escalating a conflict before it boils over into something only legal action can address. And if legal action is necessary to protect your practice, we know how to do it. Our Founder and CEO, Jeff Segal, MD, JD, is a neurosurgeon and an attorney – he understands both medicine and the law viscerally.  

If you are in conflict with a patient, we can help. Schedule a free consultation with our executive team. 

How can doctors and their staff predict patient conflict before there’s an outburst? 

Preventative care is almost always less expensive and less bloody than remedial care. If you can anticipate a problem before it manifests, you can neutralize it. Apply this logic to patient conflict. Monitor patient behavior and triage based on perceived volatility. Enlist the help of your entire practice. You engage the patient directly and can judge those at risk of creating a problem. But the value of your staff cannot be understated. They engage your patients in different environments – over the phone, while the patient is awaiting care, etc. You see one side of the patient’s behavior, they see another. And they’ve likely seen or heard things that, placed in the proper context, will help identify who is happy and who is not. 

Here’s a quick and dirty list of red flags that frequently signal a patient will create future conflicts. 

• Patient is combative; frequently argues with staff over small amounts of money/office wait-times; reasonable explanations (delay due to emergency) fall on deaf ears. 
• Patient refers to previous doctors as “butchers” and “hacks.” The patient may flatter you, insisting that they’ve heard great things about you. “You’re not like those other guys!” Don’t swallow the bait. You will frequently become the next “butcher.” 
• Patient does not commit to necessary follow-up treatment; this kind of patient can fly off the handle when their negligence contributes to a complication (such as an infection). 
• Patient enters care with unrealistic expectations; believes the doctor has the power to work miracles; believes treatment will save their marriage, advance their career, etc. Turn these patients away, and if you cannot, manage their expectations. 
• Patient fails to pay his bill on time and is unwilling to commit to a payment plan. Patients who pin insurance conflicts on the practice should also be considered a risk.  

Assigning a numerical value to these events and maintaining rolling documentation can help your staff identify who is at risk of blowing their stack. When the numeric rises beyond a specific value, task your staff with contacting the patient directly. Seek understanding. If you identify why a patient is upset, you can identify what it will take to defuse the dynamite.  

But what if the patient conflict is ongoing? What then? 

First identify why the patient is upset. Then identify what the patient wants. Don’t underestimate the power of a phone call. The source of the conflict may be independent of the doctor and the practice – like a problem in the patient’s personal life, projected unfairly onto the doctor. While it isn’t the doctor’s responsibility to fix this kind of problem, understanding why the patient is upset is critical. You must gather this information. Resist the temptation to push this kind of call onto your staff. If the patient is directing his ire towards you (fairly or unfairly), tasking a member of your staff with engaging him will likely be perceived as a dodge.  

Once you know why the patient is upset, ask the patient directly: “What do you want?” 

If the “what” is reasonable and you believe has the power to put the conflict to bed, contact qualified legal counsel and bring them up to speed. They’ll determine the best way to satisfy the patient’s request without putting you at greater risk.  

If it is obvious the doctor-patient relationship has decayed beyond salvation, your options are as follows. 

• Identify what the patient wants – and then give it to him.  

• Identify what the patient wants – and if his demand is unreasonable, release the patient. 

Either event must be a transactional event with strict conditions. Typically, the patient will sign a contract stating that in exchange for the desired item (often cash), the patient will stop driving the conflict. This contract also releases the patient from the doctor’s care. It is critical the contract makes allowances for the complete and documented transfer of the patient’s care to a different physician. Otherwise, the doctor risks an abandonment charge.  

Medical Justice is equipped to manage all kinds of patient conflicts. We’ve been protecting doctors from medico-legal threats for 20+ years – and we’ve seen it all. If you are in the midst of a conflict with a patient, know solutions exist. Schedule a free consultation with our executive team.

Learn how Medical Justice can protect you from medico-legal mayhem… 

Jeffrey Segal, MD, JD

Chief Executive Officer and Founder

Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.

Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2021 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.

Patient conflict bites.

“I expected you to make me better. You made me worse. I’m thinking about speaking to an attorney. Also, I want the whole world to know so they can be forewarned.”

Yikes. 

Doctors want to treat as many patients as reasonably possible. Our careers are long. And when we do retire, we rarely leave the world of medicine forever. But if you practice long enough, you’ll treat them. Who? Angry patients. It sucks, but it’s an inevitable part of the job. We all go through it. If this is the world you are living in now, welcome into the fold. 

The “good” news: Doctors can do a lot to de-escalate conflict with an angry patient. The “even better” news: This article will share general tips and set you on the right track. Angry patients are inevitable. But knowing how to safely de-escalate the inevitable is invaluable.  

This piece answers the following questions:  

How can a doctor de-escalate conflict with an angry patient?  

What can a doctor do?  

What can a doctor not do?  

When, if ever, is it appropriate to invoke legal tools?  

Medical Justice has been helping member doctors safely navigate patient conflict (and a bevy of other medico-legal issues) for nearly 20 years. De-escalating patient disputes is one of our many specialties. This article will dispense general tips. In addition to de-escalation tactics, we’ll discuss how to keep a conflict from escalating in the first place.  

Some fast advice: If you are in the midst of conflict with a patient, request a consultation. Our team of experts (doctors and attorneys) will provide general counsel. Without further ado, onto the piece. 

When de-escalating conflict with an angry patient, find out what the unhappy patient wants from you; if his request is reasonable, do your best to accommodate. Frequently, but not always, the request is reasonable… 

What does the patient want? You must answer this question. Consult your staff. Someone at the practice, other than you, has likely interacted with this individual one-on-one. The clues are always present. Once you know why the patient is upset, formulate a potential remedy. 

Patients are people. People do not become angry without a reason. It makes sense to them. The practice may not perceive the patient’s reason as “reasonable”, but the patient is rarely mad by default. Something has happened. They may have been surprised by an unexpected bill. They may have had an argument with your staff. They may have received a bad outcome or a grim prognosis. Once you’ve gathered your clues, we prescribe the following action: Pick up the phone. 

Just call the patient. Ask them directly to explain the challenge. Tone is important. You are gathering information so that you can diagnose the problem. But instead of diagnosing an illness, you are diagnosing an attitude. A simple phone call, accompanied by a calm, concerned inquiry goes a long way in putting out fires. If the patient perceives you care, he will likely reciprocate. Teddy Roosevelt reportedly said, “People don’t care how much you know until they know how much you care.” Listen to the patient’s explanation. If his explanation is reasonable, consider accommodating him. Pick your battles. You will know what your practice can and cannot accommodate.  

If you must refuse his request, consider presenting him with some options. A simple “No, but…” is often better received than just “No.” “Yes, if…” works EVEN better.  

Avoid patient conflict by managing expectations… 

We cannot change the fact we’ll one day encounter a difficult patient. But we can reduce the risk the doctor-patient relationship will sour by setting the correct expectations. This important point bears repeating. You must set the correct expectations.  

Storm clouds gather when a patient’s expectations are not met. You, the doctor, can manage these expectations by providing the patient with information that sets his expectations accordingly. Set the pace. The patient is the author of his own experience – but you, the doctor, can become his “editor” if you set the pace. And how do doctors set the pace? By setting the correct expectations.  

In setting reasonable expectations specific to recovery time, cost of care, wait times, etc., you scatter the storm clouds before they gather. We help our members craft documentation and processes that sets the correct expectations. And it is important to adjust this documentation to suit your practice’s style and competencies. Custom language is critical. If you need input crafting these materials, request a consultation. It is critical these templates are drafted by professionals. Attempting to write bullet-proof documentation without professional input is a high-risk maneuver.  

So, you set the right expectations, investigated the cause of the patient’s anger, and attempted to dispense a solution. But alas – the patient is still angry. Now what? 

If the patient has made it clear he cannot be pacified, it may be best to transfer care to a different doctor. Doing this right can result in multiple positive outcomes. The patient will get the care he wants or needs. You can move on with your work and focus on the needs of your practice and your other patients.  

That said, doing this wrong will likely result in downward trajectory. Like an abandonment charge propelled by an even angrier patient. We will help you get this right – request a consultation to learn how we help you facilitate a complete and compliant transfer of care. 

Now that we’ve discussed general tips for avoiding and de-escalating patient conflict, here are a few key warnings specific to patient conflict. 

When de-escalating conflict with an angry patient, no matter what, keep the conflict offline... 

If the patient posts online, the argument becomes publicly accessible. The public (existing and future patients) will be drawn to the conflict if the incensed patient makes enough noise. No practice has ever profited by arguing with a patient on the internet. If you can keep the dispute off the web, you prevent evidence of the argument from reaching the public. But if the patient goes online, the argument now exists in the public sphere. If the debate starts with a negative online review, do not take the bait. For more help here, read our article: 5 Golden Rules for Responding to Negative Patient Reviews. 

And if the patient threatens to post a negative review online unless you satisfy his demands, understand that the patient is close to taking an action that may satisfy the definition of extortion. Once again, this is our wheelhouse and we can help. Request a consultation with our experts. 

When de-escalating conflict with an angry patient, don’t be a wall. Be a human being... 

If the patient requests (or demands) a refund, proceed with caution. But don’t become inflexible. If the patient has requested a refund for a modest amount of money, it may be best to refund his money – with some critical caveats. We can help you make this determination.  

First, the patient must accept the refund is conditional. He will get his money back in exchange for signing an agreement that he will not return for more cash later. The language of the agreement must also prevent the patient from posting his negative sentiment online. To be clear – the purpose of furnishing a refund is to neutralize a dispute that has no alternative solution. The patient is mad and will remain so indefinitely. His only salve is cash. 

The above scenario assumes the patient has demanded a refund, but nothing else. Meaning he has not threatened to injure your business if he does not get his desired refund. If the patient threatens (or even suggests) he will blast you online, the game changes. The patient has threatened an action that will likely satisfy the definition of extortion. This gives the physician leverage. Extortion is a crime. 

That said, when de-escalating an angry patient, litigate sparingly... 

When should a doctor involve the law? The conditions are very simple. If the patient makes threats of violence, call the police. If he’s just making an ass of himself, do not take the bait. 

Our argument: An angry patient under the gun of litigation (for example, charging defamation) will lash out. He may contact the media. He’ll warn his friends. He’ll tell his family to stay away from your practice. These actions add up to headaches for your practice and bad outcomes for you. The temptation to use the law as a sword is strong, especially if you believe you’ll prevail. 

Here’s a fact: Litigating with angry patients consumes more calories than most doctors expect. And proving defamation (at least according to the law) is difficult. An angry human cannot be dismissed as easily as a traffic ticket. If you take the patient to court, you will likely see more of him than you’ll see your own family. We aren’t kidding. 

In closing – when de-escalating conflict with an angry patient, keep this summary close… 

When meeting a patient for the first time, identify his key concerns and set expectations accordingly. Discuss recovery time, potential risks, potential outcomes, and the anticipated cost of care. Make sure that patient is a good fit for what you intend to do. 

If the patient is already upset, contact him and determine the origin of the problem. Phones are your friends. And consult with your staff. Doctors are not full-time detectives, but some of our skills do overlap. Allowing the patient to fester in silence will make the situation worse. Human beings are not bonfires. Our emotions (typically) don’t fade when we are shut in a vacuum. We just get angrier. 

 If you are certain there is no remedy, or if the patient’s suggested remedy is unreasonable, be prepared to offer him a list of alternative solutions. If he cannot be pacified, be prepared to take responsibility for transferring his care to a different physician. This “hand-off” is a delicate process and must be done correctly to avoid being charged with patient abandonment. Medical Justice is more than equipped to help you nail this crucial process. 

Next, keep debates offline. As soon as the patient goes online, he has seized the proverbial megaphone. The public has front-row seats. You must avoid this outcome. If this has already happened (or is happening now), contact us. This is another sphere where we can help you solve problems.  

If the patient requests a refund, consider honoring the request if the amount is reasonable and the patient signs documentation stating the return of funds is conditional – i.e. he will not blast you online or deposit the check and return minutes later for seconds and thirds. Litigate sparingly. Propelling litigation against a patient will likely propel you, your patient, and your practice into spotlight. Don’t expect the media or the public to sympathize with your side. 

Lastly and most importantly: Understand these challenges represent a mundane reality that every doctor must address. An angry patient doesn’t make you a bad doctor. It makes you a human being. Do not walk alone. You don’t have to walk alone. Medical Justice is equipped to help de-escalate an angry patient and drive you toward favorable outcomes.  

As the sage wisdom goes: “You can please some of the people some of the time, but you cannot please all of the people all of the time.” It’s also said, “The customer is always right, but not everyone has to be YOUR customer, (or in this case, your patient.)” 

Our counsel will help you please those patients who can be pleased – and help you safely and compliantly manage those who cannot. Request a consultation with our Founder and CEO, Jeff Segal, MD, JD.

What do you think of our suggestions? Have you ever had to de-escalate an angry patient? If so, what was the outcome? Comment below.

Learn how Medical Justice can protect you from medico-legal mayhem… 

Jeffrey Segal, MD, JD

Chief Executive Officer and Founder

Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.

Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.