Perfecting the Patient Dismissal Letter – How to Avoid Patient Abandonment and Other Medicolegal Complications When Terminating the Doctor-Patient Relationship
Patient Dismissal Letters: Distinguishing Bad from Good in 5 Steps
Physicians dismiss patients for numerous reasons. The circumstances are never identical, nor are they always undesirable. Often the decision is mutual. As the patient’s care evolves, sometimes the physician responsible for his treatment must change. These “exchanges” are natural and sometimes necessary to drive a patient’s recovery. It’s worth noting patients can dismiss physicians, too.
Other times a patient is dismissed because he becomes a professional hazard. He doesn’t pay his bills. He abuses your staff. His presence creates distractions, which jeopardize the care of other patients.
Reasons notwithstanding, when you need to dismiss a patient, the act is memorialized in a patient dismissal letter. These letters are chameleons. Their language must change to suit your patient’s circumstances. The art of writing the “bullet-proof” patient dismissal letter is one many a physician would love to master. Written correctly, these letters insulate you against potential charges of malpractice and patient abandonment.
Let it be said – not all paper shields are useless.
At Medical Justice, we’ve co-authored hundreds of patient dismissal letters with our clients. The objective of these letters is simple: Help our clients (and indirectly, their patients) formally end the doctor-patient relationship. This allows our clients to move on with their lives without living under the threat of a rogue abandonment charge or a meritless malpractice claim. Conversely, they free the patient to pursue care elsewhere.
The purpose of this article is to teach doctors how to distinguish a competent patient dismissal letter from an incompetent one. Understanding the difference is important. If you get this wrong, the consequences will be steep. Patient abandonment can be career altering. Dismissal letters exist in part to foreclose such charges.
We’ll begin by defining the obstacle we are attempting to avoid. What is patient abandonment? Here’s our definition…
Patient abandonment occurs when a doctor cuts off the physician-patient relationship while the patient actively needs care and does so without adequate notice to allow the patient to reasonably obtain care elsewhere.
Keep in mind the decision to separate patient from doctor does not need to be mutual. It can be unilateral on your part, even if the patient objects. But medical care is a unique type of interaction because it can literally be a matter of life and death – so the dismissal letter must account for this fact. If the decision to separate is unilateral, your relationship with your patient may (or may not) be amicable. Which brings us to our next point…
What if my patient is hostile? What if he’s suing me? Do I still have to treat him?
Our answer is a hard but sympathetic: “Yes. Yes, you do.” You must remember: the doctor-patient relationship only ends when one entity discharges the other. Thus, the necessity of the patient dismissal letter. Unless the patient has previously provided you with a notice of termination of his own making, you have an affirmative duty to memorialize the termination of the relationship.
Here’s a list of circumstances that, despite their frustrating nature, do not dissolve the patient-physician relationship…
+ If the patient has an outstanding bill, you must treat him.
+ If the patient is suing you, you must treat him.
+ If he has not contacted the office for a long period of time, you must treat him.
+ If he behaves in a non-compliant manner, you must treat him.
+ If he leaves the hospital against medical advice (AMA), you must treat him.
+ If the patient changes insurance coverage to an entity you do not accept, you must treat him.
+ If the patient’s managed care plan “deselects” you, you must treat him.
Until you dismiss him (or until he dismisses you), you are married to him. That said – if your patient has an outstanding bill, intends to sue you, or regularly mistreats you or your staff, you should consider terminating your relationship with him ASAP. A companion piece that addresses these red flags – and several others – is available for download at the end of this article.
Onto the heart of the piece: Distinguishing competent and incompetent dismissal letters. We’ll demonstrate by presenting templates we believe represent examples of competent patient dismissal letters. These “competent” examples will be followed by a list of characteristics that we associate with incompetent patient dismissal letters. We’ll conclude the piece by examining our templates and identifying how each avoids falling into the five traps described.
The first item to address: Are you dismissing your patient? Or is your patient dismissing you?
In the event your patient instigates the switch, he’s likely conversed with you about it. If you have received a signed letter (or an unambiguous message – email) from him affirming his decision to seek care elsewhere, rely on it.
If you have received no documentation from the patient, don’t wait for him to act. Provide the patient with a dismissal letter. Memorialize your previous discussion.
Here’s the template we recommend physicians use in such situations:
As per our discussion on (date), this letter will confirm that you no longer wish to receive medical care through this practice, effective immediately.
It is imperative that you select another physician and arrange with our office for your records to be sent to your new physician as soon as possible. A release form is enclosed. If you have not yet done so, your insurance plan or the local medical society (insert contact information) will be able to assist you in choosing a new physician. If you wish to resume medical care through this practice in the future, please feel free to contact us.
This letter serves two purposes. It is a record of past events and demonstrates your willingness to cooperate with your patient. You are facilitating a smooth transition. You are not standing on the other side of the proverbial door, back braced, determined to repel the patient at all costs.
If the roles are reversed and you are dismissing the patient, we suggest a different approach:
Please be advised that I/this practice will no longer be able to treat you as a patient as of (date). I/this practice will remain available for emergency care only for the 30-day period beginning (date) and ending (date) or until you find another doctor, whichever comes first.
It is imperative that you select another physician and arrange with our office for your records to be sent to your new physician before (date). A release form is enclosed. Your insurance plan or the local medical society (insert contact information) will be able to assist you in choosing a new physician.
You’ll notice the reason for termination is not stated in either example. This is by design – we’ll explain why this matters shortly. The letter is careful to provide space for the physician to define the official date of termination. Do not make the date the patient receives the letter the starting line – transit is unpredictable. Instead, specify one week from the date of the letter and use that as the basis for any time calculations.
Another point to address is the period of transitional coverage. Most states require physicians remain available to dispense emergency care for a “reasonable period of time.” This is typically 30 days. However, sometimes this “floor” is insufficient. If your patient lives in a rural area or is in the middle of a complex treatment, you must account for those details. Make sure you allot plenty of time to facilitate a complete transition. You can’t leave the patient stranded.
We’ll now take a step away from the templates and review five symptoms of a “bad” patient dismissal letter. You can probably guess a few of them by examining the qualities described above and turning those qualities upside down.
A bad patient dismissal letter is excessively detailed.
When dismissing a patient, less is more. A patient dismissed under friendly skies usually does not require a verbose explanation. Presumably both parties understand why the relationship is ending. There are no surprises.
When the patient is being dismissed for “bad behavior,” the physician may feel obligated to explain his decision – both to inform the patient and to cover his back. This can backfire. We typically advise against including the reason for termination. If the relationship has soured, the patient knows why the termination is taking place. Spelling it out for him will only make you appear hostile. And perceived hostility is kindling in the hands of unscrupulous malpractice attorneys. You can’t be certain who will see the letter after you send it. Sanitize your tone. Pertinent information only.
A bad patient dismissal letter does not consider a patient’s environment.
Your patient may be hell in human skin, but if he has no other treatment options available to him, you cannot carelessly dismiss him. Physicians practicing in remote communities need to be particularly careful. Consider this example: You are the only oncologist in a small community and your patient has received 1 of 3 planned treatments for chemotherapy. If you dismiss this patient, that dismissal letter could be a death sentence. If you must terminate your relationship with him, make sure the transfer of care is complete before attempting to move forward.
A bad patient dismissal letter neglects to mention medical records.
Your patient is always entitled to receive a copy of his medical records. Even if the patient has an outstanding bill, never hold medical records hostage. A competent patient dismissal letter informs the patient that he has access to these materials. A better patient dismissal letter uses simple instructions to tell the patient what he must do to retrieve them.
A bad patient dismissal letter does not account for emergency care.
After formally dismissing the patient, you must be available to provide him with urgent or emergent care for a reasonable period of time – or until that patient finds a new doctor, whichever comes first. As we stated previously, this period usually encompasses 30 days. If your patient’s circumstances require more time, you must account for it.
A bad patient dismissal letter is poorly timed.
Think twice before dismissing a patient immediately after concluding an operation. An unexpected or oddly timed dismissal may signal to the patient something is expected to go awry. Whether this is true is irrelevant – your patient’s perceptions will determine how he reacts. Many abandonment charges are fueled by feelings of fear. In the unlikely event something does go wrong, treating the complication will be easier if the patient has remained in your care. If circumstances require you dismiss the patient post-op, take the initiative. Find the patient another doctor to assume care and don’t distance yourself from him until the transfer is documented.
In closing, the five traps we’ve identified are bound by a common thread: They all disregard an important aspect of the patient’s care or present information that could be leveraged against the physician in a malpractice case. Summarized, a competent patient dismissal letter…
+ Includes only necessary information…
+ Does not dismiss a patient in the middle of a treatment plan…
+ Affirms that medical records will remain available…
+ Affirms the physician will remain available for a period to dispense emergency care and clearly states how long this period will last…
+ Allows sufficient time to complete the transfer of care…
If this article conveys only a few essential truths, we hope this is one of them: dismissing a patient correctly is a delicate process. Most physicians would rather “stick it out” than dismiss potential hazards earlier than necessary. The labor required to end the patient-physician relationship is substantial.
But there are times when it really is best to divorce yourself from your patient and move on. This publication’s sibling piece, When to Terminate the Doctor-Physician Relationship | 6 Signs It’s Not Meant to Be, is available for download below. It provides physicians with insight into six red flags that almost always indicate it is time to raise the proverbial anchor and dismiss a patient. To request your copy, complete the form below. Qualified requests will receive the material via email.