Should a Doctor Fire a Patient? Sometimes It Is Good Medicine By RICHARD A. FRIEDMAN, M.D.

Published: September 27, 2005 Bosses dismiss employees. Spouses divorce each other. Patients leave their doctors. But can doctors ever fire their patients? This is not a topic most doctors like to talk about openly. Sure, many physicians I know, myself included, have occasionally wanted to fire a difficult or abusive patient, but no one really knows how often it happens. Of course, people are generally not on their best behavior when they are sick. Illness can make people demanding, anxious and needy - something most doctors understand and abide as a part of everyday medical care. I once had a patient with a generalized anxiety disorder who failed to respond to antidepressants and cognitive therapy The patient had accidentally discovered that opiates relieved her anxiety after she received them for a minor surgical procedure. From then on, she insisted on being treated with opiates. I didn't doubt the anti-anxiety effects of opiates, but the drugs are not a safe or reasonable treatment for anxiety. And I was not about to compound an anxiety disorder with an opiate addiction in this patient who had a history of drug and alcohol abuse. Because I would not give her a treatment that I deemed harmful, I terminated our relationship. I referred her to another colleague but later learned that she had also rejected his treatment recommendation. While the American Psychiatric Association does not have specific guidelines for ending a relationship with a patient, the American Medical Association's ethical guidelines state that a doctor is obligated to provide for continuity of medical care. Under the guidelines, a doctor may withdraw from a case only if the doctor notifies a patient, the patient's relatives or responsible friends with enough advance notice for the patient to secure another physician. A physician, under the guidelines, can decline to treat a patient who requests a treatment that is known to be scientifically invalid or that is incompatible with the physician's personal, religious or moral beliefs. But noncompliance with treatment is not a reason to fire a patient. "Patients often didn't do what I told them," said Dr. Richard C. Hughes, a retired internist in Wisconsin. "But I never thought it made much sense to refer them to a colleague, because they would probably do exactly the same thing with a different doctor." He added, "At least I knew them and could try to work things out with them." In his 32 years of practice, Dr. Hughes said he fired only one patient. "This was a patient who chronically screamed at my secretary, who was very seasoned," Dr. Hughes said. "He once even brought her to tears. I could have handled him, but he really upset my staff and other patients." He continued: "I finally told him that if he continued his abusive

behavior, he'd have to find another doctor. The next time he came in, he did the same thing, so we said, 'We'll take care of you until you have another physician,' and I referred him to several other colleagues." Sometimes a doctor dislikes a patient. If the physician is a psychiatrist, then a patient's unpleasant or obnoxious behavior is likely to be a focus of treatment. In those cases, psychiatrists have to understand their own emotional reactions and use that knowledge to help their patients. "Any physician who is thinking of firing a patient should first speak to a colleague," said Dr. Robert Michels, a professor and former chairman of psychiatry at Weill Medical College of Cornell University. "This is an enormous decision and, while it might even be right at times, the physician is probably having a countertransference reaction to his patient and should really understand that before taking action." Countertransference refers to a doctor's emotional reactions to a patient that are based on his own unconscious needs and conflicts. Years back, we had a patient in the clinic who verbally taunted several female residents in an overtly sexual manner. He was repeatedly confronted but showed no interest in understanding or changing his behavior, which was clearly within his control. I finally discharged him from our clinic. I like to think that experience possibly helped him; last I heard, he was still in the treatment I referred him to.