Anger. As is the case with drug-seeking, the AAFP course advises physicians to anticipate and develop policies for handling situations in which a patient’s anger escalates and creates a real or perceived threat.3 While this is commonly done in acute care facilities, it is often overlooked in outpatient settings.
Among the issues to address: equipping offices and exam rooms with an emergency call button or intercom, knowing where to position yourself to ensure that you can’t be trapped in a room by a threatening patient, and considering how to respond in a way that defuses—rather than escalates—the anger. Calmly ask the patient what he or she is upset about, listen carefully, and apologize, if appropriate, for your role in the upsetting incident. Then move on to the purpose of the visit, stating, for example, “Now, what brings you in today?” 3
It is crucial to set boundaries (although it’s probably not a good idea to attempt it at the time of the outburst), making it clear, for example, that profanity is not acceptable; directing anger at nurses or other staff members is not permitted; and what the consequences of continued outbursts will be. 3
A single incident that’s grounds for dismissal
Despite the emphasis on resolving problems with patients, there are times when dismissal can and should occur, with little warning and no negotiation. In its home study course, the AAFP describes this as a “sentinel incident"— a single occurrence so egregious that it damages the physician-patient relationship beyond repair.3
A threat of violence or a physical assault itself would rise to that level. Some other examples: a sexual assault or blatant sexual advance, falsifying medical records, and theft or another type of criminal activity carried out in the physician’s office.
When a sentinel incident occurs, the best course is likely to be to forego any attempt at resolution, call the police or your facility’s security officer, and, if appropriate, to immediately prepare to “fire” the patient.
Dismissal without abandonment: Here’s how
In the vast majority of cases, dismissing a patient does not in and of itself constitute patient abandonment. Even if the termination is unduly abrupt, as was the case for Susan (CASE 1) and Laura (CASE 2), it doesn’t constitute abandonment unless the patient is dismissed during a course of treatment and unable to find a physician to provide ongoing care.
Neither was true in Susan’s case, and her threat of a lawsuit based on charges of abandonment never came to fruition. Not so for Laura, who was abruptly terminated during ongoing treatment—and who nonetheless made numerous attempts to find another doctor to care for her, without success. The attorney for Laura’s physician advised that the severe consequences of dismissing without going through the proper channels made a trial defense untenable.
Although most charges of patient abandonment never rise to the level required for a successful lawsuit, attorneys often include it in a litany of charges in an attempt to damage the physician’s credibility with a jury. You can usually avoid that scenario by taking the right steps when you dismiss a patient.
CASE 3 Pregnant patient, rural physician
As part of his rural family medicine practice, Dr. J provided obstetrical care. Dr. J had a partner and they alternated call nights, but his partner did not do OB. Dr. J made it a point, however, to always be on call for his obstetrical patients as they neared delivery. Having no patients imminently due, he took a one-week vacation out of town.
One of his patients went into premature labor and went to the local hospital. Dr. J’s partner was called to attend, but indicated he did not do OB work and advised the emergency physician to call “any obstetrician around.” One obstetrical group covered the region and the on-call physician was at another hospital doing a C-section and requested that the patient be transferred to that hospital for evaluation. After a series of delays, the patient was transferred and delivered a preterm infant who showed signs of neurological injury after a lengthy ICU stay.
The family sued all providers involved on several grounds, including patient abandonment. Plaintiff experts testified that the standard of care would be for Dr. J to be in attendance for such emergencies or, failing that, to provide for adequate coverage of his pregnant patient. They also testified that it was reasonable for the patient to have gone to the local hospital where her delivery was planned and that Dr. J should have arranged for the local OB group to provide emergency coverage. The case concluded with an $800,000 pretrial settlement.