They say that breaking up is hard to do Now I know, I know that it's true Don't say that this is the end Instead of breaking up I wish that we were making up again

There are times that relationships need to end.  Usually something happens to undermine trust; it's hard to build trust, but it's very easy to destroy it.

I had a discussion today with the other physicians in my practice as to when patients should be "discharged" from our practice.  I have always found it somewhat ironic that we use the term "discharge" when we are basically telling patients we don't want them to be our patients anymore.  Doctors deal with discharges of various sorts - most of which are not pleasant.  Here is a dictionary definition of discharge: the emission of pus, mucus, or other liquid from an orifice or from diseased tissue. True, there are other definitions of discharge that don't cary that connotation (we discharge patients from the hospital), but if I see an appointment on my schedule with the word discharge as part of the reason for visit, I am not excited.  I am praying for a no-show.

So what constitutes a reasonable reason to terminate the doctor/patient relationship (terminate is another word that carries bad medical connotations)?  The breaking of trust is usually at the center.

Patients Dumping Doctors

From the patient standpoint, the doctor is paid both to do a job and entrusted with something of enormous value.  Patients are both customers wanting to get their money's worth, and people with needs looking to be cared for.  A doctor can betray the patient's trust in either of these areas.  Yet in spite of the way that some doctors honor neither end of the deal, most patients feel very guilty cutting off the relationship.

I have had numerous patients who are very unsatisfied with specialists be amazingly reluctant to change.  They are afraid what the doctor will think of them.  The don't want to be "one of those patients."  And so just like a spouse of an alcoholic will enable the drinking, bad doctors will continue to treat patients poorly because people keep coming to them.  It usually takes a strong affirmation from me that they do have the right to good treatment (especially because they are paying a lot for it), for people to make the switch.

The language used from the patient perspective is that they leave the doctor to find another, just like the ending of many relationships.  Patients don't, however, usually leave a note saying why they "just can't live in this relationship anymore."  They are one of thousands of patients, but they have only one doctor of that specialty.

Doctors Ditching Patients

The other side is quite different.  The patient often comes into the relationship broken and needy.  They are looking for help, guidance, and care.  Less is expected of them because they don't give, they receive.  So the ending of the relationship can feel like abandonment.  You are telling them that you won't meet their needs anymore.

Those of us who are tormented quick to feel guilt find it very hard to end the relationship.  It takes a lot for me to discharge a patient - more than most doctors.  For me, there are three main reasons I discharge patients:

  1. They don't pay their bill when they can afford to - this tells me that they don't value me or my services.  It's a big insult to doctors to feel less valued than cable TV or cigarettes.
  2. They lie to get controlled substances - this not only undermines our trust in the patient, but it puts our career at risk.  I can lose my license by carelessly prescribing controlled drugs like Xanax and Percocet.  I didn't go to medical school and residency to become a vending machine.
  3. They mistreat my office staff - this one is a little harder to judge.  Some people just don't relate to others well (ie. they are jerks).  This shouldn't be a complete barrier to care, but if it goes far enough, I will discharge them.  Losing a good staff person is far worse than losing a patient, and an unsupportive boss can kill morale.  I spend every day with these people and rely on their hard work; I can't afford to discourage them.

Honey, You Don't Love me Anymore

Some doctors would include medical noncompliance on that list.  If a patient doesn't follow a doctor's instructions, then why should they continue to come?  I have heard many doctors say that they fear the legal liability of someone who doesn't follow instructions and gets sick as a consequence.  What if a patient's family gets upset that grandma died of something that should have been treatable?  Why didn't she get the antibiotic?  Why didn't she get the mammogram?  Why wasn't a CT scan ordered?  The noncompliant patient, to many doctors, is a problem waiting to happen.

I think they are wrong.  Yes, it may be a small risk to keep a noncompliant patient, but most of that risk can be mitigated by documenting the patient's refusal of care.  Besides, the practice of medicine is anything but safe.  We are taking people's lives in our hands.  It is not a low-risk thing to do.  I have always felt that discharging noncompliant patients was more a case of injured pride on the part of the doctor.  How dare you ignore my good advice!  I went to medical school and have practiced for 15 years, and you are ignoring what I say? It wounds your pride to be ignored.

But patients don't usually disregard doctors' instructions because they don't trust them.  Why would they go to the doctor in the first place if they didn't trust them?  Emotions are really complex when people are dealing with their own health.  They don't want to seem like they are over-reacting, but they also don't want to admit their weakness.  Taking medications and getting tests done is an admission of mortality, which nobody likes to do.  Some of my most noncompliant patients, ironically, are doctors.

I just chalk it up to human weakness/stupidity, which all of us have in abundance.  Seeing my patients doing dumb things reassures me that I am not alone in the dumb department.  It just means more business for me in the long run.  It's job security.

Maybe it's just my fear of confrontation, or maybe I am more patient than most, but I am in the business of treating weak people.  Why should I get angry at them and ask for my class ring back when they show that weakness?

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