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This week's topic: The art of "firing" a patient (aka "discontinuation of care")
During a recent one-on-one mentor call, we discussed when and how to release a patient from our care when the reason for release isn't "obvious" (e.g. not paying, harassment, etc).
When you have to fire a patient, you may feel that you failed your client or that it will reflect poorly on you. However, we have to protect our own mental health to avoid burnout, and being honest with a patient about their care with you reflects positively on your character as a practitioner.
**Note, the following is not legal advice. I am not an attorney, and the following is based off my own experiences and research, so please consult a qualified attorney if you have any concerns with the process of discontinuation of care!
Overview of today's email:
- Subtle scenarios where a patient may not be a good fit
- Top tips for releasing a patient from your care
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1. Subtle scenarios where a patient may not be a good fit
Here are some (subtle) scenarios where we may need to send a patient a discontinuation of care letter:
- Patient is not following through on any of the care that you are providing
- You are doing more work for the patient than the patient is willing to do for themselves (from a quick internet search, this may be called "loss of rapport" or a “breakdown in the therapeutic relationship” in the legal world)
- The patient refuses to see a specialist for an active condition (e.g. eating disorder, cancer, Graves’ disease), and you do not feel it is safe to continue care without specialist involvement.
- The patient asks too much of you and is burning you out (e.g. frequent messaging). These scenarios can lead to frustration and resentment, which is not healthy for the patient or the clinician!
- The patient uses visits to unload their troubles on you instead of working with a therapist, especially when persistent negativity is affecting your wellbeing.
The patient has a complex picture of health (e.g. Lyme, chronically affected by mold exposure, etc), and you do not have the knowledge (or desire) to address their diagnoses
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2. Top tips for releasing a patient from your care
When releasing a patient from your care, there are 3 big things to avoid:
- Frank abandonment (this can be avoided with a written notice and generally need to give at least 30 day transition period)
- Discrimination (e.g. releasing a patient from care because of their sex or religion)
- Retaliation (e.g. releasing a patient following a poor review)
If you see a patient on your schedule and dread the encounter, consider the pros and cons of continuing to have them in your care. Releasing a patient is not easy, especially for caring and empathetic clinicians!
When working with patients, set expectations in a Conditions of Care Agreement in your contract, document everything in detail (e.g. in the subjective section of your notes), and have a discussion with patients about what may be impacting “compatible” care.
If you do have to release a patient, give them at least 30 days’ notice and some referral options, and use a “Discontinuation of Care” letter.
When I’ve had to release patients, what helped me make the decision was remembering that burning out and leaving medicine would impact many more patients than the one I needed to release. Sometimes we have to focus on the bigger picture!
I share more details and considerations in my paid Substack (including what I personally put in my contract, and some of my case experiences where I had to discontinue care). Note, the link takes you to the general sign up, not the paid option.
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If today's pearl was useful, you'd fit right in at the Functional Medicine Collective! It's a members-only space built specifically by me for prescribing clinicians who want peer-level content, not the sensationalist version.
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I hope this was clinically useful!
To see more of my deep dive into the literature, as well as my clinical insights, on this topic, subscribe to my paid Substack ($8 a month) to see the extended version of this email!
Meg
P.S. These emails take a lot of time to create (and I don't receive a lot of feedback on whether they are useful to those that receive them), so I've moved to Substack for an extended version of these at a low monthly cost (available within 24 hours of releasing this email). Why Substack? It has the benefits of being able to comment and ask questions about the posts, you're not bombarded with ads, I'm using the platform as a "micro-mentorship", and it's low cost!
Additional resources that may be helpful:
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