How Doctors Fire Patients—and How Patients Can Fire Back!

Soon after beginning my psychiatric residency, I encountered a patient with all the hallmarks of borderline personality disorder. She displayed volatile relationships and emotional instability, engaged in self-cutting, and made repeated threats to commit suicide. I asked my supervisor, “How do you treat these patients?”

”Art,” he replied tongue-in-cheek, “you refer them!”

As a psychiatric resident, however, I did not have that luxury. I was required to take all comers. But I did remember his advice once I completed my residency and joined the faculty of my medical school alma mater. Now I was able to saddle residents with some of the most undesirable patients1,2 in all of medicine—not only those with inappropriate conduct, but others who were socially maladaptive and did not live up to the usual expectations of the doctor-patient relationship (see sidebar).

Screen Patients

In addition to referring undesirable patients to trainees, physicians have devised various schemes to avoid dealing with them. For example, doctors may screen patients prior to seeing them. The doctor instructs office personnel to have the patient submit all pertinent medical records. Once received, the doctor reviews the records, determines whether he or she is up to the challenge, and relays the decision to the patient through staff.

Of course, doctors could screen patients in person, in the exam room. In this instance, the office is instructed to inform the patient prior to the appointment that the doctor will see the patient “in consultation.” The implication is that future visits are not guaranteed. After the physician takes an initial history, completes a physical exam, and arrives at a diagnosis and treatment plan, the doctor may accept the patient or steer the patient to a more “suitable” provider.

Don’t Accept New Patients

Doctors may close their practice to new patients for various reasons. In doing so, they may instruct office personnel to tell new patients that the doctor may be able to “squeeze them in.” The doctor may use any of the strategies discussed previously.

Finally, physicians may use the catchall phrase “lack of expertise” to jettison undesirable patients. The following euphemisms have proven effective:

• “Your problems really don’t coincide with my area of expertise. May I refer you to a specialist?”

• “I would be doing you a disservice if I took your case. I really think you need to see someone with more experience.”

• “Your medical issues are complex and extensive. A concierge physician is your best bet.”

Neglect and Abandonment

Patient neglect and abandonment represent the path of least resistance for physicians who want to unload undesirable patients. Physicians may choose not to return patients’ phone calls or e-mails, hoping that their inaction will prompt patients to switch doctors. Abandoning patients, however, is tantamount to malpractice unless the doctor provides the patient with written notice of termination, a suitable list of alternative providers, and an offer to treat the patient in the event of an emergency until a replacement physician is found.

Fire The Doctor

The best course of action may be to fire the doctor before the doctor fires the patient. A patient once fired me because I had neglected to water the plants in my office. She remarked, “If you can’t give your plants a little TLC, how are you going to take care of me?”

Here are 10 signs it’s time to fire the doctor:

1. The chemistry is not right. The patient doesn’t feel he or she can relate to the physician. The doctor relates better to the electronic medical record than to the patient.

2. The waiting time to see the doctor is always too long. In addition, the doctor spends little time with the patient.

3. The doctor can’t be reached in an emergency. The patient is instructed to dial 911 for “true” emergencies.

4. The doctor’s treatment doesn’t make sense to the patient. The physician becomes defensive when questioned.

5. The doctor doesn’t share specifics with the patient, e.g., results of lab tests and imaging studies.

6. Patients’ concerns are minimized, trivialized, or not addressed at all.

7. The office staff—the gatekeepers—are rude, patronizing, or condescending.

8. The doctor really does not know the patient. The same ground is covered each visit.

9. The patient’s preferences are not included in the doctor’s treatment plan.

10. The doctor does not coordinate care with other providers.

Case Example

My daughter, Heather, had a serious health problem several years ago. Heather’s physicians failed to distinguish between her problems and those commonly associated with undesirable patients. Two of her doctors chose the path of neglect and abandonment and discharged her from their practice. Heather gave me permission to write about her experience. Here is a synopsis of her history.

Heather has a serious and long-standing gastrointestinal motility disorder. She has undergone surgery many times. Heather is a challenging patient, not only because she has a vexing medical condition, but also because she is a medical practitioner (physician assistant) and quite knowledgeable about diagnosing and treating patients.

In June 2016, Heather experienced complications from an operation. She required corrective surgery, but her surgeon disagreed with the usually recommended procedure and refused to operate. Shortly afterward, the surgeon sent Heather a letter. It read, in part, “I believe that the relationship between our practice and you has become significantly strained. In light of this, I regretfully feel I can no longer serve as your provider. Your insurance company is able to assist you with the selection of a medical provider of your choosing. I will, of course, be available for emergencies during this time of transition.”

Heather was stunned that her surgeon had dismissed her from his practice. She sought the help of another surgeon, who performed the necessary procedure. Heather did well for 18 months, but further complications set in. Unfortunately, her current surgeon had become quite ill and was no longer practicing. Heather’s choice of specialists was limited in her geographical area. However, the surgeon who had previously abandoned Heather was no longer affiliated with the practice, so she was able to make an appointment with a new surgeon in the group.

The surgeon saw Heather twice in September 2017, and he scheduled her for surgery the following month. In the interim, Heather began to experience symptoms of an abdominal obstruction—severe abdominal pain, nausea, and vomiting. She became frightened and called the surgeon, but Heather was only able to speak with the nurse practitioner. Heather and the nurse practitioner had a disagreement. Heather wanted to come to the emergency department (ED) to be evaluated in case she needed surgery earlier than planned. The nurse practitioner informed Heather that, even if she came to the ED, the surgeon would only be available to operate as scheduled in October. Heather explained that it was not her intention to circumvent the surgery date. Rather, she wanted relief from her pain and nausea, as well as a surgical evaluation for a possible “acute abdomen.”

Heather recovered without going to the ED. She called the office to give them an update, and she asked to speak to a nurse practitioner other than the one she had had the disagreement with. Heather also wanted to learn more about the “fast-track” postoperative program her surgeon had planned for her. She was put on a long hold. The nurse practitioner with whom Heather had the disagreement came on the line and told Heather that because she had considered consulting a different surgeon in the ED, and because she had questioned the fast-track program, her surgery was being cancelled. Heather’s surgeon never spoke to her directly, nor did he respond to my phone calls and emails seeking an explanation for cancelling Heather’s surgery.

Several days later, Heather received a letter terminating her from the practice—again! It was the same letter she had received in 2016 (a form letter), except this time the surgeon did not even offer to be available in case of an emergency—that paragraph was omitted from the letter. Clearly, Heather had been abandoned by the practice, not once, but twice, according to a legal definition of abandonment: “the unilateral severance by the physician of the physician–patient relationship, without giving the patient sufficient advance notice to obtain the services of another practitioner, and at a time when the patient still requires medical attention.”3

Heather filed a formal complaint with the state medical licensing agency and the hospital where the surgeon had staff privileges. She wrote, “I may not be an expert, but I know this is not how patient-centered care was designed. Complex patients and patients perceived as challenging or difficult to treat should not be labeled ‘non-compliant’ or any other term and summarily dismissed from treatment, especially at their most medically vulnerable moment, when surgical intervention is required.”

The hospital’s findings were consistent with the narrative of Heather’s complaint. The nurse practitioner was fired. The doctor maintained his privileges. The medical board never responded to Heather’s complaint.

Catastrophic Consequences

The seminal article “The Undesirable Patient”1 begins as follows: “While the position of being undesirable is an unwelcome eventuality in any interpersonal relationship, for a patient to be regarded by [her] physician as ‘undesirable’ can be catastrophic. Not only may such a patient sense [her] situation with uneasiness, but in general [she] is likely to receive less than the best total care, including emotional, physical and social aspects.” Indeed, Heather’s providers severely compromised her care by precipitously cancelling her surgery and forcing her to seek treatment elsewhere on her own. She was dehumanized, treated without dignity, and traumatized by the actions of the nurse practitioner and surgeons.

Respect and appreciation for undesirable patients is more than some physicians can muster.

Unconsciously—and often consciously—undesirable patients evoke feelings of disgust, malice, or a desire to be punished. Doctors approach these patients with resentment and anger, viewing their conditions purely as a result of sloth, self-indulgence, greed, malingering, and apathy.4 The reaction of physicians to undesirable patients often provides important insight into doctors’ coping mechanisms. Respect and appreciation for undesirable patients is more than some physicians can muster.

A significant decline in empathy occurs in physicians as early as the third year of medical school.

Sadly, a significant decline in empathy occurs in physicians as early as the third year of medical school.5 The erosion of empathy occurs precisely at a time when the curriculum is shifting toward patient-care activities—and, ironically, when empathy is most needed. The fact that empathy begins to decline in medical school, prior to the transformation of students into physicians, is worrisome and is reminiscent of a glum remark by Novack6 that empathy in medical education often fades away like an endangered species.

Get Rid of Patients

It is undeniable that sociological factors influence how a physician relates to a patient. One author7 categorized these sociological influences into four types:

• Patient characteristics;

• Clinician characteristics;

• The clinician’s interaction with his or her profession and the healthcare system; and

• The clinician’s relationship with the patient.

The American Medical Association8 advises physicians to concentrate on the best interest of patients and avoid evaluations of social worth. Nevertheless, it is not uncommon for doctors to perceive patients as socially undesirable and “turf” them in various ways. Structural, professional, cultural, and patient characteristic variables endemic to medical training combine to produce a negative and distorted doctor–patient relationship that has been characterized as “Get Rid of Patients (GROP).”9

The use of medical slang for undesirable patients was popularized in the 1978 cult classic The House of God, by Dr. Samuel Shem (the pen name of psychiatrist Stephen Bergman). This novel, a fictionalized autobiographical account of internship training in an urban setting—later revealed as Beth Israel Hospital (now Beth Israel Deaconess Medical Center) in Boston, Massachusetts—paints a bizarre and brutal picture of the world of the intern using bawdy comedy. Many medical residents, then and today, do not perceive Shem’s description of the internship year to be an exaggerated account of their experience, which tends to be marked by social isolation and alienation from most groups of people, including the faculty.

Although writing The House of God was for Shem an “attempt to stay human and honor our patients’ humanity in a dehumanizing year,”10 it remains offensive to many readers and some in the medical establishment. Still, the “laws” that governed care in The House of God (e.g., “The only good admission is a dead admission”; “The delivery of good medical care is to do as much nothing as possible”) continue to make their way into Grand Rounds at academic medical centers across the United States, exposing the dangerously flawed culture of graduate medical education and reminding us how dark humor colors doctors’ interactions with undesirable patients.

Similar to GROP, the GOMER (Get Out Of My Emergency Room) in The House of God is used to describe a patient with complicated but uninspiring and incurable conditions. GOMERs are considered highly undesirable because they linger and “go to ground.” Although these are patients who require significant compassion and care consistent with core values embedded in the Hippocratic oath, GOMERs and other undesirable patients often receive treatment antithetical to humanistic medicine—or they receive no treatment at all.

Several decades after writing The House of God, a humbled Dr. Shem reflected on what he had learned in practice as a psychiatrist. The essence of medical care, and life, is “connection,” Dr. Shem remarked.11 Now he encourages doctors to put themselves in their patients’ shoes and speak up if they see something wrong in the healthcare system. Dr. Shem implores physicians to remember that the patient is never only the patient—the patient is the world, with family, friends, community, and history.

Conclusion

The pioneering anesthesiologist and international medical scholar E.M. Papper (1915-2002) campaigned for all patients to be treated with dignity and respect. He encouraged physicians to treat the classic undesirables—the poor, the alcoholic, the “crock,” and the ungrateful patient—in order to help physicians overcome their medical prejudices and acquire the attitudes and self-discipline necessary for personal growth. Dr. Papper advocated for justice, and he believed that physicians had a duty to care for the chronically ill, the disadvantaged, the elderly, and the poor, and treat all patients as they wish to be cared for—the application of the Golden Rule.

In a 1984 address to students and faculty at the University of Pennsylvania Perelman School of Medicine, Dr. Papper commented: “We must not pass judgment on the worth of a patient—all are equally precious—there are no undesirable patients—even though we will always like some better than others—we are human—and some people are lovable and others downright unpleasant. We respond to their traits—but it must not influence our care.”12

Empathy for undesirable patients is perhaps the noblest trait a doctor can possess.

References

1.    Papper S. The undesirable patient. J Chronic Dis. 1970;22:777-779.

2.    Jecker NS. Caring for “socially undesirable” patients. Cambridge Quarterly of Healthcare Ethics. 1996;5:500-510.

3.    Tomey SN. Removing a patient from your practice: a physician’s legal and ethical responsibilities. Medical Economics. March 16, 2015. www.medicaleconomics.com/health-law-policy/removing-patient-your-practice-physicians-legal-and-ethical-responsibilities.

4.    Ofri D. What Doctors Feel: How Emotions Affect the Practice of Medicine. Boston: Beacon Press; 2013.

5.    Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84:1182-1191.

6.    Novack DH. Therapeutic aspects of the clinical encounter. J Gen Intern Med. 1987;2:346-355.

7.    Eisenberg JM. Sociologic influences on decision-making by clinicians. Ann Intern Med. 1979;90:957-964.

8.    American Medical Association, Council on Ethical and Judicial Affairs. Ethical considerations in the allocation of organs and other scarce medical resources among patients. Arch Intern Med. 1995;9;155(1):29-40.

9.    Mizrahi T. Getting rid of patients: contradictions in the socialisation of internists to the doctor-patient relationship. Sociol Health Illn. 1985;7(2):214-35.

10.   Bergman S. Basch unbound—The House of God and fiction as resistance at 40. JAMA. 2019;322:486-487.

11.   Shem S. Samuel Shem, 34 years after ‘The House of God.’ The Atlantic. November 28, 2012. www.theatlantic.com/health/archive/2012/11/samuel-shem-34-years-after-the-house-of-god/265675/.

12.     Papper EM. Everyday ethics—doing right. Alpha Omega Alpha lecture at the University of Pennsylvania Perelman School of Medicine, October, 1984.
http://calder.med.miami.edu/papper/Papper_Ethics-lecture_9.pdf.