Turn on the nightly news and you’re bound to hear at least one report about the state of the economy. Obviously, people are worried. Economic concerns seep into every facet of life, as evidenced by a letter I recently received from a reader who was kind enough to share her questions in this open forum to benefit her colleagues.

“The economic downturn has put a strain on everyone. Many patients are losing their jobs, homes, and health-care coverage. They do not have money to pay for their co-payments, deductibles, or office visits. But many have chronic illnesses or are on long-term medications. Some of my patients are asking me to just fax or phone in their refills without scheduling a follow-up appointment or obtaining the recommended screening laboratory blood work. I explain importance of follow-up appointments and tell them that I cannot make this a habit. Many patients then get angry with me and, in some cases, threaten to “find another doctor.” Can clinicians be charged with malpractice for refusing to refill these prescriptions without a follow-up appointment?”

First, I am not a lawyer, and every situation is unique (there’s very little in medicine that is one-size-fits-all). You should feel comfortable calling your malpractice carrier or attorney with specific questions. However, there are some guidelines to remember when dealing with these difficult situations.

Do no harm

If you feel an action or inaction will cause harm, you cannot go along with it. What you must do is document everything, explain things clearly to patients, and create a written policy on how to handle refills, missed appointments, lack of lab work, and financial hardship. Have a form that patients can fill out to explain their current financial situation. You can either waive office charges completely (you cannot waive just the co-payments or deductibles) or work out a payment plan. Another good idea is to keep a list of clinics and hospitals that provide free charity care.


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Remember that you have an obligation to protect your medical license. If a patient refuses to come in for a follow-up visit or get required labs despite your best efforts, consider calling in necessary medications three to five doses at a time. Explain that you cannot give them a larger supply until they follow the steps that are medically necessary. Chances are, they won’t be happy with the increased visits to the pharmacy or higher co-payments for less then a month’s supply. At that point they’ll either comply with your treatment plan or go elsewhere.

Learn how to dismiss a patient

Talk to your clinic’s owner and find out what is required to dismiss a patient. It is completely unacceptable to have a patient threaten you, your staff, or become verbally abusive.

Know how to diffuse a tense situation

You and your staff should get regular customer service training, particularly how to handle a person who is upset. “Upset” mean be anything from angry to difficult to crying. There are books, workshops, and online seminars about the topic. Reassure the patient by telling him or her, “I hear what you’re saying. I’m going to do everything I can to help.” 

As with all relationships, the clinician/patient relationship requires give and take, effective communication, and mutual understanding. Quality health care is not like ordering a burger at a fast food restaurant. In the end, if you are treating someone who doesn’t agree with that approach, do you really want them as your patient?

Ms. Jacobson practices dermatology in Lancaster, Pa. She is also the owner of Strategic Medical Consulting, LLC and PAprofession.com.