Thorny Vignettes and Patient Abandonment

Most doctors understand that once you have agreed to treat a patient, and you are in the middle of a treatment plan, you must either complete the treatment or find an acceptable alternative to the patient. The reason is to avoid a charge of patient abandonment.

Vignette #1:

Doctor receives a consult from the emergency room for a patient with a fracture. The limb is splinted and the patient is sent home. He sees the surgeon the next day in the office. The surgeon determines the patient will need an open reduction and internal fixation. He tells the patient to wait in another room while they schedule the case. The patient sees a nice piece of artwork on a table. He scans the room, determines he’s alone, then places the artwork in his backpack. The scheduler returns to the room, they agree on a date, and the patient leaves. This was captured on video.

The doctor calls the patient at home and explains he has video memorializing the theft. He wants the art back in the office in 1 hour or he will file a police report.

The patient plays dumb. The doctor files the police report.

What about the planned surgery? This patient is in the middle of a treatment plan.

Vignette #2:

Same as Vignette #1 up until the artwork. No art is pilfered here. The case is scheduled. Then the doctor learns the patient slept with his wife. Yes, this is a crazy vignette, but it’s a thought experiment. The patient has not done anything illegal, but the doctor is understandably angry and does not want to treat this patient.

Now what?

The guiding principle is that once you’ve accepted a patient, you keep going until the treatment has been completed. Or you find an acceptable alternative to the patient. The fact that the patient is legally or ethically challenged is of no import to an analysis for abandonment if the patient complains to the Board of Medicine. Doctors know this instinctively. As residents, many of us worked at county hospitals. There, you’d see patients who drove while drunk and killed others. There, you’d see patients who tried to murder others and were shot. We’d fix them up and let the legal system take over. As doctors, we are not supposed to also be judge and jury.

But, there’s no denying that the above vignettes make it hard to treat such patients. What to do?

In the first case, once a police report has been filed, if the patient is arrested, they may be treated medically in the criminal justice system. But, it’s just as likely that they’ll make bail and the problem has not gone away.

In the second case, there is no criminal justice system involvement.

There are no good answers to managing these cases. That said, one doctor said he would respond by doing a detailed – and I mean detailed- discussion of the risks of the procedure and see if the patient affirmatively decides to seek treatment elsewhere.

Interesting.

What do you think?

By |2017-07-14T11:07:41+00:00March 10th, 2017|Compliance, Frontpage Article, News, Practice management|3 Comments

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3 Comments

  1. Michael M. Rosenblatt, DPM March 10, 2017 at 9:45 pm - Reply

    Here’s one from the patient side of the picture. You are moving into a new community in a different state. Your wife had a Senior Advantage Medicare from a large HMO where you live now. She receives a Tier 5 drug by injection twice monthly (very, very expensive) that is covered by Medicare at the HMO. However, you now need to find another doctor who will order the drug for her and take over her care in the new community…where there are no HMO’s…just regular Medicare.

    You have to select exactly the right Medicare supplement to make sure you don’t get stuck with a co-insurance on Medicare Part B. This is a big deal. It could cost 30,000/month!

    You call up numerous doctors, but are finally recommended one by the company that manufactures the drug. It’s impossible to get ahold of the physician, but you get connected to her technical assistant…or someone else in her office. It’s a big multi-specialty clinic. You never know whom you are speaking with. The “nurse” tells you the doctor is “retiring at the end of the year and won’t accept any new patients.” You kind of wonder because this is, after all a large clinic with lots of MDs.

    Should you go with this doctor? The patient care co-coordinator assures you she won’t abandon you after she retires. Then, why was the (first nurse) so dismissive?

    We legitimately wonder if we will be abandoned. When it comes to orphan, tier-5 drugs and their medical management, choices are not always obvious or available.

    In this country we treat doctors like “replaceable” commodities. Corporations look to hire foreign medical graduates who will work for half or less. Have a run-in with your department head and you can get data banked and become almost unemployable….overnight.

    You or your family might get a disease that requires an orphan drug. Specialists to treat these do not crop up in every city. Members of Congress and corporations must recognize that it is time to stop treating our doctors like shit.

    Michael M. Rosenblatt, DPM

  2. Joseph Horton MD March 10, 2017 at 11:58 pm - Reply

    Referral to another doctor is the obvious–and only–correct solution here. You cannot possibly treat the patient dispassionately, because if you did treat him, there are two possible paths to an outcome:

    1) you treat him and there’s an unfavorable outcome; or
    2) you treat him and the outcome is ~medically~ fine.

    In case 1, you’ll be faulted for treating the patient because you should have known that, given the problems, you were bound to have a bad outcome. In case 2, you’ll be faulted for a bad outcome even though you didn’t have one. Patients like that want more than medical care. They want large pieces of you or they want revenge for some imagined wrong. They don’t see artwork in a treatment room and decide that they really admire the art. They see it and decide that want to hurt you. Once treatment is completed, they still want to hurt you, and that will come in court.

    I treated a woman’s AVM in Florida a long time ago. The embolization went fine, did stage 1 of what would have been a few stages, but everyone decided that more treatment wasn’t in the cards for her. A couple years later i found that I had been named in a lawsuit because of intra-procedure problems, including a cardiac arrest and other things. None of them happened. Not one. It was a textbook case.

    She was wearing progressively shaded sunglasses during the consent conversation. I’ve noticed–and maybe I’m crazy here, but…–that women who wear these, especially indoors, are at least hysterical. Granted, my sample set is small, and I’m not a psychiatrist, so my diagnosis may be 1) incorrect and/or 2) biased. But that’s the observation. When I see that, I go to defcon 4, at least. And I usually refer to someone braver than I am.

    If a patient steals, he or she will lie. It’s not complicated.

  3. Barry Gloger, MD March 11, 2017 at 9:33 am - Reply

    These cases are actually easy. You cannot treat a patient with whom you have such an obvious negative emotional relationship, as it will affect your judgment, concentration and skills. Appearances matter. Just the existence of the possible conflict of interest makes you vulnerable to accusation and suspicion. Just document the circumstances and refer the patient to your local Mecca.

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