In each episode, we’ll delve into practical strategies, expert insights, and real-world case studies to empower you with the knowledge and tools needed to minimize legal risk and enhance the patient experience. In today’s podcast, we will continue our focus on the topic of terminating the physician and patient relationship.
A therapeutic, respectful provider physician relationship with the patient, like any relationship, requires ongoing time and attention to sustain it. Over time, that connection may also encounter periods of strain, disruption, or challenge just between the two parties. The goal is always to work through those rough patches and repair the relationship.
However, there are situations where mutual respect has eroded. And despite sincere attempts to resolve the issues in those moments, ending the relationship, however difficult, may be the most appropriate course. So I want to first introduce our guest today, and I’m really pleased to having these two guests join us again. They have been on previous episodes on this topic.
I want to welcome first Anne Huben-Kearney. Anne is an independent risk and patient safety consultant after a career in multiple healthcare roles from staff nurse to nursing administration, quality improvement, risk management and patient safety, as well as medical professional liability insurance, with experience in diverse health settings. Welcome, Anne.
ANNE HUBEN-KEARNEY: Thank you. It’s good to be back with you and Claudine. Thank you.
JOAN PORCARO: And Claudine, a hearty welcome to you. Claudine is a registered nurse with over 30 years of experience and more than 14 years in healthcare risk management and patient safety. Certified in risk management, patient safety, and operating room nursing, she works within a large hospital system in South Florida. She serves as a mentor and committee member for Florida Chapter of ASHRM, and we welcome her again today. Welcome, Claudine.
CLAUDINE: Thank you, Joan. Happy to be here with Anne as well. Thank you.
JOAN PORCARO: And for a full understanding of both Anne and Claudine’s background, their bios are housed in one of our earlier episodes. So without further ado, let’s go ahead and get started. So, Claudine, I’m going to start with you. What strategies can be employed just to repair or even restore that provider relationship so maybe a termination isn’t necessary?
CLAUDINE: That’s a great question, Joan. And one of the things that we need to do is, first, we need to basically create a patient written care behavior. That is key. And, of course, before consider terminating that relationship, it helps to listen to the patient concerns. You also want to clarify expectations and address misunderstandings. That’s always key. You have to know the why behind what’s going on so you can address it accordingly.
You look at conflict resolution, the patient education. And setting clear boundaries can rebuild trust and often prevent the need for termination. Also as well, is it a language issue? So you want to involve the language interpreters when language is a barrier so the patient fully understands and has an opportunity to correct the course.
So you want to basically address the why behind the patient being noncompliant, if they’re not showing up for office visits, if there is a payment issue. Based on the why behind what’s happening, then you can address it before you do the termination. So those things are key.
Telehealth also plays a huge part if the patient is unable to do the visit in a timely manner. You could also look at telehealth visits. So just making sure that you understand the why behind what is being done before you terminate. That will sometimes save a lot of the issues.
ANNE HUBEN-KEARNEY: Claudine, I love that why. I love because we label patients for non-compliant or nonadherent, but we don’t know, as you said, the why. Is it their barriers, bus schedules? They can’t get to the office or familial responsibilities. Grandparents are taking care of their grandchildren. I think that’s brilliant.
JOAN PORCARO: I think I want to also add we talk about non-compliance and non adherence. And I think sometimes-- we spoke about this in earlier episodes, sometimes I’m not a good match with that provider. We don’t have the same goals. And so to label me not adherent or non-compliant when the issue may be that I just don’t agree with the plan of care-- I want to try some alternatives first before we go to that next step. And not penalize the patient because their values may be different than the provider.
And I think also we have to be cautious about aspects of ageism. I think about some of the care and some of conversations happening today about perimenopausal, menopausal, and post-menopausal that there are certain things that come with moving through life at that particular stage that are symptoms that really need to be discussed. So really having the opportunity to understand and document well.
Joan, did not agree with the plan of care. We could not come to an agreement as to which direction to go next. And maybe Joan elected to say, I’m going to discontinue my care with you, or the doctor says, we are not on the same field here. Joan needs to think of some other options.
ANNE HUBEN-KEARNEY: I think, Joan, that is a really good point. And I think there’s some very hot issues going on now. Vaccinations. Some pediatric practices have made it clear in their policies is that they will only accept those that are vaccinated because they’re putting the other kids in the practice, in the waiting room, whatever, at risk. But it’s very clearly communicated.
And there’s education that goes behind it. But the patients have a right to self-determination. They have a right to refuse care. They have a right to disagree with you. It’s not necessarily grounds for termination. It might be in pediatric practices, because their policy is very clear on their website and everything else, is that we only accept those who will adhere to American Academy of Pediatric Vaccination requirements or guidelines, whatever you want to call it, but the standard of care. But I think you’re right, that there are personality conflicts. It’s OK.
JOAN PORCARO: Or just value disagreements. I might want to try-- before I go to medication as a solution, I might want to try some alternatives, examples of using some medications or maybe some supplements that might be less intense. And to have those conversations we would strongly encourage and not immediately label a patient with one of the other categories. They’re not being non-compliant. They just don’t agree with you.
ANNE HUBEN-KEARNEY: Which they have a right to do, as you do disagreeing with your patient.
JOAN PORCARO: Yes. Yeah. Well, I’m going to continue with you, Anne. So how can practices ensure that-- well, and this is in keeping with what we just spoke about-- that communication actually remains respectful and patient-centered, even when the relationship is ending?
ANNE HUBEN-KEARNEY: And that’s really important. Just reiterating as you started the introduction and as we continue this whole podcast is that you need to know professional communication exists in all situations. You may be so frustrated. You may be so filled with emotion. I’m trying to help you. I’m trying to save your life and you’re refusing the cholesterol medications or whatever else it might be.
You have to really think carefully. Where are they coming from? Why do you think that way? Tell me more. I mean, we think it’s easy, but not everyone is trained in dealing with difficult conversations. You said that upfront. And I think in a previous podcast you said, these are very-- Claudine, you said that these are really difficult conversations. But to do it in a way that is patient-centered, calm setting, you want to be able to hear them. Claudine, you said that to actually listen to the patient.
There was a study done that physicians are actually getting sued more frequently because of the number of interruptions. It’s basically like 11 seconds before they interrupt. There’s been some studies. You don’t let the patient finish. Now, I know time is tight for primary care, particularly appointments. But if you listen to the patient, make a deliberate decision not to interrupt. It will help you remain in that respectful conversation.
The other thing is know when to escalate. It really is not a single-- it should not be a single individual making that decision. When does a practice manager get involved? When does legal get involved? When does HR get involved? Claudine mentioned at a previous podcast-- when does marketing get involved? Because if they’re going to be on social media, what are the potential risks related to that?
But I think the calm setting, role playing, practicing-- I know people don’t like the word role playing, but practice with the staff, difficult conversations, difficult scenarios, so that they know and have a script or something to help them. Because when you’re being verbally assaulted by a patient about how bad you are, it’s difficult to maintain that neutrality and be calm and patient-centered when you’re hurt and angry and upset. So having those practice sessions will help when the situation arises.
JOAN PORCARO: And I want to add to that. You mentioned about the respectful conversations, but I also want to say that words are important, but body language and voice are important. I remember a patient telling me that, in the very short few minutes they had with the doctor, she had a question. She just wanted some clarity.
And she looked at the doctor and they were documenting off the computer, and they made eye contact with one another. And as she said, I just have one more question, the doctor rolled their eyes and then pushed their sleeve up on their arm and looked at their watch. And that left a really not good feeling with the patient. She had just a question. I’m here with my doctor, so I want to just ask it.
Even if it’s perceived as a silly question, it’s the body language, the tone of voice, the speed in which-- the cadence at which the words are being used that I think a lot of times people just aren’t aware of how they’re coming across.
ANNE HUBEN-KEARNEY: No, no. And if you bring in your elderly parent in, who may have some memory issues, you need to talk to the patient, not talk to the daughter or the son, whomever it might be. I had that personal-- my mother was, OK. She was the president of three organizations, three associations. She went back and told them that the doctor never looked and talked to me, even though I said to the doctor, the patient is my mother. I’m here for support, but the patient is my mother. Please, talk to her.
And he continued to just overlook the fact. Exactly. So I don’t think physicians and providers realize the reputational cost. I mean, that specialists lost potential referrals because of the word of mouth from my very active, involved mother. So just you never know. You never know.
JOAN PORCARO: That’s so true. We’re very connected world. And as the old saying was before social media, you’ll tell one person you had a good experience and 10 that you didn’t.
ANNE HUBEN-KEARNEY: Yes. Good. Yes. That’s still applicable. You’re absolutely right, Joan.
JOAN PORCARO: It’s actually not 10. It’s probably 200 because you can post it on social media. Yeah. But Claudine, I wanted to jump back over to you. We talk about some of the icky sticky spots in these relationships, but can you share examples, a situation where the termination with a patient was handled really well? And what do you think made that successful?
CLAUDINE: And that’s a great question, Joan. So overall, patient with behaviors that was escalating, the staff used de-escalation techniques. They set firm boundaries and clearly explained the reasons for ending the relationship while ensuring continuity of care. That’s also key. So they mean by being transparent, consistent, and empathetic, the termination was smooth and reduced our conflict.
So what makes these cases successful generally is that patients are not surprised. Consequences are explained in advance. Alternatives are offered. Timeliness are reasonable. And every step is documented. So I go back to Mr. John. If he was being disruptive from last week, we have those conversations with him. And, of course, you set boundaries. It’s not acceptable. You try to de-escalate and try to explain to him the reason behind why it’s not acceptable or you claim the behavior, you name the behavior.
And, of course, so when you do have to terminate, it’s not a surprise to him. He was already told about it. He has been warned before. And you give a time limit as to what will happen if he does not comply. So, of course, sometimes as well, for staffing, if you have a stalking scenario, a lot of times, too, of course, we have to terminate those cases.
And for staff, it’s all about their safety. So, of course, you also want to empower the staff to maybe reach out to the police and local law enforcement, whereby may have to get a restraining order depending on what’s going on. But, of course, these kind of cases as well, everybody is in the know, and they also feel safe. So it’s just about with the staff. It’s also about with your patients. And those kind of things make the situation successful.
ANNE HUBEN-KEARNEY: Claudine, I give you credit for bringing up stalking. I think that there is, that emotional attachment or an attraction or whatever. But stalking is so real and so scary. So I’m really, really glad you brought that up. And protecting the staff is absolutely critical. So I really, really like how you brought that to the forefront.
JOAN PORCARO: All right. Well let’s take a look at it from a slightly different angle. Tell me about a time, Claudine, where things did not go smoothly. What were some of the highlights?
CLAUDINE: So there are times as well when, of course, the patient, they don’t want to accept that their behavior is not in compliance with what we expect. And they are not feeling it to begin with. So, of course, you mean they become disruptive, become boisterous. that we go back to stalking. And that’s the case whereby you may have to get law enforcement involved, to make sure that the staff are protected, the physician or the provider is also protected.
So there are times when you have to get law enforcement involved, which, of course, is it’s a last resort. But, of course, we have to make sure that everyone is kept safe. And those are times when it does not go well. They can’t accept that, hey, I’m being terminated. I’ve been with you for 20 years. My mom has been with you. So it’s just to accept the termination that sometimes patients can’t-- it’s very hard on them.
JOAN PORCARO: Yeah. Well, thank you. Anne, what policies really are key that a practice, a medical practice should have to create standardization?
ANNE HUBEN-KEARNEY: I think there are several. And I think it’s summarizing-- you’ve heard these with other podcasts. But you want to avoid an allegation of abandonment that’s really, really important. And you don’t want to abandon the patient either. It’s not just the allegation. You don’t want to abandon the patient.
So you need to make sure that you have a formal, well-developed process for termination in place. You have criteria. It is non-discriminatory. It is looking at how you make that decision. And it, again, should not be impulsive. You’re annoyed. You’re frustrated. That call that Claudine talked about-- oh, no, you did, Joan, about rolling the eyes. I mean, the person-- the individual-- I would react, like, doctor, I have one question. What’s the problem here? Oh, well, I haven’t got time for you, and I’m terminating the relationship. You don’t want that.
So you have to be really, really, really cautious. You need a framework. You’re going to look at each patient’s health record. You’re going to document the essential record. You’re going to notify the patient of the termination. But before this, your process should include why. Claudine talked about that on another podcast. What is the why behind the patient’s behavior?
And I’m not talking about violence and verbal or physical violence. There may be reasons. They may be on the road to dementia. And they’ve lost their filters and they’re lashing out. But again, the why. So you want to figure out in your policies and be clear how many missed appointments trigger action. Three no shows-- again, how and why are you not showing? And what can we do about it?
When the patients are contacted-- I think we talked a bit about the communication with the patient, about the termination, but it should not be a surprise. And that’s, again, the process. It’s not a quick immediate-- you want to make sure there’s a process. The no-show patients, the time frame to communicate back to that you regarding their plans and their issues.
How long you’re going to have referrals out for other providers? I know many organizations say, I’m going to give you three names for those that would be to-contact usually group processes. You don’t necessarily want to give the name of your friend when you’re terminating a patient and say, I suggest you see Dr. John, and Dr. John’s not going to be your friend for long if it’s a problematic individual who has a personality disorder.
So I think three group practices that are fairly geographic. How long you’re going to provide that urgent or emergency care, because that’s really important if it’s a very difficult patient, and especially difficult in a sense of complex, a patient and limited specialists in the area, the use of telehealth, et cetera.
I think we’ve talked in other podcasts about exclusionary criteria. You don’t want to terminate necessarily an OB patient, particularly after the second trimester. I don’t think that’s a good idea. Immediate post-op patients, those that are acutely ill, those who are undergoing chemotherapy, those that you’re having long-term care that needs to be addressed, and making that sure, that that exclusionary criteria is not necessarily that you can’t terminate them, but that you really look at the time frame for doing so.
I think we talked about no-shows. We talked about communication, the letters, both certified. I like your idea, Joan. And you said in a previous podcast about using FedEx or something else besides the postal service. Do recommend sending regular mail many times logo-free. I had a practice that sent out their termination letters, both certified mail, but also in a pink logo-free envelope, and you knew the pink envelope was going to get opened up more so than the certified mail.
So I think the issue is to be consistent. The issue is to be fair. The issue is to be clear in your communication, transparent. There is a reason why. And it may be our personalities don’t gel that you had mentioned earlier or our practice is such that we require vaccination for your child. It may be that your behavior is unacceptable. You continually harass and debase the staff.
It may be that you’ve missed appointments three times in a row. We’ve asked you to communicate with us regarding the cancelation. Is there a reason why that we should know about, and there is no reason other than, well, I didn’t feel like coming. It is a process. That’s what I’m trying to say. Other than those who are actually physically or verbally abusive or violent.
Or they’re stealing. Again, how many of you have gone in and found out that someone’s stolen something from the exam room while they were waiting for the provider. It also says, don’t let the patients wait that long. But that’s a separate issue. But we’ve had individuals stealing things from the exam room. And that is also—
CLAUDINE: It’s a concern.
ANNE HUBEN-KEARNEY: Yes, exactly. Exactly, Claudine. Do you have anything to add, Claudine?
CLAUDINE: I think you covered everything. And some great points. And it’s so true as well. We just have to make sure that we’re consistent, and, of course, just to make sure that we’re documenting what we’re doing and our processes. So we’re keeping in line with what’s going on. It has to be across the board.
ANNE HUBEN-KEARNEY: I like the documentation. I didn’t mention that. And that’s really important. And if you could quote the patient, I’m refusing the medications because you’re trying to poison me or you’re just making money off of me-- that’s a pretty popular one. But documenting that and using quotes, I think. Yeah. Claudine, good excellent point. Thanks for picking up on that.
JOAN PORCARO: Yeah. So, Claudine, back to you. How can staff be trained basically to handle the communication and administrative aspects of patient dismissals? We want them to be professional and compassionate. What do you recommend?
CLAUDINE: That’s a great question, Joan. So a couple of things that can be done. One, staff can be trained through role playing, role playing difficult conversations, practicing empathy, and, of course, de-escalation. We talk about workplace violence, having those training as well for the staff. Also maybe giving simpler proof scripts for common scenarios, patient calling for appointments after termination, asking the why, demanding exceptions or becoming upset when told of practice policies.
So having those scripts. That’s basically simple. And a proof that they can speak, too, as well. Also learning the administrative steps like documentation and following the policy. That will also help them as well to be handling these situations. So, of course, if we combine these, it ensures patients dismissals are handled professionally, compassionately, and safely. So we need to make sure that the staff are trained to handle these situations. Training is important.
JOAN PORCARO: Absolutely. So, Anne, I want to throw a question your way. So what advice would you give to new physicians, brand new ones, about maintaining those therapeutic relationships and then knowing when and how to end them?
ANNE HUBEN-KEARNEY: I think this is, again, a summary of some of the things we’ve talked about. But I think the first thing is to make sure that you establish both the care and behavioral expectations and reinforce them, again, using plain language, everyday language, and then getting sign and language interpreters when needed.
I have seen more and more practices putting in their office, putting on their consent to treat, putting on their website that we have mutual respect, and these are the behaviors that are acceptable, and these are the behaviors that are not acceptable. Verbal insults, physical violence, whatever. That’s there. But also disparaging remarks. So they’re really clear. And I like that about what it that is acceptable or not.
I think we talked as well about listening to the patients and their caregivers, listening to them, what’s going on, not rolling their eyes, not demonstrating a body language that says, I don’t have time for you. I think one thing, again, is not to be impulsive when you want to end the relationship. You’re not getting along with someone. They’re not listening to you. They talk over you as the provider.
But to say, we’re having a problem here. Let’s talk about it. But then contacting your risk management professional, your med mal carrier. There’s a huge resource with your medical malpractice insurance, whether you’re self-insured or you have a commercial carrier, professional liability carrier. Please, use them.
Your legal department before you terminate the relationship-- very few terminations unless they’re absolutely physically violent, verbally abusive, stealing, assaulting someone, are emergencies. It’s usually a process, so seek assistance, as new physicians have mentors. You have risk management, either through your medical malpractice carrier, your legal support. Use the resources that are available to you.
And I think Claudine just said as well, to be consistent. You must be consistent. You’re not going to terminate the relationship because of any type of discrimination. And the last thing, I think, and I mentioned it earlier, is about using lay terms. Use lay terms in your communications. Use lay terms terms, your everyday terms in your written materials. And that means no matter with whom you are communicating. You can’t look at someone and realize that they have a health literacy issue. The person could be a PhD, but they may still have health literacy issues.
So consider everyone is not up to par with the health care terminology and use the lay terms. It’s just so much easier. And avoid the acronyms. Avoid the abbreviations. Avoid medical jargon. I’m married to a non-healthcare provider. And I’ll say something like NPO. What is NPO? People don’t know NPO. So I’ve learned to say-- but we take it for granted.
Your meds are BID. He’s like, what’s a BID? I’m like OK. So then write on it twice a day, once in the morning, once at night. So that you’re not taking them four hours apart. It should be 12 hours apart. So really look at those things when you are talking to your patients about their behavior, the expectations, the transparency, the communication. Use regular terminology.
JOAN PORCARO: So Claudine and Anne, we already touched upon the importance of de-escalation techniques, violence prevention programs, the use of telehealth when we’re attempting to work with maybe difficult patients. So I want to jump to, what roles does an effective complaint and grievance management program play in reducing the risk of termination? Anne, we’ll start with you.
ANNE HUBEN-KEARNEY: I think it’s critical. I think Claudine mentioned it in a prior podcast about data. These are an early warning system. These are really good to have. I think we look at complaints negatively. These are gold mines. They provide valuable insight. You address them in real time when there’s still time-- and I think you mentioned that earlier-- to repair the trust and to clarify any misunderstandings understandings. And you can modify your processes. We’re not perfect.
So they should be welcomed, not rolling their eyes or saying, oh, here comes Anne. She’s a constant complainer. But no, here is a very valuable perspective that we could use. Log them. Categorize them. Root them through a clear escalation pathway. And if they’re complaining about a rude staff member, that is very important because it affects the reputation, as I mentioned earlier.
Give feedback to the staff. You could have said, how are you saying this? What are you doing? You’re being perceived as rude. And it may be that they’re rushing through because they have to get to the next patient. You need to say-- you need to take a breath. You need to slow down. You need to talk to that patient. Look them in the eyes, get the right information.
And then, if necessary, change the policies. You need a formal escalation process, because there will be issues that arise and you need to make sure that they’re addressed appropriately. Joan, you mentioned patient portals. You could use patient portals to say, how was your visit? And literally, how was the communication? Were your expectations met?
You can focus onsite interactions. We don’t round on our patients when patients are waiting in the exam room. Pop in. How are you doing? How’s it going? Are you getting your needs met? Doctor will be here shortly. I had a friend of mine just this afternoon texted me to say that she was at her eye doctor’s office for three hours, in the exam room for an hour-- and she’s 89 years old-- before she got seen.
You just can’t put him in an exam room and ignore them. Same thing for the waiting room. There’s signage to say if you have not been seen in 15 minutes, let the receptionist know because that reduces the patient’s anger and aggravation. But you can find out what’s going on. And then if there is a procedure that’s done in the office, make sure you call back.
How are you doing? Do you understand the instructions? Or not even asking the question about you understand, because you want to check their health literacy. So you’re going to have them teach back. Tell me about what you’re going to do now that you’re home with this wound or whatever else. So address it. Use it. It’s valuable. And hopefully over time, you’ve modified and corrected your system so that you don’t have any more complaints. Claudine, how about making amends if there is-- I think you talked about that a little bit-- if there is a complaint.
CLAUDINE: So if there’s a complaint, of course, you want to make sure it’s addressed timely. Because sometimes, of course, patients may think that they’re being ignored. So let them know timely what exactly happened. Try to investigate. Do a thorough review with the patient. And, of course, if it’s against a staff member, you also want to talk with the staff member to get their feedback as well to see exactly what happened.
And, of course, provide feedback. You want to close the loop. You want to make sure that they just think that, OK, I made a complaint and nothing’s been done about it. And if it’s legit, of course, it’s no harm to say I’m sorry or to offer an apology. It’s about making sure that we’re being empathetic. Put ourselves in the patient’s position. If I was in that position, how would I feel?
And, of course, and validate their-- because at the end of the day, it’s their perceptions. So you want to validate what they’re feeling, of course. You mean just to make sure that you mean they’re being heard. And, of course, address any issues that they have mentioned in timely and promptly. That’s key.
JOAN PORCARO: Yeah. So we’re coming to a close in our conversation today. And I just want to ask each of you for just one key takeaway. Just if you had only one thing you could tell a practice, what would it be? Anne?
ANNE HUBEN-KEARNEY: I think mine would be that it should be, termination should be, the last resort, unless there’s criminal or violent behavior or threats. Claudine had talked about staff safety as well. It should be literally the last thing on your mind after you’ve done everything you could to address the concerns that you have.
JOAN PORCARO: Claudine, what’s your one takeaway?
CLAUDINE: I think overall, generally, it’s about listening. You want to clarify, and you also want to be empathetic. Use your tools. Keep care safe. And remember, you also want to when to hold them, when to fold them, and when to walk away.
JOAN PORCARO: That’s very true, very true. Yeah, very true. Well, as I said, we’re coming to a close to this episode. I want to first extend a hearty thank you to Anne. Thank you, Anne.
ANNE HUBEN-KEARNEY: This has been delightful. As I said, I really enjoyed this process, and I’ve enjoyed working with Claudine.
JOAN PORCARO: And, Claudine, many thanks to you. We really appreciate you joining us.
CLAUDINE: Thank you so much for having us. I appreciate it, and I appreciate working with you guys as well.
JOAN PORCARO: Alrighty. Well, that’s it for today’s episode of WTW Vital Signs. Thank you for spending part of your day with us. If you found this information helpful, please follow the show on YouTube, Apple, or Spotify and share it with any other of your fellow risk management professionals who might enjoy it, too. I’m Joan Porcaro. I look forward to being with you again next time on future WTW Vital Signs podcast.
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