Would this case be considered abandonment? RE: Great article on medical abandonment issues

[Guest guest]

75 yo WM with uncontroled hypertension, hyperlipidemia, DM (A1C 9.8), weight 290 lb on unhealthy diet, without any exercise and often missed pills or insulin shots, last seen in November 2011 for TIA symptoms. His secondary insurance copay is $25 per visit after the patient pays for the annual MC deductible. The patient did not return for follow up as directed because "had to do Christmas, no money to go to the doctor". His pharmacy has been sending refill requests on all of his medications since 11/2011, each time I approved for one month and asked the patient to come for office visit for the past six months, he said he did not have the money for the MC deductible and did not want to have a balance with us. No matter what we say, he refuses to schedule OV, but insists to get refills.He lives in his house and paints houses to make income, so he is not poor enough to qualify for indigent clinic. I don't think I should take the medical liability for keeping refilling without seeing him, nor making him out of meds. If I stop refilling for him, could this be considered abandonment?Thanks a lot.HelenTo: From: bethdo97@...Date: Tue, 8 May 2012 15:28:49 -0400Subject: RE: Great article on medical abandonment issues

Came thru my e-mail from Medscape Dr. Beth Sullivan, DO From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Thursday, May 03, 2012 9:49 AMTo: Subject: Re: Great article on medical abandonment issues Beth,Where did you find this article??DannielleSubject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM Thought some of you might find this article informational. Hope it is informative for those on our list.Dr. BethMedico-legal: Unintentional and accidental abandonment Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.Let's look at those situations now. I. Failure to carry through on an accrued duty Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed. However, the critical word there is “ongoing”. Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty. The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee. Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician. Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician. You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty. In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment. II. Constructive abandonment (i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry. Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient. For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician. However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed. (ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care. This can happen in several ways: a. Failure to initiate treatment that was warranted This is more of a technical aspect of pleading in a medical malpractice case. The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all. Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis. b. Refusal to assist the patient in accessing appropriate support Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients. Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help” situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor” should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection. d. Another situation in which constructive abandonment can come into play is with regard to coverage. Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim. This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim. III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

Not a lawyer, but yes it can be considered abandonment….. You need to give a plan of action where you tell him by certified mail and regular mail of your intention… Then you have responsibility for at least 30 days until he is able to find another provider….even then you still may have liability if he can’t find another provider…. At least that is what I have read…..Good luck! From: [mailto: ] On Behalf Of Helen YangSent: Tuesday, May 15, 2012 11:05 AMTo: IMP GroupSubject: Would this case be considered abandonment? RE: Great article on medical abandonment issues 75 yo WM with uncontroled hypertension, hyperlipidemia, DM (A1C 9.8), weight 290 lb on unhealthy diet, without any exercise and often missed pills or insulin shots, last seen in November 2011 for TIA symptoms. His secondary insurance copay is $25 per visit after the patient pays for the annual MC deductible. The patient did not return for follow up as directed because " had to do Christmas, no money to go to the doctor " . His pharmacy has been sending refill requests on all of his medications since 11/2011, each time I approved for one month and asked the patient to come for office visit for the past six months, he said he did not have the money for the MC deductible and did not want to have a balance with us. No matter what we say, he refuses to schedule OV, but insists to get refills.He lives in his house and paints houses to make income, so he is not poor enough to qualify for indigent clinic. I don't think I should take the medical liability for keeping refilling without seeing him, nor making him out of meds. If I stop refilling for him, could this be considered abandonment?Thanks a lot.HelenTo: From: bethdo97@...Date: Tue, 8 May 2012 15:28:49 -0400Subject: RE: Great article on medical abandonment issues Came thru my e-mail from Medscape Dr. Beth Sullivan, DO From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Thursday, May 03, 2012 9:49 AMTo: Subject: Re: Great article on medical abandonment issues Beth,Where did you find this article??DannielleSubject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM Thought some of you might find this article informational. Hope it is informative for those on our list.Dr. BethMedico-legal: Unintentional and accidental abandonment Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.Let's look at those situations now. I. Failure to carry through on an accrued duty Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed. However, the critical word there is “ongoing”. Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty. The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee. Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician. Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician. You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty. In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment. II. Constructive abandonment (i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry. Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient. For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician. However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed. (ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care. This can happen in several ways: a. Failure to initiate treatment that was warranted This is more of a technical aspect of pleading in a medical malpractice case. The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all. Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis. b. Refusal to assist the patient in accessing appropriate support Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients. Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help” situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor” should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection. d. Another situation in which constructive abandonment can come into play is with regard to coverage. Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim. This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim. III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

Helen , send him a letter to discharge from ur practice.U gave him a month for any emergencies andEnd of the story.Adolfo E. Teran, MD

75 yo WM with uncontroled hypertension, hyperlipidemia, DM (A1C 9.8), weight 290 lb on unhealthy diet, without any exercise and often missed pills or insulin shots, last seen in November 2011 for TIA symptoms. His secondary insurance copay is $25 per visit after the patient pays for the annual MC deductible. The patient did not return for follow up as directed because "had to do Christmas, no money to go to the doctor". His pharmacy has been sending refill requests on all of his medications since 11/2011, each time I approved for one month and asked the patient to come for office visit for the past six months, he said he did not have the money for the MC deductible and did not want to have a balance with us. No matter what we say, he refuses to schedule OV, but insists to get refills.He lives in his house and paints houses to make income, so he is not poor enough to qualify for indigent clinic. I don't think I should take the medical liability for keeping refilling without seeing him, nor making him out of meds. If I stop refilling for him, could this be considered abandonment?Thanks a lot.HelenTo: From: bethdo97@...Date: Tue, 8 May 2012 15:28:49 -0400Subject: RE: Great article on medical abandonment issues

Came thru my e-mail from Medscape Dr. Beth Sullivan, DO From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Thursday, May 03, 2012 9:49 AMTo: Subject: Re: Great article on medical abandonment issues Beth,Where did you find this article??DannielleSubject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM Thought some of you might find this article informational. Hope it is informative for those on our list.Dr. BethMedico-legal: Unintentional and accidental abandonment Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.Let's look at those situations now. I. Failure to carry through on an accrued duty Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed. However, the critical word there is “ongoingâ€. Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty. The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee. Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician. Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician. You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty. In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment. II. Constructive abandonment (i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry. Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient. For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician. However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed. (ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care. This can happen in several ways: a. Failure to initiate treatment that was warranted This is more of a technical aspect of pleading in a medical malpractice case. The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all. Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis. b. Refusal to assist the patient in accessing appropriate support Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients. Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection. d. Another situation in which constructive abandonment can come into play is with regard to coverage. Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim. This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim. III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

=

[Guest guest]

Having just been to a professional boundaries class about another issue, I see red flags all over this. You should have held your ground and refused to see him, after the first 30d fill. If you haven't seen him in 6 months and he has been non-compliant with your requests to return he is fine to be fired for non-compliance, it isn't abandonment, and in fact now you are enabling his bad behavior. No more changes, no more RX, fire him. He isn't following your advise anyway. This is a medical liability as well as a professional one. Cut ties. We let people walk on us because we are trying to help them. But it isn't helping him to let him continue his poor control and non-compliance!. He could just as easily claim malpractice as abandonment and he'd have more grounds there, because you are refilling without any knowledge of what has happened with his labs, exam or compliance since November.

CCote

To: "IMP Group" <practiceimprovement1 >Sent: Tuesday, May 15, 2012 11:05:02 AMSubject: Would this case be considered abandonment? RE: Great article on medical abandonment issues

75 yo WM with uncontroled hypertension, hyperlipidemia, DM (A1C 9.8), weight 290 lb on unhealthy diet, without any exercise and often missed pills or insulin shots, last seen in November 2011 for TIA symptoms. His secondary insurance copay is $25 per visit after the patient pays for the annual MC deductible. The patient did not return for follow up as directed because "had to do Christmas, no money to go to the doctor". His pharmacy has been sending refill requests on all of his medications since 11/2011, each time I approved for one month and asked the patient to come for office visit for the past six months, he said he did not have the money for the MC deductible and did not want to have a balance with us. No matter what we say, he refuses to schedule OV, but insists to get refills.He lives in his house and paints houses to make income, so he is not poor enough to qualify for indigent clinic. I don't think I should take the medical liability for keeping refilling without seeing him, nor making him out of meds. If I stop refilling for him, could this be considered abandonment?Thanks a lot.Helen

To: From: bethdo97@...Date: Tue, 8 May 2012 15:28:49 -0400Subject: RE: Great article on medical abandonment issues

Came thru my e-mail from Medscape

Dr. Beth Sullivan, DO

From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Thursday, May 03, 2012 9:49 AMTo: Subject: Re: Great article on medical abandonment issues

Beth,

Where did you find this article??

Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM

Thought some of you might find this article informational. Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I. Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoingâ€.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly.

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

Thank you all for your suggestions. I feel bad to discharge him, but will have to do so.Thanks again.HelenTo: From: magnetdoctor@...Date: Tue, 15 May 2012 22:22:22 +0000Subject: Re: Would this case be considered abandonment? RE: Great article on medical abandonment issues

Having just been to a professional boundaries class about another issue, I see red flags all over this. You should have held your ground and refused to see him, after the first 30d fill. If you haven't seen him in 6 months and he has been non-compliant with your requests to return he is fine to be fired for non-compliance, it isn't abandonment, and in fact now you are enabling his bad behavior. No more changes, no more RX, fire him. He isn't following your advise anyway. This is a medical liability as well as a professional one. Cut ties. We let people walk on us because we are trying to help them. But it isn't helping him to let him continue his poor control and non-compliance!. He could just as easily claim malpractice as abandonment and he'd have more grounds there, because you are refilling without any knowledge of what has happened with his labs, exam or compliance since November.

CCote

To: "IMP Group" <practiceimprovement1 >Sent: Tuesday, May 15, 2012 11:05:02 AMSubject: Would this case be considered abandonment? RE: Great article on medical abandonment issues

75 yo WM with uncontroled hypertension, hyperlipidemia, DM (A1C 9.8), weight 290 lb on unhealthy diet, without any exercise and often missed pills or insulin shots, last seen in November 2011 for TIA symptoms. His secondary insurance copay is $25 per visit after the patient pays for the annual MC deductible. The patient did not return for follow up as directed because "had to do Christmas, no money to go to the doctor". His pharmacy has been sending refill requests on all of his medications since 11/2011, each time I approved for one month and asked the patient to come for office visit for the past six months, he said he did not have the money for the MC deductible and did not want to have a balance with us. No matter what we say, he refuses to schedule OV, but insists to get refills.He lives in his house and paints houses to make income, so he is not poor enough to qualify for indigent clinic. I don't think I should take the medical liability for keeping refilling without seeing him, nor making him out of meds. If I stop refilling for him, could this be considered abandonment?Thanks a lot.Helen

To: From: bethdo97@...Date: Tue, 8 May 2012 15:28:49 -0400Subject: RE: Great article on medical abandonment issues

Came thru my e-mail from Medscape

Dr. Beth Sullivan, DO

From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Thursday, May 03, 2012 9:49 AMTo: Subject: Re: Great article on medical abandonment issues

Beth,

Where did you find this article??

Dannielle

Subject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM

Thought some of you might find this article informational. Hope it is informative for those on our list.

Dr. Beth

Medico-legal: Unintentional and accidental abandonment

Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.

However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.

Let's look at those situations now.

I. Failure to carry through on an accrued duty

Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed.

However, the critical word there is “ongoing”.

Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty.

The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee.

Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician.

Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician.

You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty.

In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment.

II. Constructive abandonment

(i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry.

Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient.

For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician.

However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed.

(ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care.

This can happen in several ways:

a. Failure to initiate treatment that was warranted

This is more of a technical aspect of pleading in a medical malpractice case.

The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all.

Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis.

b. Refusal to assist the patient in accessing appropriate support

Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients.

Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help” situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor” should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection.

d. Another situation in which constructive abandonment can come into play is with regard to coverage.

Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim.

This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly.

Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim.

III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

Excellent points! Dammed if you do, Dammed if you don’t…..the lawyers could argue in both directions….. The problem in this case is that the refills have already been started, setting the precedence….. From: [mailto: ] On Behalf Of magnetdoctor@...Sent: Tuesday, May 15, 2012 3:22 PMTo: Subject: Re: Would this case be considered abandonment? RE: Great article on medical abandonment issues Having just been to a professional boundaries class about another issue, I see red flags all over this. You should have held your ground and refused to see him, after the first 30d fill. If you haven't seen him in 6 months and he has been non-compliant with your requests to return he is fine to be fired for non-compliance, it isn't abandonment, and in fact now you are enabling his bad behavior. No more changes, no more RX, fire him. He isn't following your advise anyway. This is a medical liability as well as a professional one. Cut ties. We let people walk on us because we are trying to help them. But it isn't helping him to let him continue his poor control and non-compliance!. He could just as easily claim malpractice as abandonment and he'd have more grounds there, because you are refilling without any knowledge of what has happened with his labs, exam or compliance since November. CCoteTo: " IMP Group " <practiceimprovement1 >Sent: Tuesday, May 15, 2012 11:05:02 AMSubject: Would this case be considered abandonment? RE: Great article on medical abandonment issues 75 yo WM with uncontroled hypertension, hyperlipidemia, DM (A1C 9.8), weight 290 lb on unhealthy diet, without any exercise and often missed pills or insulin shots, last seen in November 2011 for TIA symptoms. His secondary insurance copay is $25 per visit after the patient pays for the annual MC deductible. The patient did not return for follow up as directed because " had to do Christmas, no money to go to the doctor " . His pharmacy has been sending refill requests on all of his medications since 11/2011, each time I approved for one month and asked the patient to come for office visit for the past six months, he said he did not have the money for the MC deductible and did not want to have a balance with us. No matter what we say, he refuses to schedule OV, but insists to get refills.He lives in his house and paints houses to make income, so he is not poor enough to qualify for indigent clinic. I don't think I should take the medical liability for keeping refilling without seeing him, nor making him out of meds. If I stop refilling for him, could this be considered abandonment?Thanks a lot.HelenTo: From: bethdo97@...Date: Tue, 8 May 2012 15:28:49 -0400Subject: RE: Great article on medical abandonment issues Came thru my e-mail from Medscape Dr. Beth Sullivan, DO From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Thursday, May 03, 2012 9:49 AMTo: Subject: Re: Great article on medical abandonment issues Beth,Where did you find this article??DannielleSubject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM Thought some of you might find this article informational. Hope it is informative for those on our list.Dr. BethMedico-legal: Unintentional and accidental abandonment Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.Let's look at those situations now. I. Failure to carry through on an accrued duty Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed. However, the critical word there is “ongoingâ€. Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty. The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee. Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician. Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician. You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty. In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment. II. Constructive abandonment (i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry. Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient. For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician. However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed. (ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care. This can happen in several ways: a. Failure to initiate treatment that was warranted This is more of a technical aspect of pleading in a medical malpractice case. The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all. Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis. b. Refusal to assist the patient in accessing appropriate support Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients. Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help†situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor†should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection. d. Another situation in which constructive abandonment can come into play is with regard to coverage. Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim. This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim. III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.

[Guest guest]

Thank you all for your concerns and suggestions.This patient is now getting his care at the community clinic at no or very minimum cost. Hope he will be more compliant now.Thanks again.HelenTo: From: paulhkimmd@...Date: Wed, 16 May 2012 14:43:33 -0700Subject: RE: Would this case be considered abandonment? RE: Great article on medical abandonment issues

Excellent points! Dammed if you do, Dammed if you don’t…..the lawyers could argue in both directions….. The problem in this case is that the refills have already been started, setting the precedence….. From: [mailto: ] On Behalf Of magnetdoctor@...Sent: Tuesday, May 15, 2012 3:22 PMTo: Subject: Re: Would this case be considered abandonment? RE: Great article on medical abandonment issues Having just been to a professional boundaries class about another issue, I see red flags all over this. You should have held your ground and refused to see him, after the first 30d fill. If you haven't seen him in 6 months and he has been non-compliant with your requests to return he is fine to be fired for non-compliance, it isn't abandonment, and in fact now you are enabling his bad behavior. No more changes, no more RX, fire him. He isn't following your advise anyway. This is a medical liability as well as a professional one. Cut ties. We let people walk on us because we are trying to help them. But it isn't helping him to let him continue his poor control and non-compliance!. He could just as easily claim malpractice as abandonment and he'd have more grounds there, because you are refilling without any knowledge of what has happened with his labs, exam or compliance since November. CCoteTo: "IMP Group" <practiceimprovement1 >Sent: Tuesday, May 15, 2012 11:05:02 AMSubject: Would this case be considered abandonment? RE: Great article on medical abandonment issues 75 yo WM with uncontroled hypertension, hyperlipidemia, DM (A1C 9.8), weight 290 lb on unhealthy diet, without any exercise and often missed pills or insulin shots, last seen in November 2011 for TIA symptoms. His secondary insurance copay is $25 per visit after the patient pays for the annual MC deductible. The patient did not return for follow up as directed because "had to do Christmas, no money to go to the doctor". His pharmacy has been sending refill requests on all of his medications since 11/2011, each time I approved for one month and asked the patient to come for office visit for the past six months, he said he did not have the money for the MC deductible and did not want to have a balance with us. No matter what we say, he refuses to schedule OV, but insists to get refills.He lives in his house and paints houses to make income, so he is not poor enough to qualify for indigent clinic. I don't think I should take the medical liability for keeping refilling without seeing him, nor making him out of meds. If I stop refilling for him, could this be considered abandonment?Thanks a lot.HelenTo: From: bethdo97@...Date: Tue, 8 May 2012 15:28:49 -0400Subject: RE: Great article on medical abandonment issues Came thru my e-mail from Medscape Dr. Beth Sullivan, DO From: [mailto: ] On Behalf Of Dannielle HarwoodSent: Thursday, May 03, 2012 9:49 AMTo: Subject: Re: Great article on medical abandonment issues Beth,Where did you find this article??DannielleSubject: Great article on medical abandonment issuesTo: ericacodes , Date: Wednesday, May 2, 2012, 3:41 PM Thought some of you might find this article informational. Hope it is informative for those on our list.Dr. BethMedico-legal: Unintentional and accidental abandonment Last week we looked at how to avoid a claim of abandonment of a patient when you are terminating that patient from your practice.However, it is still possible to be the subject of an actionable abandonment claim by patients you specifically had no ongoing physician-patient relationship with and patients you discharged in full technical compliance with all formal requirements and even by patients you consider to be fully active in your practice.Let's look at those situations now. I. Failure to carry through on an accrued duty Last week, the necessity to engage in limited-scope work like physicals and screenings only under a disclaimer that no ongoing physician-patient relationship is thereby established was discussed. However, the critical word there is “ongoing”. Even within the scope of the limited care that you are providing, you still have the duties of a physician relative to what that examination reveals, even if it exceeds the intended purpose of the examination and is not part of your specialty. The law assumes that the examinee would expect to be told of any medically important issues the physician finds and that this imposes a duty of reasonable care on the physician to reveal any such to the examinee. Therefore, for example, if you notice a suspicious mole on the back of a patient you are performing a disability physical on, you are obligated to not just document it in the record with a recommendation for follow-up but to inform the patient that it is something they need to have attended to by their own physician. Similarly, if you are doing an initial evaluation to decide if you will even accept the patient into your practice, as, for example, many plastic surgeons do, and you identify significant hypertension that was previously unknown, yo! u are obligated to both inform the patient and to offer to send the results to their primary care physician. You do not, however, have to order a biopsy or prescribe an anti-hypertensive or even make sure that the patient followed-up as you suggested. That would all be care associated with an ongoing relationship with the patient and it exceeds your duty. In other words, your duty was limited to dealing appropriately with what might accrue during the examination that you performed and that limited duty was fulfilled in full when you alerted the patient and activated an appropriate follow-up system. More is not required, but less is abandonment. II. Constructive abandonment (i) This can occur when the termination process looks perfect on paper but, in the real world, the patient is actually left high and dry. Whether the patient can get another physician, either within the time frame you specified or at all, must be realistic or you will be deemed to have constrictively abandoned the patient. For example, if you have specialized skills not otherwise available in your area, or you practice ! in an isolated rural town where traveling to another physician is impossible for your patient, or even if you are the only practitioner in your area who accepts Medicaid or Medicare and your patient is otherwise completely unable to pay for treatment, then your responsibilities as the discharging physician are higher than usual in terms of making sure that your patient can actually get alternative treatment, beginning with allotting more than the usual time for the patient to get a new physician. However, if no matter how ample the transition period you offer is there simply are no practical alternatives to you, you may not be able to terminate the patient without facing an abandonment claim. In that case, you should contact your state medical board for instructions on how to proceed. (ii) Constructive abandonment can also occur when the patient is still part of your practice but is actually not getting needed care. This can happen in several ways: a. Failure to initiate treatment that was warranted This is more of a technical aspect of pleading in a medical malpractice case. The premise is that the patient is internally abandoned within the active doctor-patient relationship because the ! care that was needed never began, leaving them as though they actually had no access to the treatment at all. Abandonment is alleged separately from medical negligence, but from your point of view in terms of defending the two issues are inextricable on a practical basis. b. Refusal to assist the patient in accessing appropriate support Physicians who refuse to fill out forms for such matters as legitimate disability claims or to get the patient an appropriate medical device or to keep a patient’s medically-required utilities on, or who will do so only for a significant fee that the patient cannot pay, can be held to have abandoned their patients. Of course, a physician is not expected to be a kowtowing hand-puppet to an overly demanding patient or to an outright scammer to avoid being charged with abandonment. Constructive abandonment would only apply when the treatment or the assistance really were warranted but were unilaterally denied by the physician without good cause.c. Refusal to see the patient.This most commonly occurs when the patient has a very large outstanding bill that they are refusing to address and the doctor tells them that they will not be scheduled for further appointments until that is dealt with. This acts as constructive abandonment because the patient thereby loses substantive access to the doctor while the bill remains unpaid.Such a situation should instead be dealt with by the! formal discharge of the patient from the practice, followed by all appropriate collection procedures. The potential for falling into constructive abandonment in such “self help” situations is an important reminder of two points:- There is no such thing as de facto termination by conduct. Even if the patient actually sues the doctor, that does not, in and of itself, end the physician-patient relationship. Therefore, any approach to a troublesome patient that begins with the idea that “Well, since the patient did (fill in thing that drives you bonkers) it means that I am no longer bound by my duties as a doctor” should be immediately avoided.- The law views the physician-patient relationship as one in which thepatient, as the one needing expert services for their health, is in the dependent role. It is therefore protective of the patient. This means that any doctor who finds themselves in opposition to a troublesome patient should make sure to use only clearly sanctioned methods, such as formal discharge, that actually afford the doctor considerable protection. d. Another situation in which constructive abandonment can come into play is with regard to coverage. Because you are responsible for providing an adequate alternative to your patients when you are unavailable for an extended period, if you do not do so, thereby leaving the patient functionally uncovered, it can give rise to an abandonment claim. This could occur if you use a covering doctor who is not reasonably equivalent to you & nb! sp;(e.g.; not from the same specialty or a closely allied one, such as internal medicine and cardiology covering for each other, or is barely out of training when you are very experienced) and so cannot provide a comparable level of expertise. It can also occur if you continue to use an answering service even after it habitually proves unreliable at getting messages from the patient to the covering doctor accurately and promptly. Since in both of those situations the patient really has no meaningful access to appropriate care through the coverage system their doctor has put in place, there is a predicate for an abandonment claim. III. Inadvertent abandonment(i) Coverage can be an issue in this regard as well when it is completelyabsent. This is not the situation where the doctor deliberately puts no coverage in place and simply leaves a voice message telling patients to call 911 or to go to ER. That is overtly inadequate.Instead, this occurs when there is a proper call schedule in place but the covering doctor becomes unavailable and no replacement is provided. In that situation, to the extent that the doctor needing coverage could have reasonably - that would be something like taking the call yourself instead of going to a planned party, not coming back from your vacation in China - prevented the problem, they can be deemed to have abandoned their patients. (ii) Abandonment can also occur at your office level if your staff refuses to let a patient with a real problem talk to you or schedules a necessary appointment too far in the future or i! f your staff merely files away the chart of a patient who actually needs to do some important follow-up. You need to have set office policies in place - preferably in writing, since you may have to prove them - to avert these problems.In summary: The laws governing medical abandonment are predicated on the more dependent status of the patient in the relationship with the physician. Therefore, when terminating a patient or when dealing with a patient actively, it is essential to fulfill your duty to make sure that your patient will not be left without appropriate care.