Re: Great article on medical abandonment issues

[Guest guest]

So,

actual message is we have no right to terminate patients for any

reason and have to deal with what ever they throw at us. I wonder if

this term, abandonment, exists for lawyers?

> 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, you 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 the

> patient, 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 (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 completely

> absent.

>

> 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 if 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]

This article is the kind that gives me panic attacks!!! It makes my heart race and my blood boil. So I am supposed to guarantee that anyone who covers for me has my same level of expertise? are you crazy???? Does this mean that older doctor's cannot have their younger partners cover for them? Should I be having my patients sign a consent regarding this??? I hate that doctors seem to be responsible for everything and everybody. It takes all of the joy and compassion out of caring for people. 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 dutyLast 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 warrantedThis 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 supportPhysicians 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]

in my book...

if a patient does not make any effort to pay i dont have to see them.

they can go elsewhere. i do put a slip in there that if they dont pay the bill i

will not provide them anymore.

not necessarily a threat. if one goes to walmart and takes a pack of cigarettes

and says see ya later, you go to jail for shoplifting.

so what gives?

grace

> > 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, you 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 the

> > patient, 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 (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 completely

> > absent.

> >

> > 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 if 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]

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]

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.