RE: Culling the Clinic Flock --> RE: firing a patient

[Guest guest]

Thanks ,

Life’s short. And the more I read about what

patients really want; the more I think we are just so far off with what we

think they should want. More and more I am thinking that for those

who constantly feel the need to express their displeasure with the service

provided and everything about their medical care but don’t have the

common sense to find someone else they are less unhappy with, might just need

to get a nudge from me. And, like you said, it’s such a small

percentage which will hopefully stay that way.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Locke's in

Colorado

Sent: Friday, April 18, 2008 8:14 PM

To:

Subject: Culling the Clinic Flock --> RE:

firing a patient

Kathy,

I'm like you -- I

used to try to accept the challenging patients and work with them and do my

best - often to failure.

Possibly that is

my fault for not researching my feelings about why a patient and I weren't a

good fit...etc.

If a patient is

willing to work with me, I'm happy to give them my best efforts to reach their

health goals.

But if all I get

from them is difficulties, irritation, stress because they won't come in

regularly for medical problems that can't be treated over the phone, tenseness

when I see them on the schedule, etc -- then I recommend they seek healthcare

elsewhere -- and often end up firing them.

I've basically

been culling them from my clinic flock.

Maybe that is a

crude term, but it probably fits the process.

Culling

Removing animals

from the herd to assist in herd improvement and maintain herd size. Selection

criteria are normally based on factors such as disease, infertility, milk

yield, etc.

www.specialistcheesemakers.co.uk/best_practice/Glossary_of_terms.htm

Life is too short

to see a day full of patients that put my teeth on edge.

Now, if

>50% of the patients irritate me -- then maybe I really do need to

look in the mirror.

But I think most

of us know the patients we are talking about -- and we could all count them on

1 hand -- the 5 or so patients out of 500-1,000 patients that are just know

fun.

The patient is

never happy with your service and you are never happy seeing them.

Why shouldn't we

encourage them to seek healtcare elsewhere -- dismissing them if necessary?

As Warren Zevon

says -- Enjoy every sandwich.

I've only got so

much energy to take care of the sick healthy respectful patients -- why lose

energy on patients that don't respect you -- thereby doing your other patients

a disservice because you are exhausted by the handful of patients in the practice?

Firing the patient

that started this thread was the right thing to do.

It is the dramatic

stroke that needed to be taken in this circumstance to shake up this patient

and show him his actions have consequences -- IMHO.

Also, I think we

need to be aware of psychiatric issues in patients -- if we go out to save

every borderline personality (aka Emotion-Impulse Regulation Disorder), we will

fail.

We have to pick

our battles in life -- with compassion -- but ultimately with an eye toward our

own lives, families, and business.

Locke, MD

From:

[mailto: ] On Behalf Of Kathy

Saradarian

Sent: Friday, April 18, 2008 4:36 PM

To:

Subject: RE: firing a patient

Did I miss some e-mails? Because I

don’t know when this turned into accusations of “dissing”

each other. But since Jean’s post was a reply to mine, I

somehow think I started it?

My point was, it’s all well and

good for us to grow from every relationship and figure out why some people

annoy us and some don’t and become better people, yada, yada yada

but….that really does nothing for the patient.

What does dismissing this patient

do? It tells the patient “I will no longer be your enabler.

Bye Bye. I am jumping from this sinking ship.” Because that

is what Lonna was in fact doing, enabling him with Valium. It is not what

she wanted to do, probably, but that’s the fact. So I feel she did

a very healthy thing in dismissing him, even though she is eaten from guilt

about it and I doubt he is losing one wink of sleep with any soul searching

about why his doctor fired him.

I am glad you try to gut out every

patient relationship Jean. I did it for years. But, just as

dismissing the patient is done for us, the doctor; gutting it out is done for

our egos too. “If I dump him who else does he have.”

“I am the only one who can help him.” “He is so

difficult, no one else could handle him any better.” Whereas I

believe that unhealthy relationships benefit no one; and if that patient sets

my teeth on edge and ruins my day, every time I have to see them, then am I

really the best doctor for him? I can go to therapy and figure out why

the patient bothers me, but it won’t change that he does. And

the bottom line is, I don’t have to. There are probably other

doctors out there that wouldn’t even notice him.

I no longer feel the need to try to

please everyone and get along with everyone (no kidding right) and have come to

realize that if the patient is “too dumb” to find a new doctor when

they are unhappy then I might just have to give them that push.

This patient is really no different than

the drug addict using us as a legal source of acquiring drugs. That is

what he was doing. Why is it OK to fire the drug addict and not

him? He is a drug addict and he is acquiring drugs under false

pretenses. What is the difference, really?

I apologize if “harsh” was a

bad word, it certainly seems to have created a sensitive spot. Should we

look into that? I thought “harsh” was a

…not so bad word to use. And I am not “dissing” or

Lonna or anyone else by intention

From:

[mailto: ]

On Behalf Of Lonna Larsh

Sent: Friday, April 18, 2008 12:42 PM

To:

Subject: Re: firing a patient

I did not feel dissed, although I did feel a little challenged and it was

OK coming from you especially. The subject is tough and that's why I

wrote in. I didn't really expect everyone to tell me how great a job I

did.

I do appreciate your further words here. Part of why I feel

conflicted about this particular guy is that I feel that he doesn't have many

places to go. He doesn't qualify for regular Medi-Cal (Medicaid).

He might qualify for emergency insurance (Medicruz here in Santa Cruz)

because he has a life threatening condition if he applies and can convince

the folks there that his history of alcohol withdrawal is significant enough

to require medical care. Because he doesn't have insurance, I am

probably the most affordable medical care he can find in town. I didn't

abandon him though. I gave him info I copied regarding applying for

Medicruz as well as names of 3 other docs in town one of which at

least who I know is liberal in his prescribing habits.

(Though I didn't say that in my letter!)

I've seen this guy 7 times for about and hour each time. I'm sure he was

drunk each of those times, clearly trashed twice, late twice (not the same

times). He called me on Thanksgiving day despondent and crying...

I don't really have any regrets in letting him go.

In my inbox is this from medscape:

Video conferences from NIAA: helping patients who drink too much. I

haven't looked at it yet, but I will. For next time.

http://www.medscape.com/viewprogram/8979?src=mp & uac=113201DZ

Best,

Lonna

There were some posts about this recently but I have something new I

wanted to add today. I fired a patient today and I am feeling a

bit mixed about it. Since this is my community of like

physicians, I guess I would like to know how others would

have handled this. I have been seeing this 40ish alcoholic for

9 months or so, almost since I started up. He came to see me after

he was hospitalized with DTs and w/d seizures. He quits every month

or 6 weeks and calls me or comes in for Valium so he won't go through it

again. I have given him increasingly fewer amounts, the last 2

visits I told him I would not be giving him Valium anymore, but did

it because we wrote out a contract for him going to

AA and contacting me withing a week following the

visit. Both times he broke the contract. Last time, about a month

ago he was actually going to AA, but it turned out it was because it was

court ordered he go 10 times for a traffic violation. He was supposed to

call me a week after his last visit and he never did. Today he

called again. He's been out of work for the last 2 weeks and has

been drinking again. I told him I won't keep prescribing him

Valium. He refused to come in to discuss his options.

Admittedly, he doesn't have many. If he came in, I probably would

write him another presciption along with his termination letter, but

instead I just mailed his termination letter by registered mail.

Any comments?

Thanks,

Lonna

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[Guest guest]

Thank you everyone for all your comments. I am pretty much past the guilt now. I think I did the right thing for this guy. I am hoping my firing him will be a wake up call of some sort. Maybe I am just rationalizing it, but it was the right thing for me.Lonna

There were some posts about this recently but I have something new I

wanted to add today. I fired a patient today and I am feeling a

bit mixed about it. Since this is my community of like

physicians, I guess I would like to know how others would

have handled this. I have been seeing this 40ish alcoholic for

9 months or so, almost since I started up. He came to see me after

he was hospitalized with DTs and w/d seizures. He quits every month

or 6 weeks and calls me or comes in for Valium so he won't go through it

again. I have given him increasingly fewer amounts, the last 2

visits I told him I would not be giving him Valium anymore, but did

it because we wrote out a contract for him going to

AA and contacting me withing a week following the

visit. Both times he broke the contract. Last time, about a month

ago he was actually going to AA, but it turned out it was because it was

court ordered he go 10 times for a traffic violation. He was supposed to

call me a week after his last visit and he never did. Today he

called again. He's been out of work for the last 2 weeks and has

been drinking again. I told him I won't keep prescribing him

Valium. He refused to come in to discuss his options.

Admittedly, he doesn't have many. If he came in, I probably would

write him another presciption along with his termination letter, but

instead I just mailed his termination letter by registered mail. Any comments? Thanks, Lonna

Be a better friend, newshound, and know-it-all with Yahoo! Mobile. Try it now.

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If you are a patient please allow up to 4-8 hours for a reply by email/

please note the new email address/

e mail may not be entirely secure/

MD

ph fax

Be a better friend, newshound, and know-it-all

with Yahoo! Mobile. Try it now.

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If you are a patient please allow up to 4-8 hours for a reply by email/

please note the new email address/

e mail may not be entirely secure/

MD

ph fax

Be

a better friend, newshound, and know-it-all with Yahoo! Mobile. Try

it now.

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