Difficult Patients and Doctor Refusal

Doctor writing on a prescription pad
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As frustrated as patients often are by doctors who have lousy bedside manners, are short with us, arrogant, or sometimes just won't spend enough time with us, there are plenty of doctors who complain about patient behavior, too. That may lead doctors to reject some patients, which in turn denies them the medical care they need.

Problem Patients

Problem patient behavior ranges from being disruptive in waiting or exam rooms, to not paying the doctor's bills, to filing lawsuits.

Patient behavior is probably aligned on a bell curve like so many aspects of life: some patients are so passive they are barely remembered at all, most patients are collaborative and respectful, and some patients, at the extreme, are aggressive, disruptive, and extraordinarily difficult. Nobody wants to deal with someone else who behaves in those ways. It's no surprise doctors don't either.

If a patient is mildly unpleasant, a doctor may spend time with her, but accomplish the meeting in as short a time as possible, or refer her to someone else as quickly as possible.

Some patients complain they cannot find any doctor to care for them at all, even reporting that they had appointments canceled after waiting to see a doctor. Other patients have complained about being "fired" by a doctor, being told the doctor no longer wishes to work with them. A report in the New York Times corroborates this phenomenon.

Rumors of secret codes posted to a patient's chart by providers, signifying that the patient is difficult, turn out to be true. There may be a notation in the patient's record that is as simple as PITA (pain in the "backside") or "GOMER" ("get out of my emergency room").

One former healthcare worker reported that her office used a real ICD code in patients' records: 569.42, indicating anal or rectal pain. Others reported additional codes that would indicate the patient was a problem.

Still, other patients believe doctors or other providers are sabotaging their records so no other doctor will even see them. They report being blackballed or blacklisted, believing they cannot get an appointment with any doctor, anywhere, and believe the only way doctors who are out-of-state or even out of their country could know to reject them would be if such a blacklist existed.

How Can Doctors Refuse to Treat a Patient?

Many people believe that a doctor could not possibly get away with not treating a patient. They cite patients rights, or a doctor's oath of "first, do no harm."

In fact, neither of those is a reason a doctor must accept a patient into her practice.

In the United States, the only time a patient has a right to care is when that patient needs true emergency care and accesses the emergency room of a hospital that accepts federal money through Medicare (which is 98 percent of all U.S. hospitals). This is codified in the Emergency Medical Treatment and Labor Act (EMTLA).

If a patient is deemed not to require emergency care, he may be refused care and told to see his primary care physician or to check in with an urgent care clinic.

Further, there is such a shortage of physicians, in particular, primary care physicians, in the United States that running a medical practice is mostly a seller's market. With too few medical providers and too many patients that need their services, doctors can afford to be choosy about the patients they will accept.

From there, it is simply the means of refusal. Every day, patients call doctors' offices to make appointments, only to learn that a doctor is no longer accepting new patients or has no time in his or her schedule for many months. Whether or not that appointment-maker has accessed a blacklist, or is checking codes on a patient's chart, really makes no difference.

This situation will get worse before it ever gets better. As baby boomers continue to age, and as health care reform in the United States makes having insurance more available and/or required, we will see more and more rationing and more difficult access to care.

Providers will continue to have the choice: given a patient who is pleasant and collaborative, vs a patient who is difficult and demanding, which would you choose?

Smart patients will learn why doctors may choose to deny them care and will take the steps necessary to repair the relationship or move on.

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