Ending the Provider Patient relationship is never easy, nor should it be. From the patient's perspective, without regard to the reason for separation, it is very much like a bad break up; you're angry, likely feel misunderstood, and your old partner still has a box full of your personal items (think PHI). The provider may feel like they could have done more to salvage the relationship. Neither party walks away feeling whole, but terminating that relationship may have been a necessity. Safeguarding our medical practices from lawsuits, aggressive behavior, and damage to our reputation is of paramount concern. We work tirelessly to provide outstanding care, and the vast majority of our patients work with us to achieve their optimal health goals. This article seeks to address those instances where despite our best efforts, we simply cannot move forward for the sake of all involved. 

Mark Twain, American writer, humorist, and lecturer, remarkably said, "Never allow someone to be your priority while allowing yourself to be their option." Sage words of wisdom from a man who clearly grasped the common inequality of relationships. In the course of developing a trusting provider-patient relationship, both parties are required to be open, honest, and willing to work together for the common good. Providers want healthy patients who trust them to help when there is a health concern, especially a serious life-threatening issue. However, they also expect compliance. Whether that compliance is in the form of following up with other providers as requested or adhering to the practice's Code of Conduct, providers expect patients to be active participants in their healthcare. Unfortunately, some patients neglect to keep scheduled appointments, fail to complete testing, procedures, or lab work, and blame the office staff when they reach less than optimal health goals. These are the patients who call the office and demand that the provider drop everything and tend to their health concerns, although they have failed to do their part. In this instance, the relationship cannot continue, mostly for liability reasons, but also for a much simpler reason: trust. Without trust or the assured reliance on the character, ability, strength, or truth of someone or something, there is no basis for a relationship. 

For their part, patients expect providers to deliver sound medical advice, and quick and painless procedures, all for the lowest price possible. Patients expect to be treated with respect and dignity, and medical practices should absolutely live up to that expectation. Patients expect grace when they miss an appointment or are late due to no fault of their own. And on occasion when they are not feeling well, they may be less than friendly, and we also need to be okay with that. Patients terminate their relationships with providers by never showing up again. There's no letter, no phone call, no 30-day notice to quit; just no more revenue generated from that patient. It's a brutal breakup, but to be perfectly honest, sometimes, we deserve it. 

With both sides of the relationship demanding so much of each other, it's a wonder we have good provider-patient relationships at all!

Sometimes, there are incidences where providers must dismiss a patient from the practice. For the most part, many practices give patients multiple chances to self-correct before making the decision to dismiss a patient. When we are forced to dismiss a patient, there are a few tried and true methods to ease the pain of watching your revenue walk out of the door. The American Medical Association Code of Ethics says physicians' fiduciary responsibility to patients entails an obligation to support continuity of care for their patients. At the beginning of the patient-physician relationship, the physician should alert the patient to any foreseeable impediments to continuity of care. 

1. Notify the patient (or authorized decision maker) long enough in advance to permit the patient to secure another physician.

2. Facilitate transfer of care when appropriate.

Some practices send more, some send less, but no matter the documentation, as medical managers, we must always be aware of the dangers of a "bad breakup" with a patient. These dangers include poor reviews on the internet, damaging posts on social media, and in rare but horrifying circumstances, physical attacks on our staff members. While most patients will likely grumble about the dismissal to a few friends and simply move to the next provider, others may take the dismissal personally. In communities across the country, medical office workers have been targeted for attacks. Places like Mount Laurel, New Jersey; Buffalo, Minnesota; West Houston, Texas; and West Palm Beach, Florida have all had medical office workers murdered and others seriously injured. Therefore, it is especially important to be respectful in your dismissal.

Ending the provider-patient relationship is never easy and requires a thorough discussion of all the other possibilities before dismissal or termination. In my practice, we ask what we would want to happen if this was one of our loved ones. Admittedly, there are circumstances that are egregious enough to warrant immediate dismissal, but for the most part, perhaps trying an alternative solution may save the relationship. And you might not have to say goodbye.