Risk Management

Dealing with a disruptive patient

HANS K. BRUHN, MHS, and MICHELLE PINEDA, MBA, OMIC Risk Managers

As noted in the lead article , there are myriad factors that lead to physician stress and burnout. One of those factors is disruptive patients. On the Hotline, we receive many calls from insureds who need assistance in managing patients who are rude, demanding, and non-compliant. Taking early action to resolve these issues will mitigate the risk of a medical malpractice claim, ensure your patients receive the excellent care you wish to provide, and help you avoid burnout.

Q: More and more of my patients are rude, demanding, and sometimes hostile to me and my staff. What is the liability to my practice from these patients and how can I manage them more effectively?

A: Difficult or demanding patients are distractions to providing quality care in a timely fashion (see OMIC Digest Vol. 19, No 3, 2009 (Summer): When Patients Become Difficult, Hostile or Violent https://www.omic.com/when-patients-become-difficult-hostile-or-violent-2/). Difficult patients can also create a stressful situation for you and your staff, and may result in hostile work environment claims. Patients who witness such behavior in your office may lose confidence in your practice and be reluctant to return. They may also post their dissatisfaction on social media, which is a very difficult issue to manage.

Develop a clear code of conduct that explains how patients are expected to behave, and how they can expect to be treated. Post this information in your practice and provide patients with a copy. Include the consequences for not following the code. Unacceptable behavior should be reported to you and your practice administrator’s attention so it can be addressed.

Mutual trust is the basis for an effective physician-patient relationship. Disruptive behavior may indicate an erosion of that trust, and immediate action is needed to determine the cause for the behavior. If trust cannot be reestablished, consider a second opinion (to confirm your medical advice) or discharging the patient.

The informed consent discussion is an opportune time to confirm that mutual trust is in place. Avoid meeting surgical patients for the first time on the day of surgery. It is difficult for a patient to trust his or her physician if they have not had time to establish a relationship.

Be aware of challenges to providing care, such as a patient’s special needs or disabilities, as well as the behavior of family or friends who accompany a patient. If the individual authorized to make decisions is disruptive, determine if care can be provided effectively.

Surgical patients who experience a complication can become disruptive due to frustration with care. The entire practice can be proactive to build faith and trust.

High deductibles, copays, and large out-of-pocket expenses can cause patients to become angry. Train billing staff to report patient concerns to the physician and practice management.

Develop a protocol to handle disruptive patients. It should include steps to: alert patients regarding unacceptable behaviors, explain how such behavior negatively impacts quality of care, and communicate consequences of non-compliance, including discharge from the practice. Contact our Risk Management Hotline (800) 562-6642, Press 4, for guidance on developing a protocol and help with specific patients.

Q: Patients who don’t pay their bills can be difficult to deal with and contribute to physician stress. Does OMIC have recommendations for dealing with these patients?

A: Patients who carry insurance with high deductibles are often slower or noncompliant with paying their bills especially in the first quarter of the year.

Ask new patients about their insurance when the appointment is scheduled. It is better to resolve this before the patient is seen.

Provide new patients with a written explanation of the financial protocol, and ask them to sign it at the first visit. The financial responsibility form might include statements like:

• “I understand that I am financially responsible for my deductible, coinsurance, or non-covered service. Co-payments are due at time of service.”
• “If my plan requires a referral, I must obtain it prior to my visit.”
• “I agree to pay for charges that are not covered by my health plan.”
• “If I am uninsured, I agree to pay for the medical services at time of service.”

Discuss financial issues. Patients with serious conditions might need extensive treatment that involves costs exceeding the patient’s ability to pay. In this situation, consider care options that might reduce financial burden, such as referring the patient to a teaching or county hospital, or offering to create a payment plan for your services.

Dissatisfied patients often don’t pay their bills. Ask the patient if he has any questions or concerns, and address those carefully. Talking to the patient can prevent escalation to a claim or lawsuit.