Terminating a Patient-Doctor Relationship

Unsalvageable relationships. Terminating the physician-patient relationship.

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast we have Dr. Scott Stern discussing terminating care with patients.

[00:00:12] Dr. Stern: And she said, "You know, I appreciate that you cared for me. And I understood that I was taking huge risks of my life by not going, but I'm quite poor and I keep two jobs to keep my daughter in school because I won't let her see us be unemployed and just taking hand-outs, and I'd rather die than have her see us like that."

[00:00:31] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast sponsored by the Bucksbaum Institute. During this podcast, we discuss, dissect, and promote clinical excellence. We review research pertinent to clinical excellence. We invite experts to discuss topics that often challenge the physician-patient relationship, and we host conversations between patients and doctors.

I'm Adam Cifu, and today I'm joined by Dr. Scott Stern. Dr. Stern is a valued friend, colleague, and mentor. We've worked together on enumerable projects, including co-directing the medicine clerkship here at the Pritzker School of Medicine for years, co-authoring with Dr. Diane Alcorn, our textbook, Symptom to Diagnosis: An Evidence-based Guide, and even co-hosting another podcast, S2D, the Symptom to Diagnosis podcast.

Scott is one of the most skilled and dedicated educators, either inside medicine or outside medicine that I've ever known. He's won basically every teaching award there is to win at the University of Chicago, multiple of them multiple times, if I can say that. And the graduating class has chosen him as one of their favorite faculty members for 20 years.

Welcome Dr. Stern.

[00:01:43] Dr. Stern: Thank you, Adam. It's a real pleasure to be here. And that was very kind of you.

[00:01:48] Dr. Cifu: Trying to throw you off your game.

[00:01:49] Dr. Stern: Yeah!

[00:01:50] Dr. Cifu: Because I have not asked you here to talk about your role in medical education, but as a wise and seasoned, and by that I mean elderly internist, I want to talk to you about an issue that physicians don't discuss much, terminating relations with patients.

Sometimes we refer to it as firing patients, though I think that's kind of a horrible way to say it. And so because you agreed to be on this episode, I gave you a little bit of warning. I assume you've had experience of terminating a relationship with a patient, without getting into specifics or compromising patient confidentiality, can you tell us about a relationship with a patient that you had to end?

[00:02:28] Dr. Stern: I can. You know, it's always with some trepidation to have this conversation because it makes me feel bad, but it should make us feel bad. I'm going to actually give you two cases because they illustrate different things.

So the first patient was a patient from many years ago who, you know, frankly was exceptionally difficult. And what made him exceptionally difficult was that he would lie all the time, and was a racist and offensive to the staff, and he would purposefully provoke me. And as an example, he would call me up and ask me about test results. And when I would say, "I can't find those," he would say, "Well, they're not done yet. Why didn't you know they weren't done yet?"

[00:03:07] Dr. Cifu: Oh my God.

[00:03:08] Dr. Stern: So it was clearly a pathological behavior and I really felt that there was no way to have a functional relationship in that environment.

[00:03:15] Dr. Cifu: Yeah, yeah.

[00:03:16] Dr. Stern: The other illustrative case was more recent in a patient who lost his confidence in me and despite conversations, we weren't really able to repair that. And I'll talk a little bit more later about what we could do for that, but it was pretty clear that that totally disrupted the relationship. I didn't actually agree with what he said, but that was irrelevant, frankly. And in that case, I truly thought it was in his best interest to find someone that he trusted.

[00:03:45] Dr. Cifu: Right. Those are great examples because, you know, we've talked about this in the past and a term that people throw around as kind of the underlying reason that physicians have to terminate relationships is a loss of effective neutrality, which is kind of the idea that to do a good job, right? You have to be at your best in the room.

And if something is undermining that, whether it's because a patient is violent or threatening, or is provoking you, or maybe has just lost confidence in you, maybe you can't do as good of a job anymore.

[00:04:21] Dr. Stern: I think that's really key. And you know, the effective neutrality is a great way to express it. And that's very physician-dependent, meaning that it's idiosyncratic to us. And if we... Sometimes we can get past that. And if we can, great, but if we can't, we have to accept that we can't, and then we can't do a proper job by the patient, and that's our obligation. We're not doing this because we don't want to care for that person anymore. We're doing it because we realize it interferes with our care of that patient, and that makes us ineffective or less effective.

[00:04:49] Dr. Cifu: Right, right. It's interesting because as you talk about it, I think about, well, that's the same reason that we say we shouldn't take care of family members, right? Because there's no way you can sit in a room and be neutral with somebody you love.

[00:05:03] Dr. Stern: Boy, that is so true, and I have made that mistake, and I would reiterate for all of our listeners not to make that mistake, because it's okay when they're healthy and you say, "Oh, I'd love to help you out." Your cousin or your whoever. And the next thing you know, they're very sick and all of a sudden your heart is wrenching and you can no longer think straight.

[00:05:17] Dr. Cifu: Yeah, yeah. So let me ask kind of a follow-up question to sort of this, you know, if the decision to end a relationship comes down to the physician feeling they've sort of lost that effective neutrality, like that's very subjective. You know, you mentioned that. So whenever something's really subjective like that, I worry that that opens us up to sort of all sorts of potential for bias, right? So if the physician is making this decision, how do we make sure that those decisions are made kind of fairly and equitably?

[00:05:54] Dr. Stern: Well, I don't think that those would be the terms I would use. I don't think you can say that it's fair or equitable because it should be considerate and thoughtful. And so what I mean by that is, ultimately, if we're saying that something about the relationship is impairing the physician's ability to function optimally, it is whether or not, it's a bias the physician carries.

I think in a second, I'll tell you how I think we can try to adapt to those situations, but ultimately, if the physician's not able to get past that, then it's not in the patient's best interest to continue it, and that way it's in their best interest regardless of the motivation. Now, I would add two things that can be helpful.

You know, first is reflecting with others without exposing the patient's confidential information about what you're struggling with. Other colleagues can be invaluable for the insights that might change your perspective. Right? And might give you insights that help you to create the empathy that you're not feeling at that moment and to extend that relationship.

And the other thing that's hard to do, but I would encourage folks to do, and it's sometimes earth-shattering is to share with the patient what your observations are and to ask them what their thoughts are about it, because sometimes the revelations are shocking. Probably one of the most chagrined feelings I ever had, and it still makes me sad 30 years later, is a patient I saw years ago for asthma and um, she was very sick when she came in to see me. She was in the office. She wasn't moving very well. She was wheezing rapidly, she was in a distress.

[00:07:30] Dr. Cifu: Yes. Sick.

[00:07:31] Dr. Stern: So I sent her to the emergency room and these were in the days when you admitted your own patients and we weren't on-site. So as soon as my office closed up, I drove over to the hospital, got ready to admit her, you know it was a schlep, et cetera, and she wasn't there and never showed up.

[00:07:43] Dr. Cifu: Hmm.

[00:07:44] Dr. Stern: And I was mad, frankly. I mean there's a lot of times—

[00:07:47] Dr. Cifu: You were probably scared as well.

[00:07:48] Dr. Stern: Mad and scared and whatnot. And when she came back the next time, I was young and more immature than I am now and was quite upset with her, and I told her I was quite upset and I didn't see how I could care for her if she wasn't going to follow my advice, because how can I possibly provide good care?

[00:08:03] Dr. Cifu: I can see where this is going, keep going.

[00:08:05] Dr. Stern: So, I then did what I should have done initially, what I'm advising folks to do, which is to say, "Hey, what happened?"

[00:08:12] Dr. Cifu: Yeah, right.

[00:08:14] Dr. Stern: How foolish. Embarrassing but true. And she said, "You know, I appreciate that you cared for me and sent me in and I value the fact that you cared for me. And I understood that I was taking huge risks of my life by not going, but I'm, you know, quite poor. And I keep two jobs to keep my daughter in school because I won't let her see us be, you know, unemployed and just taking hand-outs and I'd rather die than have her see us like that."

[00:08:43] Dr. Cifu: Wow.

[00:08:44] Dr. Stern: And I almost started crying.

[00:08:48] Dr. Cifu: There are a couple of things that I want to kind of unpack from what you just talked about. The first one, getting all the way back to my question, which probably got the least interesting thing out of you, but I like the idea that—

OKay. Right, we all have our biases. There may be some patients who we are not doing a good job for because of the biases that we bring into it, and although maybe that is a reason to terminate care, it's also important to be mindful. And as you sort of think about why you're breaking up relationships, you may actually realize that, "Boy, I've got a problem. You know, that there is a subset of patients who I really struggle to take care of, and why is that? And can I do a better job?" And maybe improve yourself as a physician.

[00:09:40] Dr. Stern: Exactly. And that's where reflecting with other physicians or colleagues can be helpful. And then you can realize that's on you.

[00:09:46] Dr. Cifu: Yeah.

[00:09:47] Dr. Stern: And if it is on you, you should certainly struggle to improve yourself before you make a decision about the patient.

[00:09:53] Dr. Cifu: The other thing you said that I think I've figured out, you know, over time, and maybe it's one of the good things about having podcasts like this to talk about the things that we've figured out over time and maybe have other people be able to figure them out a little bit faster, is that whole idea of, I always think about it as like, kind of naming the emotion. It's like, you know, how am I feeling here? What's going on here? And it's seldom necessary, but occasionally you'll be in the office and just things won't be going in the right direction. You'll be getting annoyed, the patient's getting angry. And you just have to step back and sort of say like, "Why am I feeling this way?" And often, you know, verbalizing it to the patient.

[00:10:32] Dr. Stern: Well, and not only what you're feeling, but say to them, "It seems to me that you're angry. Can you talk about that?" I had an interesting experience once recently where the patient seemed very angry, he was very loud, and I actually was somewhat intimidated. And I said to him, "You know, you seem very angry." And he goes, "Actually, I'm not angry. I'm very frustrated. And here's why I'm frustrated." And then I could feel, instead of feeling afraid and intimidated, I felt sad and empathic and wanted to help him. Right?

[00:11:03] Dr. Cifu: Yeah. Yeah.

[00:11:04] Dr. Stern: So I think we're often not trained to name the emotion, but occasionally I think you're spot on.

[00:11:09] Dr. Cifu: Right. That's a powerful story. I've had similar experiences where, you know, when I say like, "You seem annoyed," and people say, "You know, it's just how I am."

[00:11:20] Dr. Stern: Right.

[00:11:20] Dr. Cifu: And then occasional experiences where I think the relationship is bad or strained, and then after the visit they sort of say like, "Hey, would you mind if I sent my mother to see you?" And you just realize like, "Huh! This is actually a good relationship in this person's life."

So I've kind of got another question which I think follows from what we've talked about. So, you know, usually when you hear about terminating a relationship, people say, "Oh, well if you're going to terminate the relationship the things you have to be cautious about are not abandoning the patient, you know, you have to give the patient warning and you have to help them find another doctor. You have to provide prescriptions until they've found another doctor." And I think these days a lot of people talk about, you know, actually communicating with that next doctor to kind of do a warm handout, not to bias the next doctor, but to sort of say, "You know, this is what's going on," to make sure that there's no lapse in care.

I kind of think of that as the easy stuff. What sort of things do you think about as you get to the point where, "Boy, I'm struggling with this patient. Every time I leave the room, I feel like saying, Ugh, you know, that didn't go very well." Or, "Man, I'm just making no progress with this person's diseases. And their hemoglobin A1C has been 13 for the last three years, and maybe I'm the wrong person for them."

[00:12:42] Dr. Stern: Well, I think, I want to come back to that 13 in just a second. I mean, the first steps I think are really to take some time to reflect on the situation. You know, when I was younger, I was more impulsive, and I think now I'm more comfortable saying, "Let me sit on this for a while."

Now, there are exceptions. If somebody is actually threatening, or threatening to the staff, I think that's a completely different animal. There's no reason to reflect. You need to protect people's safety. And if, again, I feel kind of the same thing about frank lying, I just find that breaks the relationship.

Um, but the other things that I think can be helpful are to, and very difficult, is to bring the patient in on the conversation. If it's not something like what we just said, lying and threatening, we can say and I have, although boy, it churns your stomach to say this to a patient, "I don't really think the relationship is going well. What's your impression?" And I have found that with that there're two different outcomes. I have found outcomes where we have figured out what the issues were and resolved to work together, and it's worked. And I have found situations where the patient agrees and after some time pondering it, agreed that they would be better served by someone else. That does feel better, but boy, it creates a lot—

Walking in a room knowing you're going to have that conversation is a stomach turner for sure.

[00:13:59] Dr. Cifu: It's funny when you have that conversation, and you figure out new ways to go forward, and it's usually on both sides, right? It's both having to change your approach to the relationship. I have found that those relationships become one of the most valued on both sides. Because often those are patients who have, you know, a little bit of a hard sort of relationship with medicine in general. And they'll be at an urgent care or something and you know, you'll get a call from the doctor and be like, "Oh, how do you take care of this person?" and you're sort of like, "Yeah, you know, we've worked at it."

[00:14:39] Dr. Stern: Right, exactly. Although sometimes it still fails in the end, but it's worth the try.

[00:14:43] Dr. Cifu: Yes.

[00:14:44] Dr. Stern: In terms of people not... I've changed a lot on my perspective on people who don't adhere sufficiently and are at risk for bad outcomes. So I think in our medical legal environment, it's easy to think, "I don't want to take care of this patient. They're not going to do well. I'm putting myself at risk." I actually put that aside at this point. I think if we can make a connection and we feel that we're doing the best we can, and that it's simply that for whatever reason in their life they can't manage, it's not our information, it's not our recommendation, it's not our connection to the patient, but there are social structures that sometimes people can't avoid, then I think you just keep the connection with the hope that that connection will in and of itself be a motivator over time, because we only disenfranchise them further with this.

[00:15:27] Dr. Cifu: I have to say, maybe to protect myself and make myself not seem like a terrible person, I have used that to open up conversations but have never ended a relationship because of that, but I've said, and it's often when I've been very frustrated that like, "Man, I've put a ton of work in this and you know, you're still smoking, you know, you're still using dangerous illicit drugs, you know, your diabetes is still under terrible control," that I'll say, "Ah, you know, I really feel like I'm failing you because of X, Y, and Z."

[00:16:06] Dr. Stern: Right.

[00:16:06] Dr. Cifu: "You know, is that true? Would you be better with someone else?" And at least that really opens the floor, and sometimes brings up issues as you mentioned, that you don't know about, about the difficulties outside the office that people are often protective of, even in a robust relationship.

[00:16:28] Dr. Stern: Right, but my recommendations to our listener on that, just to really understand what's going on in your own head before you have that conversation, because regardless of the words that come out of your mouth, if you're frustrated, everybody can read frustration. Most communication is not language, it's visual cues.

And so I have had people, for instance, who had horrible morbid obesity, who I know that if we don't help them to lose weight somehow, then nothing I'm going to do is going to matter. Right? And so it can be frustrating, and when I've had patients like that, I never have that discussion unless I'm in the room with them and feeling empathic to them.

And when I feel connected and I say to myself, "Boy, this is horrible," and I'm really worried about that person, I feel it in my heart, that's when I'm going to have that conversation, not when it's the end of a day and I'm tired and I'm frustrated and the person hasn't done what I wanted because then you're communicating something completely different.

[00:17:17] Dr. Cifu: Right, right. I've always talked about, and I've written about in the past, what I call sort of, there're the forest days, there're the tree days, and there're the leave days. And like, you know, the forest days are those days where you're like, "Boy, I'm really good today and I can sort of look at relationships even when they're difficult in a very mindful way and sort of not only be in the chair, but also be the third person in the room." Right? Like those are the days to have those. It's not the day where you're like, "I just got to get through this, and all I'm thinking about is, is this patient's blood pressure okay? Is this A1C, you know—"

[00:17:56] Dr. Stern: Totally.

[00:17:57] Dr. Cifu: They really say that—

[00:17:58] Dr. Stern: And I think you really have to pay attention to your own mind.

[00:18:02] Dr. Cifu: Good. Those are all the questions I had for you. Do you have anything else you feel like we should touch on before we wrap up?

[00:18:07] Dr. Stern: No, I think, you know, we're in a mission of healing is what we do. And I do worry about ending relationships. I do think it is important at times, but I think the take-home message should be, you should be doing it when you really think it's in the best interest of the patient or in the rare occasions where it is simply intolerable because of risks and threats or things of that sort.

[00:18:30] Dr. Cifu: Yeah, I think you're right. I mean, our job is really to care for patients who seek our services. Right? And we're kind of ethically obligated to provide the best care possible to each of our patients, and that's usually as long as they want us to. Right? So I think we would both say that this is something that, you know, maybe happens once every decade in your career, and it's probably the reason that it's written about so infrequently.

[00:18:56] Dr. Stern: Right.

[00:18:56] Dr. Cifu: And it's unpleasant when it happens.

[00:18:59] Dr. Stern: Totally unpleasant.

[00:19:00] Dr. Cifu: You often just want to like say—

[00:19:01] Dr. Stern: No, even talking about it is unpleasant.

[00:19:03] Dr. Cifu: Right.

[00:19:05] Dr. Stern: Not talking to you, of course, but just thinking about it.

[00:19:07] Dr. Cifu: Well that'll let you off the hook. So thanks for joining us for this episode of The Clinical Excellence Podcast. We are sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page. The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.