When the college greenlights firing a patient

Hey, the CPSO (College of Physicians and Surgeons of Ontario) wants feedback on its policies. I looked at the first document about signing up new patients. Basically, they want you to take everyone first come, first served and not discriminate against complex patients. Since I don’t have a clinic, I didn’t weigh in. The ER does not discriminate against complex patients, which means we can’t do first come, first served. I know that my friends offer an intake form to new patients, at least, so they know what they’re getting into when they sign a patient up. It’s not discrimination, only information.Next, I checked out ending the physician-patient relationship policy. This question comes up often. One of my colleagues may ask if we’re “allowed” to discharge a patient who is swearing, uttering sexist or racist epithets, threatening to come back with a shotgun or whatever egregious behaviour du jour. Often the response is “Yes, I have to provide a safe environment for my MOA (medical office assistant)” or “That behaviour scared the patients in the waiting room.” There’s no consideration for the physician being threatened.As expected, the CPSO spent a lot of time literally highlighting that we must (seriously, they bolded every must) use clinical judgement and consider patients’ needs. For example, if the patients haven’t paid a fee, you must consider if the fee is an undue burden, discuss it with them and consider waiving the fee. Really takes the teeth out of no-show fees, but I understand that penalties may be more to discourage patients than actually enforced.Read: Dr. Melissa Yuan-Innes: Charting: chore or charm?Now the meat of the matter. The CPSO does acknowledge that if “the patient poses a genuine risk of harm to the physician, the physician’s staff or to other patients . . . in these circumstances, physicians are under no obligation to engage with the patient prior to ending the relationship.”That’s good, because I could only think of that patient killing Dr. Walter Reynolds in Alberta. When someone is literally hacking through the door with a machete, does the CSPO seriously think we should chat with him/her through the splintering wood about the breakdown in our physician-patient relationship?Answer: no. But otherwise, I only found one line for us: the one saying that we can fire them for “other forms of inappropriate behaviour, including abusive or threatening language.”Of course they threw in a lot of caveats:“Proactively communicating expectations for patient conduct to all patients.”Some of my colleagues have mentioned reviewing expectations and having patients sign waivers in their clinics. More unpaid labour, more paperwork, more time away from patient care. I know that some get around this by having the clerk do it.We have some signs in my ER. Hope that’s enough.The first time I saw one of these “zero tolerance” signs, I could not imagine an irate patient bothering to read and/or obey one of these signs.The next time I thought about it, I realized that the signs are lip service, or what my friend calls “security theatre.” We look after patients who yell and hit us all the time. I have never seen anyone booted from the ER for bad behaviour.The vast majority of good patients don’t need the sign. We’re trying to dissuade some who are getting restless. The dangerous ones will continue to attack.As per the CPSO’s wishes, I guess the signs will count as us warning them. Maybe. “Considering whether a problematic incident or behaviour is an isolated example or part of a larger pattern.”The nurses tell me if a patient is a frequent flyer. I wouldn’t enjoy having to page through notes to figure out if it’s the first time an adult patient has started to micturate in the waiting area, and if that’s considered a fireable offense. Since we’re using our clinical judgment, we’d better run the urine first!“Discussing with the patient the reasons affecting the physician’s ability to provide care.”I can just imagine how popular a “Dear John” conversation this would be with everyone. When I do this, I try to bring staff with me and keep our conversation short and sweet. The patient growls at me, and I say, “We’re done.”What do you think about the college’s policies? Will you give them feedback? Why or why not?Melissa Yuan-Innes is an emergency physician in Alexandria, Ontario and the author of Sugar and Vice.

When the college greenlights firing a patient

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