practice management
Too many patients? Fire some
How to shrink your patient roster -- without getting in trouble

A year and a half ago, Edmonton family physician Allen Ausford was buried beneath an unmanageably large patient roster of 2,100, working 14-hour days. He elected to hold a lottery to pick 500 patients to dismiss from his practice.

Last summer, Dr. Ken Runciman, an FP from Powassan, Ontario, did the same thing, dropping 100 patients in two random drawings. “There is only a certain number of people I can see in a day,” Dr. Runciman told the National Post. “My day is already 11 hours and I don't care for it being longer. I realize that, at 47, I can't run my ass off like I did 20 years ago.”

The “fired” patients weren’t happy, of course, and nor were the doctors -- “It is the toughest thing I have done in 26 years of practice,” said Dr. Ausford to CBC News -- but patients and doctors alike will face more and more of these situations in the future, says Dr. Jeff Blackmer, the executive director of the Canadian Medical Association’s office of ethics. “As long as there is discrepancy between the number of patients and the number of doctors, this will continue to be a problem.”

If you find yourself overloaded with work and forced to cut the size of your practice, you’ll need to know how to protect yourself by taking into account ethics guidelines, regulatory policies and even human rights laws.

IS IT ALLOWED?

First of all, know this: you are more than likely within your rights and your professional ethics obligations to dismiss patients because your practice has become too large and unwieldy.

Few such cases have come up so far -- Dr. Ausford’s and Dr. Runciman’s cases are among the first -- and therefore most provincial Colleges of Physicians and Surgeons don’t specifically address the issue. “The issue of discharging patients because you have too many is something that wasn’t really anticipated,” says Dr. Blackmer.

But while the colleges may not address it, nor do they forbid you from firing patients from an overloaded practice. Quebec's College des medecins comes the closest, demanding a “reasonable and just cause” to dismiss a patient, but, of course, even that is largely unclear. What exactly qualifies as a “reasonable and just cause” from an exhausted family doctor’s perspective may not jibe with a patient’s definition.

The clearest advice comes from the College of Physicians and Surgeons of Ontario, which just updated its guidelines last year. The CPSO examines two “situations which may result in a decision to end the physician-patient relationship”: one, a breakdown of trust and respect, or two, your practice is too large to manage. “The College recognizes that Ontario is currently experiencing a shortage of health human resources, which places increasing pressure on both physicians and patients,” the policy reads. “As a result, physicians may find on occasion that their practice has become too large to manage and that they must decrease the number of patients to whom they provide services.”

Here, a major question must be asked: how do you decide which patients to fire?

WHOM TO FIRE

Because this is a relatively new problem in Canadian healthcare, there are even fewer recommendations available on this than there are on the question of whether it’s acceptable to do in the first place. The CPSO simply asks that you “proceed in a manner that is fair, transparent and compassionate.” But what does that mean?

Dr. Blackmer acknowledges this is unexplored territory. “The challenge from an ethical standpoint is how to decide which patients to discontinue,” he says. “It’s not clear-cut how to decide that.” Is a lottery acceptable? What about the strategy used by an Ontario family doctor who fired all his patients who hadn’t come in for a visit in the last two years?

The CPSO declined to give general advice. “It has to be done in a way that seems fair when being done,” says Jill Hefley, the college’s associate director of policy and communications. “We don’t provide suggestions for doing that.”

You’re not all on your own, however. One way of thinking about the problem, suggests Dr. Blackmer, is to consider it in the same way you would when accepting patients into your practice. The current thinking on accepting patients, as the Ontario and BC colleges’ latest guidelines reflect, is that screening new patients whom you are qualified to take care of is unethical and may violate human rights laws. “The easiest and least controversial [way to build a practice] is first-come, first-served. That doesn't work in all situations, but in terms of the fewest ethical complications, that is the one,” says Dr. Blackmer. “The same would probably apply in terms of the fewest ethical complications to pare down your practice.” So it’s first-come, first-served, only in reverse. Last in, first out.

PROTECT YOURSELF

Following the “last in, first out” strategy is a good start, but it’s no guarantee that you’ll avoid getting in trouble. To truly protect yourself, you’ll need to familiarize yourself with your provincial College of Physicians and Surgeons’ procedural guidelines on ending a physician-patient relationship. Though the details vary slightly from province to province, the basics are essentially the same.

Give notice to the patient in writing, using registered mail to ensure that no one can later claim that the letter never arrived. In your letter, you should explain your reason for terminating your relationship. (It’s probably best to avoid using the word “fired”). You needn’t draft a letter from scratch: sample letters are available on many of the colleges’ websites.

Your letter must clearly state that you will remain available for any immediate or emergency care the patient requires until a certain “reasonable” date in the future, keeping in mind that that date may not end up being the final deadline, because the patient may not be able to find another family doctor within that time period. Some colleges recommend explicitly advising the patient to seek medical care from another doctor. Your objective is, at all costs, to avoid abandoning a patient, which the College of Physicians and Surgeons of Alberta defines as “the unilateral termination by the physicians of the physician-patient relationship while the need for medical care still exists.” You probably don’t need anyone to tell you what could happen if a patient you fired were to get very sick or die because they couldn’t access medical care. The CPSO policy recognizes that with most doctors’ practices now full, you may end being responsible for providing emergency care indefinitely for patients you fired if they can’t access it elsewhere, for instance if you live in a very rural area.

You should give the patient a list of local doctors accepting new patients or refer them to a website or phone number where they can find listings of doctors with open practices.

Also, you should offer to transfer records to their new physician whenever they ask you to do so. Ensure you have the proper consent to do so.

Document in the patient’s chart that you sent the letter, and keep copies of the letter and the mailing receipt. This step is emphasized strongly by the Canadian Medical Protective Association (CMPA).

For advice, you can call your provincial College of Physicians and Surgeons.

As unpleasant as these onerous steps are -- not to mention the necessity of firing patients -- you may simply have to get used to doing these things in the future. “Until we get the health human resources issue sorted out, it is going to continue to be an issue,” says Dr. Blackmer.

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