August 2003

Raising red flags for difficult patients

by Timothy J. Feuling

If you knew ahead of time which patients might slap you with a lawsuit, or file a complaint against you, you could avoid a lot of problems. Unfortunately, there's no 100% certain method of predicting who will cause problems for you.

However, there are some "red flags" that can signal you to take extra risk management precautions.

For example, if a patient has already been to several other D.C.s, and complains about the care provided by all of them, there's a good chance that person will complain about your care as well. This is particularly true if the patient indicates the real problem may be chiropractic rather than the chiropractors he or she has seen. Ironically, many people who go to a chiropractor are extremely skeptical about the benefits they may receive. They want you to "prove" to them that chiropractic will work for them. While most of these people end up being great chiropractic supporters, you can't ignore the hurdle they place in front of you.

Patients who are belligerent, argumentative, or accusatory are among those at "high risk" for trouble. So are those who try to dictate the kind of care you should provide, such as the patient who says, "Look, doc, I only want to come in two or three times. None of this 'every‑week‑for‑a‑ year' business. I know that scam," or the one who demands certain non‑chiropractic therapies from you.

If, when you first meet the patient, you have a strong hunch that the person will cause difficulty for you, you have the legal right to refuse to accept him or her as a patient. An article in Peoria Medicine, titled "Handling the Difficult Patient," by Murvel Pretorius, Jr., and Laura A. Petersen, advised, "If you determine, at the initial consultation that you would not be comfortable treating this type of patient, you may refuse to accept him or her as your patient. You should follow up with a letter indicating that you have declined to accept him or her as your patient. This will ensure that there is no dispute later about whether a physician‑patient relationship existed. Rejecting a problem patient at the outset is the only certain way to protect yourself from future liability associated with caring for that patient."

The situation is a bit different for existing patients who begin to exhibit signs that they'll become problems. Although there is no universally established rule for doctors of chiropractic, you can be safe in adapting the ethics code of the American Medical Association, which allows doctors to terminate the patient relationship for a variety of reasons, as long they are given sufficient notice. Let those patients know you are uncomfortable continuing as their doctor, and tell them they'll need to find another chiropractor. Give them a reasonable time to do so and make sure everything is well documented.

One of the reddest of red flags is financial conflict with the patient. Many lawsuits and board complaints can be traced back to a patient's problem paying his or her bill. Make sure you are aware of any such situations, and pay particular attention to proper risk management with those individuals.

If you choose to continue caring for a patient you suspect may cause legal or board problems for you, take extra precautions to document your care and minimize the opportunity for conflict. For instance, if the patient has been complaining that the adjustments have "cured" his or her presenting problems, review your patient education material and make sure the patient has signed the terms of acceptance and informed consent agreements. Likewise, if you suspect a patient may lodge an accusation of sexual misconduct, take extra precautions to make sure another staff member is present during your interactions with the patient.

Of course, many "difficult" patients can be transformed into good patients by using a bit extra care and attention. The book "Verdict Pending," by Fredonia French Jacques, contains this insight: "It is patients who have been slighted or treated abruptly ... who have been depersonalized, whose feelings have been hurt, who will sue. ... Patients seldom sue those who have cared for them with kindness."

That may be true, and treating patients with kindness is always important ‑ but make sure you also pay attention to your malpractice prevention techniques!

(Timothy J. Feuling is president of Chiropractic Benefit Services (CBS) and vice president of the World Chiropractic Alliance. He assists doctors in maximizing their practices through the proper choice of insurance and related services. Doctors may contact him with questions, comments, and requests for insurance quotes at 2950 N. Dobson Rd. Ste. 1, Chandler, AZ 85224, by phone at 800-883-0412 or by e-mail: feuling@cbsmalpractice.com).