The Myth of the 30 Day Notice

When the doctor patient relationship goes sour medical ethics clearly allows the physician to discharge the patient, but in theory at least the physician must ordinarily make some attempt to help the patient find another doc, and continue to provide care until the patient can establish care elsewhere for a reasonable time, traditionally 30 days.

But what happens during those 30 days?

Although physicians discharge patients for many reasons, such as failure to pay, dishonesty, noncompliance, personality conflicts and others, in my practice at least patients seem to discharge themselves. They miss an appointment and don't return calls to reschedule. With phones and voice mail as they are we often encounter "mailbox full" messages, and of course sometimes we eventually do make contact and discover the patient just lost her phone. But when the patient has really dumped me I want evidence of providing adequate warning of discharge as much for liability reasons, to protect myself, as anything else. While the letters I send do often result in a phone call and continuation of care, for the patient who has left for good the letter becomes tangible evidence that I am no longer responsible for care. If I something bad happens to the patient, but I am clearly not the patient's doc at the time, there is little chance of a successful liability suit.

My standard discharge letter starts out by saying I don't know whether the patient wants to continue treatment, and to please let me know. I inform the patient that I will only continue to act as her physician for 30 days after which I will discharge her. I may also suggest some resources for finding a replacement physician. Often the letters come back undeliverable.

Many physicians seem to accept, but I hereafter challenge, the myth that we must provide a 30 day supply of whatever medication the patient takes. While that may be appropriate in some cases, simply providing a prescription does not equate with medical care, and may lead to increased, rather than decreased, risk. Suppose for example that the patient's condition changes during the 30 days. The responsible physician would want to examine the patient, possibly face to face, to evaluate and explore treatment options. In some cases the patient would be happy to oblige, but suppose the patient refuses. I believe in that situation the physician should consider refusing to provide a refill until the patient has kept an appointment. Not infrequently a patient lost to follow-up will request a refill through a pharmacy. Typically I have by that time given up after many attempts to make contact with the patient. I refuse to fill the prescription and ask the pharmacist to tell the patient to contact me.

But suppose the patient responds to your demand for a face to face visit in order to obtain a prescription or other treatment. Can I demand payment before scheduling the visit or actually seeing the patient? From the perspective of avoiding a lawsuit, the better choice might be to take the loss. But this can be hard to accept, especially when you know the patient will spend much more than your fee on the drugs you prescribe, or on their month supply of cigarettes.

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