Wrong Word, CA Board

The Medical Board of California requires physicians to provide emergency care to patients they discharge, contradicting the ubiquitous phone message, “If this is an emergency, call 911.”

Ethical physicians do not “abandon” patients (correctly characterized as unprofessional conduct by the CA board), leaving them in the lurch with no medical care, even when the relationship has deteriorated to the point that the physician fires the patient.

According to the Medical Board of California’s page on “Terminating/Severing Physician/Patient Relationship”

“... in order to avoid allegations of patient abandonment (unprofessional conduct), a physician should notify patients of the following in writing when the physician wishes to discontinue care:

  • The last day the physician will be available to render medical care, assuring the patient has been provided at least 15 days of emergency treatment and prescriptions before discontinuing the physician's availability.

Emergencies? Doctor’s offices do not have the staff, equipment, around the clock availability or rapid response required to handle emergencies. If you need emergency medical care, you need an emergency room, thus the phone message: “If this is an emergency, hang up and dial 911.” Perhaps physicians should change their messages: “If this is an emergency, hang up and dial 911, unless the doctor has just notified you of imminent discharge, in which case you should flag down the first ambulance you see and the doctor will meet you at the office in a few minutes.”

Unfortunately, physicians all over the country seem to believe they must provide emergency care after they notify a patient of intent to discharge them. I believe substitution of the word “critical” for “emergency” would better serve the interests of patients and physicians. Misleading a patient by promising emergency care where none exists could endanger them.

What about other elements of the California policy?

California’s requirement of only 15 days notice undercuts that expected by other states, most of which stipulate at least 30 days advance notice. In many underserved areas even 30 days may not suffice, but the shorter notice makes it much easier on the physician.

Better to provide even routine care for the requisite period, but continuing whatever medication the patient happened to be taking at the time? Sometimes that works, but indications for medication and other treatment can change. The doctor should always have the prerogative to require a patient encounter to determine whether the patient needs different medication, or none, before ordering a refill. This particularly applies when the termination arises out of failure of the patient to keep appointments.

“Physician's availability”: In my opinion the essence of abandonment has nothing to do with emergencies or medication but everything to do with refusal to meet with the patient, even though the patient may not pay.

  • "Alternative sources of medical care, i.e., refer patient to other physicians, by name, or to the local medical society's referral service."

Today patients find physicians not so much by referral from other physicians or the local medical society. We more likely will use Google or obtain a list of physicians with whom they contract from our insurance company. If I discharge a patient for failure to pay their bill or keep appointments I will not refer them to another physician, except maybe one I dislike. Better for the patient to find a new doc on their own.

  • "The information necessary to obtain the medical records compiled during the patient's care (whom to contact, how and where)."

Once again the California Board has used the wrong word. In this day of digital records, especially when kept on cloud-based servers, “access” may fit better, especially since digital records do not always come in pages accurately reproducible on pieces of paper.

Physicians often ask, too, what “reasons” medical boards accept for discharging a patient. Except, perhaps, in emergencies (real emergencies), doctors can treat whomever they wish to treat. Note that the California policy correctly omits mention of acceptable reasons. Discharge has nothing to do with “reasons.” Doctors can stop treating patients who fail to pay their bills, who abuse the relationship, whose needs fall outside of the physician's scope of practice, and who fail to keep appointments. If I had to cite one single best ever justification for discharge, it would be simply to serve the patient’s best interest.

If your doctor has just notified you of intent to terminate your relationship, regardless of the California Board or what the letter says, if you’re facing an emergency, medical or otherwise, call 911. If you’re a physician, regardless of the state in which you practice, do not promise emergency availability to any patient unless you can deliver.

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