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Breaking up is hard to do, even with difficult patients.

Fam Pract Manag. 2006;13(1):72

At first, things were awkward between us, but over the course of several months, we had come to know each other well. She confided in me about birth control and bowel movements. I told her about my family. But then our relationship began to fizzle. We agreed to meet three or four times, and each time she stood me up. I was getting the hint and growing impatient, but I wanted to make it work. When I heard the rumor about her seeing another doctor, I knew it was over for good.

Like an anxious adolescent trying to break up with a high school sweetheart, I struggled with how to dismiss my first patient. Rules were rules, and clearly she had violated them, I tried to reassure myself. But we had a relationship, and ending it wouldn’t be easy. I agonized over how to break the news. Initially, I decided to tell her in person. But I had no idea whether she would show up. And if we did meet face to face, I feared I would get nostalgic and change my mind. I considered telling her by e-mail but decided that only a coward would call things off in cyberspace. Besides, how would I know if she received the news? I finally settled on the traditional approach: the certified letter. In my epistle, I described how clinic policy, not my disdain for her, required that she be dismissed. Between the lines, it queried, “Can we still be friends?”

My colleagues tried to lend support. They gathered around like drinking buddies, lamenting the close relationship I had formed. One revealed how she had “fired” a patient twice – the second time after he had returned to our clinic with a different name. Another claimed I was overthinking the whole situation. Dismissing patients was easy, he explained, and he had done so seven times in the previous year. He strolled around the clinic like a balding Donald Trump, wrist cocked and ready to deliver the familiar phrase. Other physicians called him for advice on the difficult cases, and he developed something of a dismissal consult service. As legend has it, he even slipped into the ICU one night and presented a letter explaining that the patient had 15 days to find a new physician. Another time, after firing a patient for missing several appointments, he received an attorney’s letter explaining that the patient had been delinquent because she was dead.

But stories of firing patients twice, dismissing them in critical condition and canning them posthumously could not console me. I’ve come to realize that my partners and I have differing perspectives on the physician-patient relationship. I am seeking a long-term, committed relationship. I want my patients to know that I will be there in sickness and in health. Until death do us part, so to speak. But my colleagues’ encounters sometimes sound more like one-night stands, and their counseling, devoid of regret, coldly holds that there are other fish in the sea.

I’ve fired plenty of patients since. No one will ever consult me on how best to do it, but it’s become a part of practice that I can live with. I still want to make things work with almost any patient, and I take pride in trying to get along with patients others have dismissed. By nature, I’m drawn to patients and their stories. The proximity makes doctoring satisfying and enjoyable. But as that first breakup taught me, finding the right distance in the doctor-patient relationship is one of the hard parts about medicine.


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