In almost 50 years of practice, I've never fired a patient, but during the COVID-19 pandemic one nearly pushed me over the edge.

Mary was not the only patient in my panel who espoused anti-vaccine views. I have more than a few, and we generally get along just fine. But due to my compromised immunity, I wasn't accepting new patients who weren't vaccinated against COVID at the time (we've since changed our policy to require masks rather than the vaccine). I knew that vaccinated people could still spread the virus, but I wanted to take what precautions I could for myself and my patients while the virus was raging. Mary was established to the practice, however, and I wasn't going to fire her just because she refused the vaccine. But then she asked me to lie for her.

“Doctor,” she said via email, “Mike and I want to go to Bali on vacation, but there is a COVID vaccination requirement to go there, so we need you to say that we can't take the vaccine for medical reasons.”

I was agog. Mary had some medical issues, but none were a contraindication for the vaccine. As far as I knew, her partner also had no medical problems that would preclude vaccination, but he hadn't seen me as a patient for more than 10 years.

That was nervy, I thought. But before I could respond, I received a second email from her: “Could you also write us both a letter so we can use cannabis while we travel? In Thailand we had to have a doctor's note, and I'm not sure about any other country at this time. Mike needs to smoke a joint or two a day for his aging body. It helps him sleep and keeps him in a happy mood.”

That was over the top. My first thought was that I was going to fire this patient for assuming I would acquiesce to her unreasonable demands. But how should I do it? My malpractice insurance company's risk manager had some helpful advice. She suggested I tell Mary that we obviously had different philosophies about medical care, and she might be happier having a physician who could better meet her expectations. Now that's a reasonable way of firing a patient, I thought.

But I decided to put it on hold. By that time, I had cooled down and wanted to give Mary one more chance. So, I composed the following email:

Dear Mary,

I cannot find any medical reason why you and Mike should be exempted from being vaccinated. I am not aware of any of your medical conditions being a contraindication, and I haven't seen Mike in so many years that I don't remember his medical history but doubt he is allergic to any of the vaccine's components. You chose not to be vaccinated because of your beliefs, but I do not share them. The overwhelming scientific evidence is that it is safe and saves lives. I'm sorry that you can't go to Bali without being vaccinated, but that is not a rule of my making.

I don't write prescriptions for medical marijuana. It is still against federal law to use or prescribe it, and I would risk losing my license for controlled substances that many of my patients depend on. Perhaps you can call a local dispensary and find a doctor who does.

Mary's response didn't start out promisingly: “Please send your overwhelming scientific evidence,” she said, referring to the COVID vaccine as “a bioweapon unleashed on society for depopulation.”

However, she ended on an upbeat note: “I know your license depends on following protocol, and I would never want to jeopardize that for you for any reason. … Thank you for your time. I wish you and your family all the best.”

I was glad I had shown restraint and hadn't fired Mary. She was misinformed, but she was also accepting of my position — and didn't fire me either. Sometimes, we just have to give each other a second chance and keep the conversation going.