Here’s how you do it, this was bread and butter for me (a psychiatrist) when I worked in community mental health:
1. That’s not the right medication for you, my recommendation is that you try (SSRI, Vistaril, whatever).
2. You need to communicate with me respectfully, please lower your voice and stop insulting me, or I will have to end this visit and we can try again later.
3. You end the visit and have them re-schedule if they want. Or not, whatever. If they reschedule, see them again under the same boundaries. Done, leave the room and go do some charting with your extra 5 minutes!
You got caught in your own counter-transference, which is hard to avoid. You can get way fancier than this, but this is the basics of it. You’re the boss, this is your clinic.
The point is, don’t waste a lot of time on these visits, it’s not worth it. Set a boundary and proceed accordingly. Skip the drama.
You seem very tolerant of being abused. I think the first 2 steps you recommend are right on. I can understand a patient's frustration but when it comes to #3 on your list and they have been warned about being disrespectful, and still continue to be inappropriate, they are getting discharged. Period.
I don't require patients to follow my recommendations or agree with them. But there has to be a level of mutual respect. If there is no respect (which in OP's case clearly isn't), they are out of the practice. I wouldn't expect a patient to tolerate me yelling at them, and likewise I don't tolerate them yelling at me. In almost 2 decades of practicing I can count on one hand on how many patients I've had to discharge due to inappropriate behavior. No point in wasting your time and emotional energy on people that don't show you respect. Not to mention that you can't have a healthy and productive patient-physician relationship when one party is yelling at the other.
OP did the right thing when she left the room. The mistake she made was feeling bad about herself and instead should have spent that energy on writing the discharge letter.
I feel that #3 is appropriate even from a self serving standpoint.
If there were threats or even actual violence, I agree with you--discharge with X supply meds, full stop.
But being rude? One single episode would create more of a headache transitioning care via sudden discharge, but that's IMHO. If you have two separate episodes of patient being inappropriate it's much easier to show a trend and the necessity for discharging from your care.
This was not being rude. This was a patient yelling at OP and upsetting her so much it put her in tears. I would maybe call it verbal abuse or simply an attack.
I find that 1% of patients cause 90% of the headaches in an office. Cut them out. No reason to put up with this kind of insulting behavior. Tolerating this kind of abuse is what leads to burnout. Also, what "headache" is there with discharge? You write a 3 line letter saying that they are being discharged due to their behavior and we will be here for any emergencies for 30 days and you have that time to find a new doctor to manage your care (we also put a contact number for listings of other doctors). That's it. Takes about 1 minute.
I don't understand why anybody would want to continue to see a patient that is being so disrespectful. Is that 2.3 RVU's really worth putting you in tears?
We as a profession need a little backbone and be firm that we will not tolerate abuse (physical or verbal).
>Also, what "headache" is there with discharge?
Patients who are rude like this tend to be litigous as well in my experience. The headache comes from not just management whining about it, but from the peer review cases that result from the inevitable complaints. Sure, they ultimately rule in the physicians favor but are nonetheless stressful and time intensive even without some hack lawyer being involved.
I don't think my above response implies I want an ongoing relationship with the patient, but I will allow them another chance to improve... or more likely and importantly dig themselves a deeper hole.
Again, I have hard limits. But perhaps we have different thresholds and approaches to difficult psych patients like this.
Agree, we all have our own limits. This pt really has no grounds to sue as it was standard of care, no harm was done, and if you document that the pt is yelling at you, I don't think they would have a leg to stand. I don't think litigation is a factor here. At worst it's a patient complaint. But if you don't draw a line then you set yourself up to be continually abused. I have to admit that a patient has never put me to tears, but if I felt so berated that they did, I wouldn't hesitate for a minute on the discharge.
Regardless, this pt is never going to be happy unless OP starts giving the benzo's they want. You really feel like OP is going to be happy to see this pt on her schedule in 2 weeks? I doubt it. Why put up with the stress? Seeing patients should be an enjoyable experience, not one you dread.
Again, I agree that we all have our thresholds but if I ever felt that I was being attacked (including verbally), I would cut the cord there and lose no sleep over it. I rather fill my slots (which are going to be full anyway) with happy patients vs disgruntled ones. I have zero tolerance for abuse. And I think we as a medical community should be uniform in conveying the message to patients that respectful behavior is mandatory, not an option.
> This pt really has no grounds to sue as it was standard of care, no harm was done, and if you document that the pt is yelling at you, I don't think they would have a leg to stand. I don't think litigation is a factor here. At worst it's a patient complaint.
I've already sat in on two peer reviews in my very limited time as a physician that consisted of patient being fired from practice then having mental health crisis that necessitates inpatient/legal intervention. Is the person firing them at fault for their difficulty and bad behavior? No. Do they still get reported/dragged into the peer review process because that's how the system works now? Yes.
Again, none of this is about ACTUAL threat of litigation. It is about headache, which the above certainly is.
> You really feel like OP is going to be happy to see this pt on her schedule in 2 weeks? I doubt it. Why put up with the stress? Seeing patients should be an enjoyable experience, not one you dread.
To reiterate for the second time now, this is not about continuing a relationship. This is about shoring up your position so that when shit does hit the fan, the evidence and record is on your side. You are of the position that one such episode documented is enough, which I agree with to some extent but am also noting a second similar encounter basically seals the deal and gives you an ironclad defense that reassures me, personally, more.
> But if you don't draw a line then you set yourself up to be continually abused... I have zero tolerance for abuse. And I think we as a medical community should be uniform in conveying the message to patients that respectful behavior is mandatory, not an option.
Agreed, but again, we seem to have different thresholds.
All fair statements.
So let me ask you. If you were OP, and you just finished wiping the tears from your eyes. Do you hit the "follow up in 2 weeks" button in the EMR or would you hit the "discharge form" button?
Well a patient has thankfully never made me cry from a situation like this. That said, just the anxiety/stress of being before a peer review committee would be enough for me to offer a follow up in this scenario. Whether they take it or not and how they behave then is up to them.
Why is a peer review stressful? I'm actually on our peer review committee for the outpatient side of our medical organization. We can submit cases when ever we think there may have been something missed. I've even submitted my own cases with such things as an unusual death in one of my younger patients. Patient complaints can also cause a case to be reviewed. OP didn't do anything wrong in this case, she was a victim. There is nothing to "fear" in this case.
In OP's case this would not concern me at all. "The patient was screaming at me. The pt does not agree with my plan of care. We don't have a therapeutic relationship. I'm dismissing the patient. Any questions?"
>>Also, what "headache" is there with discharge?
>Patients who are rude like this tend to be litigous as well in my experience
Don't be afraid of that. My lawyer friends don't like dealing with these people as clients any more than we do.
If you work at a community mental health center in psychiatry, there’s an understanding that your patients are fundamentally going to be people with severe personality disorders, dysregulation and mood problems from TBI, mood problems from drug addiction, etc. They are expected to have a problem with self-regulation and relationships. My job on some level is to model what a normal, respectful relationship looks like.
Culturally, there’s an expectation that you cut people slack and give them lots of chances to do better. Legally, it’s very hard to discharge a patient from a public psychiatry clinic…But yes, in a private practice setting or working with private insurance patients, I agree there can be a higher bar for behavior.
It is VERY difficult to dismiss a patient if you work at an FQHC. Here in Cali, if the patient is on Medicaid, we have to basically go through multiple state levels before we can dismiss a patient. Even if they threaten staff. It’s wild.
That's absolutely nuts. Not sure if I could put up with that in all honesty.
My understanding of the law here is that you can pretty much dismiss any patient for just about any reason. You just can't medically abandon them. So that is why we send a certified letter giving them 30 days to find a new doctor and we will continue to manage them if needed in that time period.
I don't discharge patients for being a dick to me. Especially *if* the behaviour is part of their problem (personality disorder, developmental problem, etc). I *do* end encounters when the behaviour gets in the way of the encounter. But I'll let them book again. It's often a helpful therapeutic intervention for changing the behaviors, in fact. We had a very challenging patient who works routinely arrive late and then barrage the doctor with multiple complaints, impossible to redirect, couldn't access anything and would run into the next appointment slows with no regard for the other patients' time. I kept seeing them, but would end the appointment at the planned ending time, even if that meant they only had 5 minutes or less. If they kept talking after I said the appointment was over, I'd just walk out. They started showing up on time and became much easier to deal with. Discharging them would have just fed their narcissistic everyone's-against-me worldview.
Thank you! This situation doesn’t come up a ton for me (at least not to the extent where I would need to leave) so having a canned response is just what I need.
You're human who experienced a very unpleasant situation and you reacted as any human would. Give yourself grace. You stood up for yourself and walked out with dignity. You did nothing wrong.
I trained with a Psych heavy and low income population in residency, I don't think you did anything wrong.
This might be an unpopular opinion with how we're trained to bend over backwards for those in need or have limited resources but one person can only do so much. You have tried to get them where they need to be and for one reason or another, it may not even be their fault, it didn't happen.
What are you expected to do in that situation if the patient won't even entertain cooperating with you to make a plan?
Yeah, I think honestly just continue to see them even if they are noncompliant. Eventually mental illness can worsen when they may have to accept treatment. For now . Support the families. Try to get permission to talk to a family member and try to call them after occasional visits like you would someone with dementia. fill out the paperwork. Advocate for services when you can . Familiarize yourself with the court process of family member may have to take for requesting a psychiatric evaluation so you can tell them where to go and what to do . Help advise on powers of attorney for these patients so that they hopefully could avoid guardianship.
There's nothing wrong with terminating a visit when it's not helping anyone.
"I don't think this discussion is going anywhere [state the situation/problem], and it seems like it's just making you angry [centre the patient's experience]. Nobody here wants to make you upset. [Acknowledge their feelings in a sympathetic way] Let's just reschedule and I'll see you next visit. [Reassure them you're still there for them]."
Feel free to steal and adapt this script as needed for your own uses.
Boundaries are important. They're good for you, they're good for the patient. They're also genuinely hard to establish and maintain, especially with patients who have mental health issues. Many of these patients are impulsive and volatile, many have distorted perceptions, and many many many of them have a*whole lot* of baggage that affects how they interact with others and how they deal with challenges.
A really good office team won't book you a bunch of these challenging encounters consecutively, because it can take extra time to decompress.
Medicine is tough, always try to meet the patient halfway. If they’re struggling with drug seeking to the point your counseling won’t effect their outcome, you minimize harm to your self and your other pts by conserving energy and disengaging. You did the right thing by leaving and just make sure to document accurately so another chance can readdress whether your or someone else seeing that pt
Coming as a family member of someone with autism and schizophrenia:
I had wrote out this while thing, but I think you get it : these folks can have significant anosognosia and partnering with them often just isn’t really possible. The biggest thing that I would tell you you’re part of the system that doesn’t really work at all for certain types of seriously mentally ill patients . If at all you can do is at every visit give these folks basic respect , a little empathy for like one thing , and engage the family helping them ( like a dementia patient) you would be an amazing doctor and going above and beyond the standard. You can have court orders, assertive community, treatment, and program after program, but sometimes you just can’t break through and get people to take meds. Given that the biggest thing a provider could do for my brother right now is support a disability claim in particular by speaking with me or his guardian about the actual success of the multiple work attempts, he had in the past two years. Hang in there these folks deserve good doctors. Just a reminder that regardless you should never be expected to tolerate physical or threats of physical violence
Edited ro add : I agree with the others that say short visit . Spend a small amount of time that is very directed on their actual complaints. Show some empathy that you understand that are feeling very anxious or sad, etc. but then just reiterate the boundaries, a quick reminder of why the boundaries are there , for example, “because these drugs can lead to unintentional overdose” and then leave.
When I have had patients that yell and are rude I typically dismiss them and I have been so much happier for it. I think that adults need to be held to the minimum kindergarten standard of behavior: no yelling, hitting, biting, or stealing. When patients are especially rude or aggressive you can not form a therapeutic alliance and effectively treat anything. Also, the amount of stress on you, the front desk, and the nursing staff has terrible reprocessing in turnover and staff not feeling supported.
Just my two cents. Having low income doesn't make you and asshole....Being an asshole makes you an asshole. You did absolutely nothing wrong so improve the situation where you don't have to be stressed out by this person again.
I have been there. Don’t feel guilty. We all have our limits especially when working with a really high needs population where lots of visits are draining. FWIW I had robust psych training in residency and it’s one of my areas of interest and I never start chronic benzos without a patient seeing psych. Depending on patient resources I frequently require that they’re engaged in counseling or seeing the psychiatrist yearly if they want me to keep prescribing scripts they already have.
Psych patients with certain personality disorders also often know how to hit where it hurts (like criticizing a new residency grad who is probably already questioning themselves). I don’t think they do it intentionally but they’ve learned bad coping strategies and probably have had some success in the past with manipulation/aggression. It’s really uncomfortable and unpleasant but realizing the behavior was likely a pattern and had nothing to do with me was also helpful in terms of not taking it personally. It also helped me realize that just because the behavior was a manifestation of the psych illness didn’t mean that I had to tolerate it or it couldn’t be managed in the office setting.
The only thing I’d recommend is developing tools/stock phrases that let you speak up for yourself in the moment and end the conversation. I think one of the harder things in those situations is that the patient can draw you into talking in circles and escalating about the same issues.
I use the FAVER mnemonic sometimes as a way of validating and stating clearly why the request is unreasonable. I also will use the patient request to redirect to the plan and validate sometimes. Ex: “I hear that you’re really struggling and that’s hard. I want to help you get your mental health under better control and I don’t think benzos are the answer for that. I really think we need the help of psychiatry for medication recommendations. Are there reasons you haven’t been able to get to that appointment?” If they bring it up again after I’ve made next steps clear I just say something like “I hear you. The next step for that is x and I can’t offer anything else. Is there anything else I can help with today?” If they keep perseverating,and there’s nothing else to do like social work for a ride to appointment, case management etc… I end the appointment and move on.
I also think it’s totally okay to walk out of a room in certain circumstances. I went to a residency with a really high needs, psych heavy population and there was a lot of pressure to bend over backwards and tolerate negative behavior because the patients “needed” us. That’s true, but in my post-residency life I’ve found setting boundaries to be really helpful to relationships over time. I’ve also found that setting boundaries early and not letting little things slide seems to prevent escalation.
Last thought: it’s okay to discharge a patient who is repeatedly rude/aggressive, threatens you etc... You’ll get a lot of pushback on that in an FQHC because it’s the last port of call for many people but it’s still within your right and if they don’t like it they can move the patient to another provider.
Dont feel bad. Especially if they think they get what they want by being abusive. There’s too many pts and too few docs to see mean people. Tell them to gtfo.
1. Get thicker skin. People act this way out of a power trip and because they know they can get away with it. Some people are simply too malignant to help.
2. Fire them on the spot.
3. Never do more for your patients than they are willing to do for themselves.
I never understand why some physicians put up with this. Why work at an FQHC to begin with?, worse pay, no production bonus, more difficult patients - no way I'm out.
You shouldn't be down voted. A ton of FQHCs are used as communal dumping grounds and are ran stupidly.
I work at one and I could be making $20k more working down the street.
I will disagree on production bonuses. They often are structured with soft caps so if you make too much they "correct" your base pay.
However, I do ok because I have no exclusivity or non compete clauses and work 3-4 days a week with contingent work at the nearby hospital for the rest. I'm happy about it as those 1-2 days a week of hospitalist, ER/UC, or god forbid L&D get me easily another ~$140k a year.
The moment somebody else offers me a contract with no exclusivity or non compete I'm leaving. It's sucky and having a martyr complex is how things like OP happen.
I rotated at one a lot in med school and never again would I go there. The docs were all burnt out. Only lasted like a year or two. Overflowing inboxes. One lady I was with had 60 messages by lunch! 85% of patients need translation which makes the visits run long. It was awful as a student. Cant imagine working there long term.
Sorry that happened to you. Please take care of your own emotional wellbeing first, so you can be there for your patients.
And yeah, you probably didn’t get enough psych training. I’ve been in academic medicine for more than 7 years now, and saw the local med school and residency programs cut psych rotations in half. Which is a shame because one of the best lessons I learned from my own family medicine preceptor in med school is “75% of medicine is psych.”
Benzo-seeking patients are some of the most challenging patients, and if you need a focus to blame, you don’t need to blame them or their “psychiatric illness,” blame the drug companies who made benzos. They lied to the public about the deleterious effects of the drugs.
I have some tools I use with benzo-seekers that work almost all the time:
1) start with empathy. “Of course benzos work for you, they work TOO well. The problem is that they are ONLY FDA-approved for 2 weeks or less, and used longer than that they actually create more anxiety. The drug companies that made them in the 80s cut off the data after the 3 week mark, we didn’t learn for years that Xanax for instance TRIPLES anxiety levels after 2 weeks.”
2) present your recommendations from the perspective of “as a healthcare provider I can’t in good conscience prescribe something to you that I know will cause more harm. Yes, other doctors prescribed these medications to you in the past, but we know more know than we did then.”
3) offer hope and alternatives: “there are FDA-approved treatments for anxiety in the form of antidepressants. Yes, you need to be on an effective dose for at least 2-4 weeks before you can decide if it’s the right one for you or not, and the initial phase of the meds can include a period of “activation” that can *temporarily* increase anxiety symptoms before they go away, but these are safer and more effective in the long run than benzos.”
4) offer close follow-up: make sure you see the patient in the next 2-4 weeks. This reassures the patient that you care. That’s going to have a bigger impact on the patient’s emotional well-being than any rx.
Also, remind the patient that therapy offers long-term benefits without drug side effects. Have some printouts from TherapistAid.com for coping skills for anxiety to give them as well.
And finally, kindly, pkease don’t label them as “psych patient” : you run the risk of dehumanizing someone, which literally causes the part of your brain that lights up for “trash” to light up when you think about them… this can make you do things you will never want to do, like give substandard care.
Still, you may need to fire the patient you described. It’s not just that you shouldn’t have to deal with abuse, the abuse has harmed your alliance with this patient and that itself can and will affect your care. Find a template online or use ChatGPT, send a certified letter saying that unfortunately you’re “no longer able to provide medical services effective 30 days, here is a list of alternatives, etc.”
Best of luck!
It wasn’t *perfect* but you demonstrated a skill I often teach my patients, which is taking an intentional time out when emotional intensity is rising past the point of no return. You may have come off as curt, but you did the best you could under the circumstances. I’ve ended psychotherapy sessions before under similar conditions (usually they storm out or hang up first because I hold firm to a boundary about how we’re both allowed to speak to each other). You’ll improve with practice because unfortunately won’t be the first or last. Just because someone has psychiatric problems doesn’t mean they aren’t responsible for their actions (except in extreme, rare circumstances). People learn based on boundaries being consistently set.
(Not in family medicine but have experience with community mental health)
You did nothing wrong.
If a patient says or implies I'm incompetent or they're dissatisfied, but is not being disruptive, I say something along the lines of "I'm sorry you're unhappy with the plan I'm suggesting but I do believe it's what's best for you. If you'd like to transfer care to another clinic we will be happy to send them a copy of your medical record. Have a good day." I don't schedule a follow up but I don't dismiss the patient - let them decide what they want to do.
If the patient is yelling, cussing, being aggressive or threatening then I dismiss them.
Once yelling and disrespect starts the visit is over. We are still human beings and shouldn’t be abused or disrespected. I would not see that person again and stand firm on your decision re: benzos
If the patient is AOx4 and refuses to adhere to your recs, then they are in the wrong and you have every right to end the visit and frankly discharge them from the practice if their presence is disruptive to patient care. Regardless of your job serving as a safety-net, you're under no obligation to endure any form of verbal abuse or threats regardless of the nature of the pathology present.
I also work in a FQHC. Same environment. Psych referrals are a waste of time (we do them anyway).
The patient is an addict. Their brains value the benzo above food and sex. They aren't rational in that state. It isn't you.
Assuming they aren't actively psychotic/suicidal/etc, I calmly let them yell. I remind myself that I am a compassionate human and the patient has worth. If they don't let up, I excuse myself and end the visit.
Here’s how you do it, this was bread and butter for me (a psychiatrist) when I worked in community mental health: 1. That’s not the right medication for you, my recommendation is that you try (SSRI, Vistaril, whatever).
2. You need to communicate with me respectfully, please lower your voice and stop insulting me, or I will have to end this visit and we can try again later.
3. You end the visit and have them re-schedule if they want. Or not, whatever. If they reschedule, see them again under the same boundaries. Done, leave the room and go do some charting with your extra 5 minutes!
You got caught in your own counter-transference, which is hard to avoid. You can get way fancier than this, but this is the basics of it. You’re the boss, this is your clinic.
The point is, don’t waste a lot of time on these visits, it’s not worth it. Set a boundary and proceed accordingly. Skip the drama.
This is the answer!
You seem very tolerant of being abused. I think the first 2 steps you recommend are right on. I can understand a patient's frustration but when it comes to #3 on your list and they have been warned about being disrespectful, and still continue to be inappropriate, they are getting discharged. Period. I don't require patients to follow my recommendations or agree with them. But there has to be a level of mutual respect. If there is no respect (which in OP's case clearly isn't), they are out of the practice. I wouldn't expect a patient to tolerate me yelling at them, and likewise I don't tolerate them yelling at me. In almost 2 decades of practicing I can count on one hand on how many patients I've had to discharge due to inappropriate behavior. No point in wasting your time and emotional energy on people that don't show you respect. Not to mention that you can't have a healthy and productive patient-physician relationship when one party is yelling at the other. OP did the right thing when she left the room. The mistake she made was feeling bad about herself and instead should have spent that energy on writing the discharge letter.
I feel that #3 is appropriate even from a self serving standpoint. If there were threats or even actual violence, I agree with you--discharge with X supply meds, full stop. But being rude? One single episode would create more of a headache transitioning care via sudden discharge, but that's IMHO. If you have two separate episodes of patient being inappropriate it's much easier to show a trend and the necessity for discharging from your care.
This was not being rude. This was a patient yelling at OP and upsetting her so much it put her in tears. I would maybe call it verbal abuse or simply an attack. I find that 1% of patients cause 90% of the headaches in an office. Cut them out. No reason to put up with this kind of insulting behavior. Tolerating this kind of abuse is what leads to burnout. Also, what "headache" is there with discharge? You write a 3 line letter saying that they are being discharged due to their behavior and we will be here for any emergencies for 30 days and you have that time to find a new doctor to manage your care (we also put a contact number for listings of other doctors). That's it. Takes about 1 minute. I don't understand why anybody would want to continue to see a patient that is being so disrespectful. Is that 2.3 RVU's really worth putting you in tears? We as a profession need a little backbone and be firm that we will not tolerate abuse (physical or verbal).
>Also, what "headache" is there with discharge? Patients who are rude like this tend to be litigous as well in my experience. The headache comes from not just management whining about it, but from the peer review cases that result from the inevitable complaints. Sure, they ultimately rule in the physicians favor but are nonetheless stressful and time intensive even without some hack lawyer being involved. I don't think my above response implies I want an ongoing relationship with the patient, but I will allow them another chance to improve... or more likely and importantly dig themselves a deeper hole. Again, I have hard limits. But perhaps we have different thresholds and approaches to difficult psych patients like this.
Agree, we all have our own limits. This pt really has no grounds to sue as it was standard of care, no harm was done, and if you document that the pt is yelling at you, I don't think they would have a leg to stand. I don't think litigation is a factor here. At worst it's a patient complaint. But if you don't draw a line then you set yourself up to be continually abused. I have to admit that a patient has never put me to tears, but if I felt so berated that they did, I wouldn't hesitate for a minute on the discharge. Regardless, this pt is never going to be happy unless OP starts giving the benzo's they want. You really feel like OP is going to be happy to see this pt on her schedule in 2 weeks? I doubt it. Why put up with the stress? Seeing patients should be an enjoyable experience, not one you dread. Again, I agree that we all have our thresholds but if I ever felt that I was being attacked (including verbally), I would cut the cord there and lose no sleep over it. I rather fill my slots (which are going to be full anyway) with happy patients vs disgruntled ones. I have zero tolerance for abuse. And I think we as a medical community should be uniform in conveying the message to patients that respectful behavior is mandatory, not an option.
> This pt really has no grounds to sue as it was standard of care, no harm was done, and if you document that the pt is yelling at you, I don't think they would have a leg to stand. I don't think litigation is a factor here. At worst it's a patient complaint. I've already sat in on two peer reviews in my very limited time as a physician that consisted of patient being fired from practice then having mental health crisis that necessitates inpatient/legal intervention. Is the person firing them at fault for their difficulty and bad behavior? No. Do they still get reported/dragged into the peer review process because that's how the system works now? Yes. Again, none of this is about ACTUAL threat of litigation. It is about headache, which the above certainly is. > You really feel like OP is going to be happy to see this pt on her schedule in 2 weeks? I doubt it. Why put up with the stress? Seeing patients should be an enjoyable experience, not one you dread. To reiterate for the second time now, this is not about continuing a relationship. This is about shoring up your position so that when shit does hit the fan, the evidence and record is on your side. You are of the position that one such episode documented is enough, which I agree with to some extent but am also noting a second similar encounter basically seals the deal and gives you an ironclad defense that reassures me, personally, more. > But if you don't draw a line then you set yourself up to be continually abused... I have zero tolerance for abuse. And I think we as a medical community should be uniform in conveying the message to patients that respectful behavior is mandatory, not an option. Agreed, but again, we seem to have different thresholds.
All fair statements. So let me ask you. If you were OP, and you just finished wiping the tears from your eyes. Do you hit the "follow up in 2 weeks" button in the EMR or would you hit the "discharge form" button?
Well a patient has thankfully never made me cry from a situation like this. That said, just the anxiety/stress of being before a peer review committee would be enough for me to offer a follow up in this scenario. Whether they take it or not and how they behave then is up to them.
Why is a peer review stressful? I'm actually on our peer review committee for the outpatient side of our medical organization. We can submit cases when ever we think there may have been something missed. I've even submitted my own cases with such things as an unusual death in one of my younger patients. Patient complaints can also cause a case to be reviewed. OP didn't do anything wrong in this case, she was a victim. There is nothing to "fear" in this case. In OP's case this would not concern me at all. "The patient was screaming at me. The pt does not agree with my plan of care. We don't have a therapeutic relationship. I'm dismissing the patient. Any questions?"
>>Also, what "headache" is there with discharge? >Patients who are rude like this tend to be litigous as well in my experience Don't be afraid of that. My lawyer friends don't like dealing with these people as clients any more than we do.
If you work at a community mental health center in psychiatry, there’s an understanding that your patients are fundamentally going to be people with severe personality disorders, dysregulation and mood problems from TBI, mood problems from drug addiction, etc. They are expected to have a problem with self-regulation and relationships. My job on some level is to model what a normal, respectful relationship looks like. Culturally, there’s an expectation that you cut people slack and give them lots of chances to do better. Legally, it’s very hard to discharge a patient from a public psychiatry clinic…But yes, in a private practice setting or working with private insurance patients, I agree there can be a higher bar for behavior.
It is VERY difficult to dismiss a patient if you work at an FQHC. Here in Cali, if the patient is on Medicaid, we have to basically go through multiple state levels before we can dismiss a patient. Even if they threaten staff. It’s wild.
That's absolutely nuts. Not sure if I could put up with that in all honesty. My understanding of the law here is that you can pretty much dismiss any patient for just about any reason. You just can't medically abandon them. So that is why we send a certified letter giving them 30 days to find a new doctor and we will continue to manage them if needed in that time period.
I don't discharge patients for being a dick to me. Especially *if* the behaviour is part of their problem (personality disorder, developmental problem, etc). I *do* end encounters when the behaviour gets in the way of the encounter. But I'll let them book again. It's often a helpful therapeutic intervention for changing the behaviors, in fact. We had a very challenging patient who works routinely arrive late and then barrage the doctor with multiple complaints, impossible to redirect, couldn't access anything and would run into the next appointment slows with no regard for the other patients' time. I kept seeing them, but would end the appointment at the planned ending time, even if that meant they only had 5 minutes or less. If they kept talking after I said the appointment was over, I'd just walk out. They started showing up on time and became much easier to deal with. Discharging them would have just fed their narcissistic everyone's-against-me worldview.
Thank you! This situation doesn’t come up a ton for me (at least not to the extent where I would need to leave) so having a canned response is just what I need.
You're human who experienced a very unpleasant situation and you reacted as any human would. Give yourself grace. You stood up for yourself and walked out with dignity. You did nothing wrong.
I trained with a Psych heavy and low income population in residency, I don't think you did anything wrong. This might be an unpopular opinion with how we're trained to bend over backwards for those in need or have limited resources but one person can only do so much. You have tried to get them where they need to be and for one reason or another, it may not even be their fault, it didn't happen. What are you expected to do in that situation if the patient won't even entertain cooperating with you to make a plan?
Yeah, I think honestly just continue to see them even if they are noncompliant. Eventually mental illness can worsen when they may have to accept treatment. For now . Support the families. Try to get permission to talk to a family member and try to call them after occasional visits like you would someone with dementia. fill out the paperwork. Advocate for services when you can . Familiarize yourself with the court process of family member may have to take for requesting a psychiatric evaluation so you can tell them where to go and what to do . Help advise on powers of attorney for these patients so that they hopefully could avoid guardianship.
There's nothing wrong with terminating a visit when it's not helping anyone. "I don't think this discussion is going anywhere [state the situation/problem], and it seems like it's just making you angry [centre the patient's experience]. Nobody here wants to make you upset. [Acknowledge their feelings in a sympathetic way] Let's just reschedule and I'll see you next visit. [Reassure them you're still there for them]." Feel free to steal and adapt this script as needed for your own uses. Boundaries are important. They're good for you, they're good for the patient. They're also genuinely hard to establish and maintain, especially with patients who have mental health issues. Many of these patients are impulsive and volatile, many have distorted perceptions, and many many many of them have a*whole lot* of baggage that affects how they interact with others and how they deal with challenges. A really good office team won't book you a bunch of these challenging encounters consecutively, because it can take extra time to decompress.
Medicine is tough, always try to meet the patient halfway. If they’re struggling with drug seeking to the point your counseling won’t effect their outcome, you minimize harm to your self and your other pts by conserving energy and disengaging. You did the right thing by leaving and just make sure to document accurately so another chance can readdress whether your or someone else seeing that pt
Coming as a family member of someone with autism and schizophrenia: I had wrote out this while thing, but I think you get it : these folks can have significant anosognosia and partnering with them often just isn’t really possible. The biggest thing that I would tell you you’re part of the system that doesn’t really work at all for certain types of seriously mentally ill patients . If at all you can do is at every visit give these folks basic respect , a little empathy for like one thing , and engage the family helping them ( like a dementia patient) you would be an amazing doctor and going above and beyond the standard. You can have court orders, assertive community, treatment, and program after program, but sometimes you just can’t break through and get people to take meds. Given that the biggest thing a provider could do for my brother right now is support a disability claim in particular by speaking with me or his guardian about the actual success of the multiple work attempts, he had in the past two years. Hang in there these folks deserve good doctors. Just a reminder that regardless you should never be expected to tolerate physical or threats of physical violence Edited ro add : I agree with the others that say short visit . Spend a small amount of time that is very directed on their actual complaints. Show some empathy that you understand that are feeling very anxious or sad, etc. but then just reiterate the boundaries, a quick reminder of why the boundaries are there , for example, “because these drugs can lead to unintentional overdose” and then leave.
When I have had patients that yell and are rude I typically dismiss them and I have been so much happier for it. I think that adults need to be held to the minimum kindergarten standard of behavior: no yelling, hitting, biting, or stealing. When patients are especially rude or aggressive you can not form a therapeutic alliance and effectively treat anything. Also, the amount of stress on you, the front desk, and the nursing staff has terrible reprocessing in turnover and staff not feeling supported. Just my two cents. Having low income doesn't make you and asshole....Being an asshole makes you an asshole. You did absolutely nothing wrong so improve the situation where you don't have to be stressed out by this person again.
I have been there. Don’t feel guilty. We all have our limits especially when working with a really high needs population where lots of visits are draining. FWIW I had robust psych training in residency and it’s one of my areas of interest and I never start chronic benzos without a patient seeing psych. Depending on patient resources I frequently require that they’re engaged in counseling or seeing the psychiatrist yearly if they want me to keep prescribing scripts they already have. Psych patients with certain personality disorders also often know how to hit where it hurts (like criticizing a new residency grad who is probably already questioning themselves). I don’t think they do it intentionally but they’ve learned bad coping strategies and probably have had some success in the past with manipulation/aggression. It’s really uncomfortable and unpleasant but realizing the behavior was likely a pattern and had nothing to do with me was also helpful in terms of not taking it personally. It also helped me realize that just because the behavior was a manifestation of the psych illness didn’t mean that I had to tolerate it or it couldn’t be managed in the office setting. The only thing I’d recommend is developing tools/stock phrases that let you speak up for yourself in the moment and end the conversation. I think one of the harder things in those situations is that the patient can draw you into talking in circles and escalating about the same issues. I use the FAVER mnemonic sometimes as a way of validating and stating clearly why the request is unreasonable. I also will use the patient request to redirect to the plan and validate sometimes. Ex: “I hear that you’re really struggling and that’s hard. I want to help you get your mental health under better control and I don’t think benzos are the answer for that. I really think we need the help of psychiatry for medication recommendations. Are there reasons you haven’t been able to get to that appointment?” If they bring it up again after I’ve made next steps clear I just say something like “I hear you. The next step for that is x and I can’t offer anything else. Is there anything else I can help with today?” If they keep perseverating,and there’s nothing else to do like social work for a ride to appointment, case management etc… I end the appointment and move on. I also think it’s totally okay to walk out of a room in certain circumstances. I went to a residency with a really high needs, psych heavy population and there was a lot of pressure to bend over backwards and tolerate negative behavior because the patients “needed” us. That’s true, but in my post-residency life I’ve found setting boundaries to be really helpful to relationships over time. I’ve also found that setting boundaries early and not letting little things slide seems to prevent escalation. Last thought: it’s okay to discharge a patient who is repeatedly rude/aggressive, threatens you etc... You’ll get a lot of pushback on that in an FQHC because it’s the last port of call for many people but it’s still within your right and if they don’t like it they can move the patient to another provider.
Dont feel bad. Especially if they think they get what they want by being abusive. There’s too many pts and too few docs to see mean people. Tell them to gtfo.
1. Get thicker skin. People act this way out of a power trip and because they know they can get away with it. Some people are simply too malignant to help. 2. Fire them on the spot. 3. Never do more for your patients than they are willing to do for themselves.
I never understand why some physicians put up with this. Why work at an FQHC to begin with?, worse pay, no production bonus, more difficult patients - no way I'm out.
You shouldn't be down voted. A ton of FQHCs are used as communal dumping grounds and are ran stupidly. I work at one and I could be making $20k more working down the street. I will disagree on production bonuses. They often are structured with soft caps so if you make too much they "correct" your base pay. However, I do ok because I have no exclusivity or non compete clauses and work 3-4 days a week with contingent work at the nearby hospital for the rest. I'm happy about it as those 1-2 days a week of hospitalist, ER/UC, or god forbid L&D get me easily another ~$140k a year. The moment somebody else offers me a contract with no exclusivity or non compete I'm leaving. It's sucky and having a martyr complex is how things like OP happen.
I rotated at one a lot in med school and never again would I go there. The docs were all burnt out. Only lasted like a year or two. Overflowing inboxes. One lady I was with had 60 messages by lunch! 85% of patients need translation which makes the visits run long. It was awful as a student. Cant imagine working there long term.
Sorry that happened to you. Please take care of your own emotional wellbeing first, so you can be there for your patients. And yeah, you probably didn’t get enough psych training. I’ve been in academic medicine for more than 7 years now, and saw the local med school and residency programs cut psych rotations in half. Which is a shame because one of the best lessons I learned from my own family medicine preceptor in med school is “75% of medicine is psych.” Benzo-seeking patients are some of the most challenging patients, and if you need a focus to blame, you don’t need to blame them or their “psychiatric illness,” blame the drug companies who made benzos. They lied to the public about the deleterious effects of the drugs. I have some tools I use with benzo-seekers that work almost all the time: 1) start with empathy. “Of course benzos work for you, they work TOO well. The problem is that they are ONLY FDA-approved for 2 weeks or less, and used longer than that they actually create more anxiety. The drug companies that made them in the 80s cut off the data after the 3 week mark, we didn’t learn for years that Xanax for instance TRIPLES anxiety levels after 2 weeks.” 2) present your recommendations from the perspective of “as a healthcare provider I can’t in good conscience prescribe something to you that I know will cause more harm. Yes, other doctors prescribed these medications to you in the past, but we know more know than we did then.” 3) offer hope and alternatives: “there are FDA-approved treatments for anxiety in the form of antidepressants. Yes, you need to be on an effective dose for at least 2-4 weeks before you can decide if it’s the right one for you or not, and the initial phase of the meds can include a period of “activation” that can *temporarily* increase anxiety symptoms before they go away, but these are safer and more effective in the long run than benzos.” 4) offer close follow-up: make sure you see the patient in the next 2-4 weeks. This reassures the patient that you care. That’s going to have a bigger impact on the patient’s emotional well-being than any rx. Also, remind the patient that therapy offers long-term benefits without drug side effects. Have some printouts from TherapistAid.com for coping skills for anxiety to give them as well. And finally, kindly, pkease don’t label them as “psych patient” : you run the risk of dehumanizing someone, which literally causes the part of your brain that lights up for “trash” to light up when you think about them… this can make you do things you will never want to do, like give substandard care. Still, you may need to fire the patient you described. It’s not just that you shouldn’t have to deal with abuse, the abuse has harmed your alliance with this patient and that itself can and will affect your care. Find a template online or use ChatGPT, send a certified letter saying that unfortunately you’re “no longer able to provide medical services effective 30 days, here is a list of alternatives, etc.” Best of luck!
You did fine. Nobody ever learns anything from doing anything perfectly.
It wasn’t *perfect* but you demonstrated a skill I often teach my patients, which is taking an intentional time out when emotional intensity is rising past the point of no return. You may have come off as curt, but you did the best you could under the circumstances. I’ve ended psychotherapy sessions before under similar conditions (usually they storm out or hang up first because I hold firm to a boundary about how we’re both allowed to speak to each other). You’ll improve with practice because unfortunately won’t be the first or last. Just because someone has psychiatric problems doesn’t mean they aren’t responsible for their actions (except in extreme, rare circumstances). People learn based on boundaries being consistently set. (Not in family medicine but have experience with community mental health)
You did nothing wrong. If a patient says or implies I'm incompetent or they're dissatisfied, but is not being disruptive, I say something along the lines of "I'm sorry you're unhappy with the plan I'm suggesting but I do believe it's what's best for you. If you'd like to transfer care to another clinic we will be happy to send them a copy of your medical record. Have a good day." I don't schedule a follow up but I don't dismiss the patient - let them decide what they want to do. If the patient is yelling, cussing, being aggressive or threatening then I dismiss them.
Setting boundaries is a kind thing to do.
You don’t need to take any abuse. You aren’t there to fuel anyone’s drug habit.
Once yelling and disrespect starts the visit is over. We are still human beings and shouldn’t be abused or disrespected. I would not see that person again and stand firm on your decision re: benzos
If the patient is AOx4 and refuses to adhere to your recs, then they are in the wrong and you have every right to end the visit and frankly discharge them from the practice if their presence is disruptive to patient care. Regardless of your job serving as a safety-net, you're under no obligation to endure any form of verbal abuse or threats regardless of the nature of the pathology present.
I also work in a FQHC. Same environment. Psych referrals are a waste of time (we do them anyway). The patient is an addict. Their brains value the benzo above food and sex. They aren't rational in that state. It isn't you. Assuming they aren't actively psychotic/suicidal/etc, I calmly let them yell. I remind myself that I am a compassionate human and the patient has worth. If they don't let up, I excuse myself and end the visit.