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Thread: termination of doctor-patinet relationship

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    termination of doctor-patinet relationship

    I sent a letter to a 14yo parents to terminate the dr-patient relationship after she complained of numerous concussions from cheerleading, yet the parents refused dfe (dilation) at 3 differents times (exam and cl fu's).

    Well, the RN mom and the Pharmacist dad sent a letter back stating how they have the right to refuse care and that refusal should not affect continuity of care (they used some former lawsuit or some law not in the state optometric law book).

    Has anyone ever heard of this??? They still want to keep coming to the practice to see my husband, but I think that's crap. It's not like we're the only optometrists around.

    They seem to think that my liability is lessened by them saying no to dilation, but when there is a RD, I know the first thing any OMD is gonna say looking at my records was that I should have dilated.

    If refusing to see a patient becasue they refuse your professional advice is illegal or unethical, what's the point of even being able to terminate the doctir-patient relationship??

    The best thing is they made a huge stink when the closest CL trials that I had were the correct rx in one eye and a .25 less minus for the other eye (they needed what was best for her then.... 20/20-- in one eye, 20/20 in the other!!- big whoop!)

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    bilateral peripheral scotoma LandLord's Avatar
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    Wave

    Tell them you'll see them but you're fully booked until 2010.

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    Did they actually give you the name of the ruleing? Chances are, their point is nill, because, as you said, you're not the only optometrist's office around. I'm no lawyer, but I would imagine you have every right to not see this person anymore. I can't see there being any laws that FORCE you to see someone when it puts you in a grey area when it comes to liability.

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    Has it crossed your mind that the patient may have a physician who takes care of thier body. Despite efforts by O.D.'s to elevate themselves to "optometric physician" status, many patients "just want a refraction."
    See an MD for matters physical (including trauma) and wouldn't take the diagnosis by a non-M.D. anyway.
    Just refract 'em and send them on thier way. Both you and the patient will be happy. Trust me, I have run more patient's off by fussing about things like: "Never wet your contacts in your mouth." "Have a check up every six months!" "Come see us everytime you have a problem." "Don't handle or rinse your lenses over the sink." "Wash your hands with Ivory Soap." "If your contacts hurt or bother you come see us after they have been worn for most of the day, don't just get a new one!
    Little "helpfull instances" like this have allowed me to run more patients off than most people have ever seen, much less run off.

    Chip:cheers:

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    Master OptiBoarder TLG's Avatar
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    I work for an Ophthalmologist. When we "fire" a patient we send them a certified letter stating so and allow them a specified amount of time, usually 30 days, to complete any current care.

    You really need to take a look at who you're dealing with here. Speaking as a father of 4, any activity my children were involved in that caused "numerous concussions" would be terminated due to my concern of their long term mental and physical health. These people are stupid and they are endangering their daughters health in a huge way. You need to get rid of them NOW. I can't imagine there's a law requiring you to provide care if there is an alternative in your community. If you are unsure of the laws in your state, do yourselves a favor and contact an attorney or your state association and find out so you can protect yourselves now and in the future. Good luck!

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    Master OptiBoarder OptiBoard Gold Supporter Judy Canty's Avatar
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    My son is a competitive cheerleader and a cheerleading coach. Cheerleading is responsible for more injuries than almost any other sport. That being said, if these parents are allowing their child to cheer in a facility without the proper flooring, spotters and trained staff, they are begging for more trouble than they can imagine. My suggestion would be to check with your attorney and then cut them loose via certified mail as was mentioned in an earlier post.

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    The idea of terminating care of a patient because you don't approve of thier behavior (other than hygene with the product you sell) is rediculous. Would you terminate, sky divers, welders, sheet metal workers, police officers, motorcycle riders, professional football players (of course not, they have money and you get prestige for treating them) and the like. All these things are dangerous. These people all need help from the rigors of their activities from time to time.
    Remembe we are in the Optical Business not emergency room care. If you see a problem with their eye or glasses, fix it. If you happen to see something that should be treated or examined by a physician, tell the patient, your responsiblilty ends there.
    Even people that work in optical labs cut themselves (at least when the work was glass) daily, so what. If it needs sewed up, or iodine on it send them to the doctor or paint it with iodine, don't make them change jobs, we need them.

    Chip

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    ATO Member HarryChiling's Avatar
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    Quote Originally Posted by scograd View Post
    I sent a letter to a 14yo parents to terminate the dr-patient relationship after she complained of numerous concussions from cheerleading, yet the parents refused dfe (dilation) at 3 differents times (exam and cl fu's).

    Well, the RN mom and the Pharmacist dad sent a letter back stating how they have the right to refuse care and that refusal should not affect continuity of care (they used some former lawsuit or some law not in the state optometric law book).

    Has anyone ever heard of this??? They still want to keep coming to the practice to see my husband, but I think that's crap. It's not like we're the only optometrists around.

    They seem to think that my liability is lessened by them saying no to dilation, but when there is a RD, I know the first thing any OMD is gonna say looking at my records was that I should have dilated.

    If refusing to see a patient becasue they refuse your professional advice is illegal or unethical, what's the point of even being able to terminate the doctir-patient relationship??

    The best thing is they made a huge stink when the closest CL trials that I had were the correct rx in one eye and a .25 less minus for the other eye (they needed what was best for her then.... 20/20-- in one eye, 20/20 in the other!!- big whoop!)
    Negligence changes a lot of things and if their negligence leads to harm they could be in a heap of trouble. If you wanted to you could probably report them to child services, if you truly felt that the child was in danger; then of course make sure you have documentation. Sounds like a horrible situation, personally if a doctor I go see is that alarmed that they are willing to to terminate our relationship that should send a red flag up.

    As an RN and a Pharmacist they should be even more ashamed of their behaviour.
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    I did send the original termination letter via cert. mail with return receipt.

    Here's the "good" parts of their letter back to me:

    Canterbury v. Spence- "it is the perogative of the patient not the physician to determine for himself the direction in which the interests seem to lie. In contrast, the arguments for the 'professional' standard smack of an anachronistic paternalism that is at odd with any strong conception of a patient's right to self determination."

    Also some tidbit about pts bill of rights in NJ (for hospitals), the patient has the right to refuse treatment to the extent permitted by law and to be informed of the medical consequences of such and the right to expect reasonable continuity of care.

    If all that were true, we'd never be liable for anything, nor would we even be able to determine the doctor patient relationship, would we??

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    All I got from that was that it's up to the patient to decide what course of treatment is right for them. Which is fine and dandy, they refused dilation, you didn't dilate. No where in there does it say you have to keep treating them.

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    ATO Member HarryChiling's Avatar
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    http://www.stanford.edu/group/psylaw...Canterbury.htm

    Canterbury vs. Spence - that was totally out of context and isn't even remotely close to the content of the case, sounds like they're blowing smoke at you doc.
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    Master OptiBoarder rbaker's Avatar
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    Quote Originally Posted by scograd View Post
    I did send the original termination letter via cert. mail with return receipt.

    Here's the "good" parts of their letter back to me:

    Canterbury v. Spence- "it is the perogative of the patient not the physician to determine for himself the direction in which the interests seem to lie. In contrast, the arguments for the 'professional' standard smack of an anachronistic paternalism that is at odd with any strong conception of a patient's right to self determination."

    Also some tidbit about pts bill of rights in NJ (for hospitals), the patient has the right to refuse treatment to the extent permitted by law and to be informed of the medical consequences of such and the right to expect reasonable continuity of care.

    If all that were true, we'd never be liable for anything, nor would we even be able to determine the doctor patient relationship, would we??
    The focus of this ruling seems to be the definition of the word "physician." Are you a "physician?" If so, your feet will be held to the fire as such. If not, don't worry.

    You really can not ride on both ends of the see-saw at the same time. You can not chose to be a "physician" when it is convenient for you and avoid being a "physician" when things turn sour.

    Is you is or is you isn't a doctor of medicine?
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    Let them be 'held to the fire' all they want. No where in there does it say that the physician has to continue treating the patient if he or she doesn't want to. It's all about the patients right to refuse treatment. And as I said before, they never broke that rule. They didn't want the dilation, they didn't get it.

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    There is in the law a situation called "abandonment". A physician must provide an avenue for the patient to recieve future care before "abandoning" them. I don't think this applies to opticians and ocularists as I often tell prosthetic eye patients to seek help elsewhere once they have accrued three no-show appointments.

    One cannot refuse treatment of an "emergency" patient who presents.

    One cannot refuse continueing care on contact lenses for example unless you present the patient with somewhere else (other than where you would lke to tell them to go when infuriated) to secure care.


    Chip

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    ATO Member HarryChiling's Avatar
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    Quote Originally Posted by chip anderson View Post
    There is in the law a situation called "abandonment". A physician must provide an avenue for the patient to recieve future care before "abandoning" them. I don't think this applies to opticians and ocularists as I often tell prosthetic eye patients to seek help elsewhere once they have accrued three no-show appointments.

    One cannot refuse treatment of an "emergency" patient who presents.

    One cannot refuse continueing care on contact lenses for example unless you present the patient with somewhere else (other than where you would lke to tell them to go when infuriated) to secure care.


    Chip
    I would agree with that. In this case the doctor can't find out if it is an emergency because he/she can't look passed the superficial because the patient is refusing treatment.
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    Patient is not refusing treatment. Patient is refusing exam and diagnosis. What can an O.D. do to treat concussion anyway? Maybe see if one pupil is larger?

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    The primary concern is that there might be an asymptomatic retinal tear which could turn into a retinal detachment without treatment. Ever hear of boxers getting retinal detachments from a blow to the head?

    NYS law holds ODs to the same standard of care as a "physician" in the diagnosis and treatment of ocular disease. Other states do the same.

    So, if an OD is presented with your scenario, and you limited yourself to optical care only, (such as examining for, and dispensing new contacts or glasses), you WILL be liable if things go south. I would not move forward with any optical treatments unless the medical end of things were taken care of. You should not prescribe contacts if you have any unmet concerns about tests which are necessary in your professional judgement. Even if you document in your records that the patient (or the parents) declined, YOU are responsible to make sure the eye is free of disease. Caselaw on this issue is clear.

    So, then I suppose if you decline to prescribe or dispense further CLs unless the medical tests are done, (either by you or someone else) then the patient has the option to go somewhere else.

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    In our practice, (Ophthalmology) it is our regular risk managment policy that any patient that goes against medical advice that is detrimental to their health, or does not follow up as advised--again people that have conditions that can result in vision loss, (like glaucoma vs cataracts) they are given 3 chances--no shows, etc. and they are warned of discharge from the practice. If they persist, then they are discharged and we tell them we will forward their records to the practice of choice. We are obligated to see them in an emergency situation and we will, but only for that reason. We will not continue care of their chronic issues.

    In the case of kids, its a different story all together. Children are at their parent's mercy so to speak. When a parent does not follow medical advice and it is something that can result in harm to the child, it is considered neglect and we report it to Social Services. It may seem harsh, however, as an example, we have had situations where patching a child has ended up in harming the good eye from over patching and the parent not following up properly. Our latest was a parent whose child has glaucoma that is not well controlled. They are chronic with no-shows and don't medicate properly.

    That's how we do it.

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    Bad address email on file NC-OD's Avatar
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    Quote Originally Posted by chip anderson View Post
    Has it crossed your mind that the patient may have a physician who takes care of thier body. Despite efforts by O.D.'s to elevate themselves to "optometric physician" status, many patients "just want a refraction."
    See an MD for matters physical (including trauma) and wouldn't take the diagnosis by a non-M.D. anyway.
    Chip:cheers:
    DING. DING. DING. THIS IS YOUR MONHTLY UNNECESSARY OPTOMETRIST BASHING ON OPTIBOARD. THIS MESSAGE (AS USUAL) WAS BROUGHT TO YOU BY THE HIGHLY UNINFORMED MR. ANDERSON.

    SCOgrad, you are doing the right thing. Cut this patient loose and let his parents be someone elses problem. You are free to discontinue care at any time and I would.
    Last edited by NC-OD; 12-08-2007 at 07:23 PM.

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    Ophthalmic Optician OptiBoard Gold Supporter
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    Now that's profound!

    Quote Originally Posted by NC-OD View Post
    DING. DING. DING. THIS IS YOUR MONHTLY UNNECESSARY OPTOMETRIST BASHING ON OPTIBOARD.
    Sorry about that...I'll talk to Chip and make sure he only bashes ODs when it is absolutely necessary.:hammer:
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    Quote Originally Posted by chip anderson View Post
    Has it crossed your mind that the patient may have a physician who takes care of thier body. Despite efforts by O.D.'s to elevate themselves to "optometric physician" status, many patients "just want a refraction."
    Chip:cheers:
    If they just want a refraction, I'd send them to the cut-rate rent-a-doc at the closest price war dispensary.

    When a patient with symptoms of a retinal detachment receives only a refraction from the examiner whom is qualified to diagnose their problem, the examiner loses in court. If you were serving the patient and your license was on the line, you'd think a lot differently.

    Quote Originally Posted by chip anderson View Post
    The idea of terminating care of a patient because you don't approve of thier behavior (other than hygene with the product you sell) is rediculous. Would you terminate, sky divers, welders, sheet metal workers, police officers, motorcycle riders, professional football players (of course not, they have money and you get prestige for treating them) and the like. All these things are dangerous. These people all need help from the rigors of their activities from time to time.
    The idea of unqualified patients being permitted to govern what is to be included in their care is ridiculous. It harms everyone involved. Those welders, police officers, etc., usually allow us to do whatever is necessary to help them. They don't normally limit our care to some foolhardy idea of what they think they need.

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    Ophthalmic Optician OptiBoard Gold Supporter
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    Quote Originally Posted by icare View Post
    The idea of unqualified patients being permitted to govern what is to be included in their care is ridiculous. It harms everyone involved. Those welders, police officers, etc., usually allow us to do whatever is necessary to help them. They don't normally limit our care to some foolhardy idea of what they think they need.
    It shouldn't matter what you are...nobody should be able to demand service under their terms, especially if their terms aren't in their best interest!

    Whether you're a bartender, an optician, a mechanic, or an OD; if it's your practice/business, it should be up to you to decide whether or not you want to serve someone.

    We've refused to deal with patients for no other reason than they are just not pleasant to deal with.
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    Even if an O.D. does see a patient and happen to observe that he has a retinal tear, what can he do? Just refer the patient to an OMD or preferably an OMD retinal specialist. For this drops, or vitamins just ain't gonna help. Which all boils down to the patient should have been sent to an M.D. first without the OMD being need in the loop at all.

    Chip

    Yeah, you can take some more shots if you want to. This is not O.D. bashing just reality.

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    why not have them sign a waiver everytime you ask to dilate...if it goes to court, youll have that on your side.
    equal opportunity offender!!

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    Quote Originally Posted by chip anderson View Post
    Even if an O.D. does see a patient and happen to observe that he has a retinal tear, what can he do? Just refer the patient to an OMD or preferably an OMD retinal specialist. For this drops, or vitamins just ain't gonna help. Which all boils down to the patient should have been sent to an M.D. first without the OMD being need in the loop at all.

    Chip

    Yeah, you can take some more shots if you want to. This is not O.D. bashing just reality.
    So you're suggesting that anyone with symptoms of flashing lights or new floaters should just call up their local retinal OMD directly, for that 1 in 20 or so risk that it is a retinal tear? I mean really, what is the general ophthalmologist going to do? They don't do retinal surgery.

    The retinal guys in your area must love you, Chip.

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