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Medscape Now! Special Edition Hot Topics July 2023

  • Authors: News Author: Christine Lehmann, MA; CME Author: Hennah Patel, MPharm, RPh
  • CME / ABIM MOC / CE Released: 7/11/2023
  • Valid for credit through: 7/11/2024, 11:59 PM EST
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This activity is intended for primary care physicians (PCPs), physician assistants (PAs), nurse practitioners (NPs), nurses, pharmacists, and other healthcare professionals (HCPs) involved in patient care.

The goal of this activity is for learners to be better able to evaluate and implement emerging data and guidelines into patient care.

Upon completion of this activity, participants will:

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    • Recent advances in medicine that are improving patient care
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News Author

  • Christine Lehmann, MA

    Freelance writer, Medscape


    Christine Lehmann, MA, has no relevant financial relationships.

CME Author

  • Hennah Patel, MPharm, RPh

    Freelance writer, Medscape


    Hennah Patel, MPharm, RPh, has no relevant financial relationships.

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  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC​


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    Director, Accreditation and Compliance, Medscape, LLC​


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Medscape Now! Special Edition Hot Topics July 2023

Authors: News Author: Christine Lehmann, MA; CME Author: Hennah Patel, MPharm, RPhFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/11/2023

Valid for credit through: 7/11/2024, 11:59 PM EST


Findings from new clinical studies continue to be reported on a daily basis, making it challenging for the interdisciplinary healthcare team to stay up to date with the latest medical advancements. In this special edition article, we discuss the management of pregnancy-related emergencies, difficult patients and new government legislation that has implications for prescribers.


It is estimated that spontaneous abortion (miscarriage), defined as loss of pregnancy under 20 weeks of gestation, impacts around one-quarter of all pregnancies. Treatment modalities for abortion include pharmacotherapy and surgery.[1,2] A new Kaiser Family Foundation (KFF) survey of office-based OB/GYNs found widespread effects on their practices and patients since the US Supreme Court's decision in Dobbs vs Jackson Women's Health Organization 1 year ago.[3]

In states with abortion bans, half say that they have patients who have been unable to obtain an abortion, about four in ten say that they have faced constraints on their care for miscarriages and pregnancy-related emergencies, and six in ten (61%) express concerns about legal risk when making decisions about patient care. Nearly as many OB/GYNs practicing in states with gestational limits on abortion also say they faced such challenges in their practices.

Among all OB/GYNs nationally, one in four (24%) say they have had patients who could not obtain an abortion they sought. More than 4 in 10 (42%) OBGYNs nationally report being very or somewhat concerned about their own legal risk when making decisions about patient care and the need for an abortion. Furthermore, large shares of OB/GYNs believe that the Dobbs decision has also exacerbated pregnancy-related mortality (64%), racial and ethnic inequities in maternal health (70%) and made it harder to attract new OB/GYNs to the field (55%).

The survey finds that 60% of OB/GYNs in states where abortion is banned report their decision-making autonomy has worsened, and 55% say it is more difficult to practice within the standards of care, which are the norms of medical treatment.

Additional findings include:

  • More than half (55%) of all OB/GYNs say they have seen an increase in the share of patients seeking some form of contraception since the Dobbs ruling, particularly sterilization (43%) and intrauterine devices (IUDs) and implants (47%)
  • Nationally, 18% of office-based OB/GYNs say they provide abortion services after the Dobbs decision, statistically unchanged from before Dobbs
  • Three-in-10 (30%) OB/GYNs practicing in states where abortion is banned say they do not provide, refer, or offer any resources for abortion services to their patients. Nearly half (48%) say they only offer information, such as online resources, to help patients seek out abortion services on their own

The KFF 2023 National OB/GYN Survey obtained responses from a nationally representative sample of OB/GYNs practicing in the United States who provide sexual and reproductive health care to patients in office-based settings. From March 17 to May 18, 2023, survey responses were collected from 569 OB/GYNs.

Read "A National Survey of OB/GYNs' Experiences After Dobbs" for details about the provision of sexual and reproductive health care provided by OBGYNs before and after the Dobbs decision.[3]

  • The interprofessional team should be aware of recent legislative changes around abortion
  • The team should discuss suitable pregnancy management options with patients, within this new framework


Approximately 15% of patient and clinician interactions are rated as ‘difficult’ by the reporting clinicians.[4] Ending these patient–clinician relationships can put the patient in a challenging situation; as such, it is only allowed under certain circumstances. Legal and ethical considerations may influence decisions about dismissing challenging patients.[5]

Some patients continually cancel their appointments, ignore medical directions, treat staff rudely, or send harassing emails. Do you have to tolerate their behavior?

No, these are all appropriate reasons to terminate patients, attorneys say. Patients also can be dismissed for misleading clinicians about their past medical history, chronic drug-seeking, displaying threatening or seductive behavior toward staff members, or any criminal behavior in the office, experts say.

But even if a reason seems legitimate, that doesn't make it legal. Clinicians should consider whether the reason is legal, said Chicago-area attorney Ericka Adler, JD, a partner at Roetzel & Andress, who advises clinicians about terminating patients. "Although a physician may think a reason to terminate a patient is legitimate, they should always be mindful of whether there is a legal concern at issue and consult with counsel if they're unsure," Adler said.

Terminating patients for an "illegal" reason such as discrimination based on race or gender or sexual orientation — even if couched as a legitimate patient issue — could open the practice to a lawsuit, Adler said. Clinicians also want to avoid patient abandonment claims by talking to the patient about problems and documenting them as they arise. If they can't be resolved, they should ensure that there's continuity of care when patients change clinicians, said Adler.

About 90% of physicians have dismissed at least one patient during their career, according to a study of nearly 800 primary care practices.[6] The most common reasons were legitimate: a patient was "extremely disruptive and/or behaved inappropriately toward clinicians or staff"; a patient had "violated chronic pain and controlled substance policies"; and a patient had "repeatedly missed appointments." 

Jacqui O'Kane, DO, a family physician at South Georgia Medical Center in rural Nashville, Georgia, said she has dismissed about 15 of 3000 patients she has seen in the past 3 years at the clinic. Before she dismisses a patient, she looks at whether there has been a pattern of behavior and tries to talk to them about the problem first to find out if there are other reasons for it. She also gives patients a warning: if the unacceptable behavior continues, it will lead to their dismissal.

When Patients Cross a Line

O'Kane warned an elderly man who used a derogatory term with her that she wouldn't tolerate that language in her office. Then, when he later called her front office employee using derogatory language, she decided to dismiss him. "I said, 'That's it, you can't say that to someone in this office. I already told you once and you did it again. I'm sorry you have to find another doctor," said O'Kane.

Another patient crossed a line when she missed four appointments, refused to come in, and kept sending O'Kane long messages in the electronic chart demanding medications and advice.

Another common reason clinicians dismiss patients is for non-payment, says Adler. Recently, however, some patients have also begun demanding their money back for services already received and billed because they were unhappy about something that occurred at the office, said Adler. "I advise clinicians to respond: 'We disagree that you didn't get the service, but we will give you your money back and we're also terminating you from our practice.' At that point, the clinician-patient relationship has become impossible," said Adler.

How to Dismiss Difficult Patients Ethically and Legally

According to the American Medical Association's (AMA's) Council on Ethical and Judicial Affairs,[7] a physician may not discontinue treatment of a patient, if further treatment is medically indicated, without giving the patient reasonable notice and sufficient opportunity to make alternative arrangements for care. Terminating a patient abruptly without transferring their care could lead to a claim of patient abandonment and the physician being called before a licensing board for potentially violating the state's Medical Practice Act, said Adler.

Clinicians can take these six steps to set the stage for dismissal and avoid a claim of patient abandonment.

1. Create written policies. Medical practices can describe their rules and behavior they expect from patients in these policies, which can cover, for example, payment, treating staff with courtesy, and medications. "When the rules are in writing and patients sign off on them, that gives doctors a certain comfort level in being able to refer to them and say that the patient hasn't been compliant," said Adler. She also recommends that your practice create a policy that doctors should let the patient know about their concerns and meet with them to discuss the problem before receiving a termination letter.

2. Document any consistent problems you are having with a patient. When you start having problems with a patient, you should document when the problem occurred, how often it occurred, any discussions with the patient about the problem, warnings you gave the patient, and if, and when, you decided to terminate the patient.

3. Meet with the patient to discuss the problem. "Talking and meeting with a patient also allows the physician to assess whether there's another issue. For example, is there a mental health concern? Is there a financial reason for non-payment or no-shows? There are multiple benefits to finding out what the problem is," said Adler.

Once you've decided to terminate a patient, here's what you should do:

4. Allow enough time for the patient to find alternative care. Adler recommends giving patients 30 days' notice, and that clinicians offer to provide emergency care during that time. However, if the patient is undergoing treatment or has other challenges, more time may be needed to transfer care.

"It's important to consider the patient's context — if the patient is receiving cancer treatment, or is in a late stage of pregnancy, or lives in a rural area where few specialists are available, you may want to treat them longer — at least until they finish their treatment," said Adler. Also, states may have their own requirements about minimum notice periods, she said.

5. Provide patients with written notice that you intend to terminate their care. Adler recommends that each letter be tailored to the patient's specific circumstances. "You could spell out a patient's history of noncompliance or non-payment or inappropriate conduct because it's been documented and the patient is already aware of it from a previous discussion," she said. Adler also recommends that doctors consult with legal counsel when in doubt or if contacted by the patient's lawyer. Some lawyers will draft the termination letters, she said.

6. Include the following information in the written letter: The date that they will no longer receive care, how they can obtain copies of their medical records, and how they can find a new clinician by providing contact information for a state medical association or similar organization, which often maintains a database of clinicians by specialty and location. The letter should also state that they will continue to provide emergency care during the 30 days. Adler also recommends sending the notice by certified mail.

O'Kane said she may be more likely to give patients a second chance because she practices in a rural underserved area, and she understands that her patients don't have many other options for healthcare. She also has developed a reputation for being willing to take on difficult patients that other physicians didn't want to deal with, she said. She encourages physicians to talk to patients to find out why, for example, they may not be compliant with medications. The patient may say, "I had to choose between paying for medications and putting food on the table,' " said O'Kane.

  • The interprofessional team should be mindful of the legal and ethical considerations around terminating clinician–patient relationships
  • If care is to be terminated, appropriate notice and information on finding alternative medical care should be given to the patient


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