Patients who want to fire their hospitalist: What should you do?

WHAT SHOULD YOU do when there are patients who want to fire their hospitalist?

While it doesn’t happen often, patients do sometime ask to fire their hospitalist, says Naznin Jamal, MD. The request often stems from a disagreement with pain management, overall treatment or a discharge plan.

“In the last 12 months, a colleague learned from a nurse that a patient and family wanted to ‘dismiss’ him,” says Dr. Jamal, hospitalist medical director at Jefferson Regional Medical Center in Pine Bluff, Ark. “But he was able to talk to them about their concerns, and the dismissal was then removed.”

That’s the outcome for the vast majority of patient requests for a different hospitalist, she adds. But in the few instances where the communication between a doctor and patient can’t be repaired, Dr. Jamal points out that her hospital maintains a formal policy that it follows when patients want to change their inpatient provider.

“We really take each request on a case-by-case basis because there are so many nuances.”

Ijeoma Carol Nwelue, MD
Baylor Scott & White All Saints Medical Center

Are hospitalists singled out for such requests because they see so many patients? “No,” says Dr. Jamal. “I think physicians of all specialties are running into this.”

Sources say that an increase in patient requests to switch doctors may be a byproduct of the distrust that’s crept into health care since the pandemic. Some hospitalist groups, like Dr. Jamal’s, can turn to formal policies or protocols, while others do not, approaching each such request individually.

All groups, however, are trying to strike a balance between meeting patients where they are and making sure that clinicians feel safe and valued—and that group leadership has hospitalists’ back.

Offering a second opinion

Given how much lack of continuity is already built into hospitalizations—between the ED and the wards, from physicians switching seven-on/seven-off, different doctors providing weekend coverage—it’s no wonder that hospitalists make strenuous efforts to maintain their roster of patients.

“Any time there is discontinuity, there’s a loss of clinical information and a need to rebuild a trusting relationship,” says Chris Reynolds, MD, hospitalist medical director at Rochester General Hospital, the tertiary/quartenary center of Rochester Regional Health in Rochester, N.Y. “That’s why we try hard to address patient or family concerns and maintain relationships.”

Fortunately, Dr. Reynolds adds, in 90% of cases where patients or families ask to switch providers, “we can coach our colleagues in how to sit down with them and address their concerns.”

As Ijeoma Carol Nwelue, MD, chief of hospital medicine at Baylor Scott & White All Saints Medical Center in Ft. Worth, Texas, points out, “We don’t have one policy across our health system that states we should always switch doctors in a specific situation. We really take each request on a case-by-case basis because there are so many nuances.”

What helps in her hospital, Dr. Nwelue adds, is having options in terms of different hospitalist services. Her own group has teaching, nonteaching and resident services. But there’s also a separate hospitalist group that’s owned independently.

“Our policy is that if one of our group members is dismissed, then our whole group is being dismissed as well.”

Naznin Jamal, MD
Jefferson Regional Medical Center

In most instances where patients claim they want a new doctor, “we are able to address any concern the patient has and continue their care,” she says. But when there’s still disagreement over a treatment or discharge plan, “the other hospitalist group will offer patients a second opinion.” That group may decide to accept the patient—or, says Dr. Nwelue, “the other group come back to us saying, ‘We’ve reviewed the case and you all are already doing everything we would do. We don’t see any reason for a transfer.’ We athen report this back to the patient.”

More often than not, she notes, that review satisfies the patient or family, “and we then will continue their care.”

Mediation via a social worker

In Pine Bluff, Ark., Dr. Jamal’s group is the hospital’s largest (and only employed) hospitalist program. But other hospitalists also work there.

“We have individual community physicians who continue to admit patients for their practices,” she points out. “We also have a sole hospitalist practitioner who works on his own instead of in a group setting.”

For another look at how to work with patients who want to fire their hospitalist, see previous coverage from Today’s Hospitalist.

When patients or families are dissatisfied with the care provided by one of her group members, the first step “is to try and troubleshoot that problem with that colleague, talking about different standards and techniques they can try to resolve the issue.”

But if the patient or family still wants to change doctors, “our policy is that a social worker then gets involved.” (Moving to have a social worker mediate such requests has been the policy now for two or three years, Dr. Jamal explains. Previously, the doctor being dismissed was responsible for finding another physician to whom the patient could be reassigned.)

The social worker will continue to try to assuage a patient’s or family’s concerns. But if that fails and change is the only course, “our policy is that if one of our group members is dismissed, then our whole group is being dismissed as well.” The social worker then reaches out to the facility’s other hospitalists to find one willing to take over that patient’s care.

“One patient demanded a new doctor because, as the patient put it, ‘his attending was brown.’ “

Anil Job, MD
Rochester Regional Health

“We don’t make those calls ourselves,” says Dr. Jamal. “When the social workers find a physician ready to take the patient, we then have a doc-to-doc conversation about the treatment plan.” Such changes work both ways, she adds. While members of her group may be dismissed by patients perhaps only twice a year, her group accepts more patients from the other hospitalists working in her facility.

When requests aren’t granted

At Rochester Regional Health in Rochester, N.Y., Anil Job, MD, a hospitalist who now heads up the health system’s transfer command center, points out that requests to dismiss doctors started out as one-off incidents. But they have increased to the point where several such requests crop up each year.

That led him and Dr. Reynolds—along with several of their colleagues—to start thinking about how to systematically approach such asks.

What are instances where they’ve decided to grant such requests? Now, within five hospitals in the Rochester Regional Health system, patients may change providers—as long as an alternate one is available—in situations where a provider may have committed a significant clinical error or a patient’s current provider triggers anxiety over past trauma. An example: Patients who have experienced sexual assault may request a provider of a different gender.

However, the hospitalists have decided to not grant such requests in instances where doctors suspect Munchausen syndrome or a patient is having a dispute with his or her physician over schedule II drugs.

“In such cases, we generally have success explaining to a patient that that isn’t a reason to change your doctor—and that it isn’t good to go shopping around from one doctor to another,” says Dr. Reynolds. “Instead, we try to help patients in situations where they have substance use disorder. If they don’t, we at least work to repair their relationship with their physician.”

Requests for change also won’t be granted in cases where a discharge is being appealed or where a Hospital-Issued Notice of Noncoverage (HINN) has been issued.

Identity-based requests

Then there’s the issue of patients requesting a new doctor based on a physician’s identity: ethnicity, religion, gender or age.

“We want to protect our staff and let our physicians know that their leadership will stand with them.”

Chris Reynolds, MD
Rochester Regional Health

According to Dr. Jamal, such identity-based requests can be “difficult to identify.” That’s because “that’s often not the reason why patients and family members say they’re requesting a new doctor. While that view might be supported by other comments the patient or family has made, we can’t really prove it.” Still, if the request stands after one of the hospital’s social workers tries to mediate, “we try to move as efficiently as we can to get another physician on board.”

But in Rochester, Dr. Job says, that sentiment on the part of patients may be very straightforward. “We actually had one patient who demanded a new doctor because, as the patient put it, ‘his attending was brown,’ ” he points out. The hospitalist group has decided to not grant such requests. In such situations, the medical director or the director on call will get involved and provide support to the physician being challenged.

At the same time, says Dr. Reynolds, when a physician in such a situation no longer feels he or she can engage constructively with a patient, hospitalist leaders do assign that patient to another physician within their group.

On any given day, he points out, “we have 20-some hospitalists onsite. We want to protect our staff from that experience, so we need to find the right balance. It’s a way to preserve staff retention—and to let our physicians know that their leadership will stand with them.”

But if such a re-assignment takes place, Dr. Job notes that it happens only once. “I have gone into a patient’s room and said, ‘We will assign a different physician to your case, but I don’t know who that will be at this time—and it may not fulfill your request.’ ” The only other option would be for patients to identify their own alternate attending and have their care transferred—a solution that no patient has ever opted for yet.

In Ft. Worth, Dr. Nwelue notes that she also has come across doctors who don’t feel comfortable staying on a case.

“I’ve heard physicians say, ‘If they are not comfortable with me on their care team, that’s not a safe place for me from a liability standpoint and I don’t want to be there,’ ” she says. In such cases, the patient may be switched over to another rounding team within the group.

Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.

For more stories on patients and their relationships with hospitalists, read the following stories.

How hospitals are addressing bad behavior by patients and their families

Strategies to work with patients who are rude to their physicians/hospitalists

How to talk to patients in the hospital who want a new doctor

Is it OK for patients to record conversations with their physicians?