On Firing Patients

Occasionally having to fire patients is one of the downsides of having an acupuncture practice. If accessibility is one of your goals, deliberately cutting off someone’s access to your clinic is one of the more stressful things you’ll have to do, but it’s inevitable. If you’re treating enough humans to have a sustainable practice, you’re treating enough humans so that every now and then, things will go off the rails with one of them and you will have to end the relationship. At WCA it happens rarely -- I can’t think of more than a dozen times in nineteen years -- and every time, we hate it.

As noted elsewhere, we believe that firing patients should only ever be about their behavior in the clinic. And if you’re considering firing someone, you should double-check yourself for unconscious bias: if a different sort of person engaged in the same behavior, would you still fire them?

The most common reason that we’ve fired patients, over the years, is for going off on WCA receptionists. This kind of “going off” is different from the kind of meltdown a person might have when they’re triggered: those bursts of anger or tears or other disregulated behavior that happen at least a couple of times a month, that everybody can recover from enough for the patient to still use the clinic. By contrast, behavior that leads to firing a patient is so intense, so disruptive, or so repetitive that it indicates a fundamentally bad fit between the patient and WCA; it’s the kind of behavior that would make it impossible for WCA to operate with the limited resources that it has. For example, a person calling back over and over on the same day to see if there are any openings on the schedule, and then yelling, “Fuck you!” to the polite receptionist trying to explain that there aren’t any, and “Fuck you all!” to the acupuncturists trying to help them.

Other behaviors that we’ve fired patients over have happened in the treatment room instead of at the front desk, but the formula is the same: something that’s so intense, so disruptive, or so repetitive that it indicates problems that we can’t resolve and also can’t live with. This can encompass everything from a patient who refuses to stop taking calls on their cellphone and having noisy conversations in the treatment room, to a patient whose anxiety is so severe that they can’t keep themselves from yelling for their acupuncturist to come back and check on them every ten minutes to see if the treatment is working yet, to a patient who makes all of the female-identified acupuncturists uncomfortable with repeated boundary-crossing “compliments” and “polite conversation” -- such as asking which car in the parking lot is theirs (!) -- and who won’t stop when asked.

One of the reasons that WCA has to fire patients relatively rarely is that we’re a large, multi-punk clinic, so that if a patient crosses a boundary with one punk, we usually have the option to give them a second chance with a different punk. Here are a couple of actual conversations that have happened over the years (names have been changed to protect the innocent):

“I’m sorry, Mr. Male Identified Patient with boundary issues, but I have to let you know that you can’t schedule with Myrtle, the acupuncturist you’ve been seeing, anymore. You called Myrtle (a female-identified punk) “baby” and “sweetie” one too many times, and also followed her with your eyes across the treatment room, and also caressed her hand while she was trying to needle you, thus making it difficult for her to do her job. So from now on you are welcome to schedule appointments with Sebastian (a male-identified punk who is willing to give you another chance) -- as long as you don’t call him baby or sweetie or stare at him or caress his hand, he won’t like it either.”

“Dear Mx. Patient whom we have been treating for 10+ years for stress and anger management issues, we regret to inform you that you will no longer be able to schedule appointments with Riley, the acupuncturist who has been your regular practitioner. Apparently, last Thursday Riley was slightly late in getting to you because it was a busy shift, you were angry about having to wait, and you berated Riley so intensely that multiple other patients who witnessed the incident emailed WCA management to check in about whether Riley was okay, and also to ensure that we know that they didn’t do anything to deserve this (since you were yelling that they should be fired -- so loudly that people in the other treatment room could hear you). You have a number of credits on your account and you may schedule future appointments with Sebastian or Myrtle. But not Riley. Also, we have to let you know that WCA can’t allow this kind of thing to happen again, ever. Please let us know if you would like a refund instead.”

In both these cases, setting the boundary resulted in the patient not returning to the clinic, so it turned out to be a lot like firing them. (For an example of giving a second chance that worked out, see Anatomy of a Safety Incident #2) Sometimes offering a second chance isn’t possible or advisable and you have to actually fire someone, however. I wish there were more of a trauma-informed way to do this -- please email us if you know of one and I’ll write a follow-up. (That said, there are definitely LESS trauma-informed ways to do this floating around out there. Pro tip: you don't need to put extra energy into shaming anybody while you're firing them.)

The Oregon Medical Board has requirements for ending the patient-provider relationship, which you can find here. Most licensing boards will have similar instructions for their licensees.

Here’s the basic template WCA uses (to be sent by email, letter, and certified mail, just to make sure it gets there):

Re: termination of services at Working Class Acupuncture

Dear _____,

please be advised, effective (30 days/immediately), Working Class Acupuncture will no longer provide services to you.

We regret that there has been an irrevocable breakdown of trust impacting our ability to welcome you into our clinics or provide care for you.

On (date), (things happened). As a nonprofit community clinic that depends on both volunteer receptionists and a low cost, high volume model, we can’t accommodate this kind of disruptive behavior directed at our staff and/or volunteers.

We encourage you to continue care with another acupuncturist or primary health care provider. With your consent, we will be happy to provide any healthcare provider with a copy of your WCA medical records.

Here are some resources that provide care at an accessible cost or can help in other ways:

Mercy and Wisdom (low cost acupuncture) Phone: (503) 227-1222

Multnomah County Mental Health Crisis Intervention (503) 988-4888 or (800) 716-9769

Wallace Medical Concern (503) 489 -1670

We wish you continued health,

WCA staff

Sonya Gregg, WCA Cully’s Clinic Manager, put together this checklist:

How to Fire a Patient
1) Always fill out an incident report - these can be found here sync: frequent use files -> safety circle WCA -> Fired Patients letters, documentation etc.
2) Please be specific with the times, dates etc so the info/narrative is as accurate as possible and upload it to the patient file.
3) Review recent chart notes to make sure you and other punks documented any other relevant information. If you missed anything, put an update in the “notes” section.
4) Might seem obv but leave the patient’s appointment in the scheduler even if they leave in a huff without getting treated - we need to document their presence at the clinic.
5) Check in with a group of people from the collective (other punks who treat/have treated them, managers etc) - this allows for you to get support and feedback and to share duties involved with deciding whether this is a termination situation or a warning. Collective members want to know what's going on (because we learn and can better handle things in the future) and help each other take next steps.
6) Often a phone call to the patient is the next step (but not always) . It doesn't necessarily have to be the punk who dealt with the original incident - especially if they are busy, still ticked off or whatever else. Clinic managers/coordinators, other punks etc can do this too. Again document the phone call and upload it to the patient file.
7) If it is time to fire the patient you can find a few template letters in sync: frequent use files -> safety circle WCA -> Fired Patients letters, documentation etc. Make sure the referrals in the letter are accurate and still available. This should be on letterhead and sent as an email, snail mail AND sent Signature Required (you have to go to the post office for this).Remember to upload it to the patient file.
8) You will want to make a note of it on the patient's profile - even possibly adding TERMINATED to their name - and a note to the notes box on their profile so if they try to book it will be obvious to the volunteers.
9) Keep everyone in the loop so they know what you are doing/have done and ask for help when you need it!
10) Definitely debrief with your comrades! It's stressful to deal with this on top of everything else - thankfully it's a rare occurrence.

Essentially, firing a patient is about holding a boundary for the clinic as a whole. Access isn’t really access if all you have to offer people, once you let them in, is chaos -- which means you can’t treat patients who generate chaos too intensely and/or too consistently for you to handle.