Are More Doctors Cherry-Picking and Lemon-Dropping Patients?

Leigh Page

Disclosures

February 15, 2017

In This Article

The Right to Select Patients

In fact, most doctors have exercised their right to select patients. A 2008 survey[4] of primary care physicians published in the Journal of General Internal Medicine found that up to 85% had dismissed a patient, usually for verbal abuse or drug-seeking behavior. However, only 14% of them had dismissed more than 10 patients altogether.

In line with this very selective use of dismissals, the new AMA code restricts the right to reject prospective patients to "certain limited circumstances," such as the physician's lack of expertise or lack of needed resources, or when patients are abusive.

The code's fourth circumstance, however, is a wide-open category. It states that physicians can exclude patients who "could seriously compromise" their ability to treat other patients. Conceivably, nonadherent and high-acuity patients might make a medical practice lose money and thus could "seriously compromise" its ability to treat other patients.

Once patients have been accepted into the practice, the AMA code seems, at first glance, to be unequivocally against dropping them. "Physicians should not decline patients for whom they have accepted a contractual obligation to provide care," it states, without creating any exceptions. Later on, however, it sets up a process for "terminating a patient-physician relationship."

Nonadherence is "a weak reason" for dismissing patients, according a 2013 article[5] in the ACP Internist paraphrasing Lois Snyder Sulmasy, director of the Center for Ethics at the American College of Physicians (ACP). "It would be wrong to discriminate against obese patients or smokers," she told the ACP publication. "These are the very people who need help."

Timothy Pawlik, MD, a colon cancer surgeon who is chair of surgery at the Ohio State University, had a similar opinion in a 2009 article[6] in the Journal of Oncology Practice, which he lead-authored when he worked at Johns Hopkins. Rather than dismiss a cancer patient who won't give up smoking, "the oncologist should provide the patient with appropriate treatment that accounts for the patient's smoking-related comorbidities and includes an appropriate complement of supportive care," the authors stated.

Practicing Physicians Have Their Own Views

Some physicians simply ignore the advice of the ethicists. The 2008 survey in the Journal of General Internal Medicine found that almost one quarter of the surveyed primary care physicians were willing to dismiss nonadherent patients.

This finding shocked the authors of the study, who stated, "Such physician behavior has serious ethical and medical ramifications for patients who are cared for by physicians in pay-for-performance programs."

However, many doctors get upset with flagrantly nonadherent patients, regardless of whether their outcomes would affect payment. "I would have a low threshold for dismissing noncompliant patients, especially if they missed appointments or did not take their medication," an internist commented in the Medscape poll.

Furthermore, some physicians reject the idea that they should work with patients to get them to be more adherent. They say this isn't their job—and in any case, it's hard to get reimbursed for the extra work.

Deciding whether to cherry-pick should be a personal decision, says Keith C. Borglum, a healthcare business consultant in Santa Rosa, California. "There's no one answer on how you should select patients," he says. "It has to do with your own ethical framework—what lets you sleep at night."

Some physicians have come up with their own parameters. In comments to the Medscape survey, a neurologist said he would limit cherry-picking to conditions that aren't life-threatening. "For migraine headache or Parkinson disease, I would definitely cherry-pick," he said. "For a life-threatening condition, such as epilepsy or a cerebrovascular event, I would not."

Others say their ethics shouldn't be any different from that of any businessman. "The ethical obligation to society that separates a physician from, say, a businessman, is no longer valid," an internist commented on a previous Medscape article on cherry-picking, in 2013. Physicians with limited payment have to care for "the legions of chronically ill obese diabetics," he wrote, in essence justifying physicians' choice to cherry-pick as a form of professional self-preservation.

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