One of the greatest joys of being a physical therapist is interacting with patients. There is truly no feeling in the world like helping someone improve his or her mobility and independence.
But, as enjoyable as patient care can be, it’s not always sunshine and roses. There’s no guarantee that every patient will treat us with respect. In fact, some even act in a threatening way toward us. And while most therapists have some war stories, it’s not always clear how to best handle these situations.
That’s why we created this post covering five legitimate reasons to fire a PT patient. To make this post as relevant to real life as possible, we did a little crowdsourcing from PTs to find out why they’ve had to fire patients over the years. Then, we asked Veda Collmer, In-House Counsel and Chief Compliance Officer at WebPT—who also happens to be a non-clinical occupational therapist—to weigh in on how to handle some of the trickiest situations that may arise when firing patients.
Reason #1: The patient is treating you disrespectfully.
When a patient treats you disrespectfully, you’ll often find yourself straddling a fine line between setting better boundaries and simply firing the patient. Sometimes, patients don’t even realize they’re doing anything wrong if we don’t say anything. But, when it comes to deciding whether to fire the patient or keep him on with stipulations, it really depends on your own comfort level—as well as the comfort of your other patients and coworkers.
Here are a few situations when firing a patient due to disrespect might make sense:
- A patient verbally abuses you, your coworkers, or other patients.
- A patient consistently arrives late, cancels, or no-shows.
- A patient acts in a manipulative or passive-aggressive manner.
A Real-Life Example
“I confronted a patient for calling our front desk receptionist bad names and demanding that he be scheduled for a follow-up immediately. We then both agreed it would be best if he not continue with us.” - Sarah Conover, PT, MHS
How to Do It
Make sure you document the exact scenario(s) that caused you to fire the patient. Collect feedback from other staff members and/or patients who might have encountered this patient so you have additional support for your case.
Then, take the patient aside and explain that her actions or words are inappropriate and counterproductive to the recovery process. Be sure to cite examples of this conduct, explain that this particular facility is not a fit for her at this time, and wish her well in her recovery.
Reason #2: The patient is being threatening.
At times, a patient’s inappropriate behavior escalates to the point where you, your patients, or your coworkers feel unsafe. Patient comments can feel especially threatening or predatory if they’re sexual in nature. Collmer points out that, as helping professionals, PTs see many patients with developmental or behavioral health disorders, which can cause friction in some cases. Still, as Collmer explains, “If the patient's behavior cannot be managed, or the physical therapist perceives the behavior as threatening or harassing, it's time to end the relationship.”
Here are a few instances when you might need to fire a threatening patient:
- A patient repeatedly contacts you outside of the professional setting without your consent.
- A patient is physically aggressive or sexually inappropriate.
- A patient attempts to lie, cheat, or steal from you.
- A patient or family member makes you feel privy to unsafe or illegal activity.
Some Real-Life Examples
“A coworker of mine had to fire a patient who started stalking her...he showed up outside her house one day!” - Juliana Bruner, PT, DPT
“A patient made sexual comments not only to me, but to all the other female patients.” - Evelyn Capdevila, PT, MPT, of The Insider PT
“I’ve walked into a situation where I was there to treat an elderly person, but walked past a room of 6-8 other people sitting down passing drugs.” - Susan Butler, PTA
“I ‘fire’ patients or clients that are rude, argumentative, make derogatory or sexual comments to anyone or feel they know more than I/my team does. If they come in with a negative attitude, I can't help them much, no matter how wonderful or great my techniques or treatments are. If they dictate what things should be, they don't need me.” - Miye Fonseca, PT, DPT, of Therapy Exam Prep
How to Do It
Safety is of utmost concern in these cases, and it’s imperative to document each instance of feeling unsafe in the patient’s medical record before you give him the boot. Collmer points out that if the patient has harmed other patients, you might need to report the incident to law enforcement or other applicable agencies. She also stresses the importance of following the practice’s incident reporting protocol, which may include informing a supervisor of the incident and completing a report detailing the facts. “If the patient was referred by a physician, the physical therapist should notify the physician that the patient was discharged due to safety concerns,” she said.
Reason #3: The patient isn’t making progress.
This one can be a bit heartbreaking. By definition, our job as PTs is to help patients improve their functional mobility. Some patients work incredibly hard, but they simply aren’t progressing toward their goals. Unfortunately, if a patient isn’t making appreciable gains—even if he is working incredibly hard toward his goals—it’s sometimes appropriate to refer him out for other interventions.
Here are a few instances when firing a patient due to lack of progress might make sense:
- A patient has tried multiple treatment approaches in PT and is not making functional gains.
- A patient has worked with multiple therapists at your practice and hasn’t made improvements.
- A patient is unwilling or unable to put in the necessary effort to continue progressing.
How to Do It
Be gentle. Keep in mind that it can be devastating to hear that you’ve reached a plateau in recovery, especially after a life-altering injury or illness. In these cases, it’s helpful to have information from the patient’s insurance plan handy, so you can point out that his care will no longer be reimbursed if he isn’t progressing. If at all possible, offer him a few alternative resources, such as local gyms or even cash-based, wellness, telehealth PT services that your clinic offers.
Reason #4: The patient is malingering or “working the system.”
There are some patients who simply don’t want to return to work. Others have a dysfunctional need for attention, or they are in some other situation that leads them to take advantage of you or your practice. These patients can often be challenging to “fire” because of their motivations, but keeping them on your schedule is inappropriate—and it takes time away from patients who truly need your help.
Here are a few instances when firing a patient due to malingering might make sense:
- A patient is caught lying, faking pain, or feigning immobility.
- A patient moves from therapist to therapist to advance his or her agenda in any way possible.
- A patient tells you that he or she is trying to avoid returning to work.
Some Real-Life Examples
“The patient would be seen in the hallway of the ALF standing up out of her wheelchair and walking through the hallway independently—whereas in all PT/OT sessions, she would need help simply repositioning in the wheelchair she ‘owed her life to’ (her words).” - Brittany Ferri, MS, OTR/L, CLT
“I had a patient on workers’ comp who consistently reported 9-10/10 back pain without relief. But during sessions, he was able to do planks and ball exercises, walk on the treadmill at an incline, and told stories about how he builds furniture since he wasn’t working.” - Alaina Hess, PT, DPT
How to Do It
This can be a touchy subject, as many malingerers aren’t even necessarily aware that they’re doing what they’re doing! As in so many other cases, documentation is key. When you have documented examples to reference, the patient has less opportunity to deny culpability. Also, be sure to let the patient’s physician know what transpired so he or she is in the loop.
Reason #5: The patient is putting in zero effort.
One of the more frustrating reasons that we wind up firing patients lies in their apathy toward their own health. Some patients simply expect the PT to do all the work, preferring to lie on the table for passive treatments.
Here are a few instances when firing a patient due to lack of effort makes sense:
- A patient is non-compliant with his or her HEP, despite multiple attempts to tweak the program and work with the patient on compliance strategies.
- A patient repeatedly cancels appointments.
- A patient demands passive treatments only.
Some Real-Life Examples
“I fire patients when I care more about their well-being than they do. It’s exhausting, and I just can’t help them if they won’t help themselves first. They have to want to get better before I will be able to do anything to improve their situation. Most people come around, but some just won’t.” - Sarah Gonçalves, PT, DPT, of The Pediatric Physical Therapist
“I fired a patient who only wanted to show up and do cervical traction and nothing else. After I got his insurance to pay for a home unit, he still wanted to come in for sessions to get more disability pay. He had refused to participate in PT at all, and just wanted cervical traction with the same unit he has at home. At one point, he told me to ‘$%& off and mind my own business.’" - Ashley Shrum, PT, DPT, of Calibrated Physical Therapy
How to Do It
In these types of cases, it’s best to give the patient a chance to explain the rationale behind the behavior, just in case there’s anything you might have failed to do on your end. If the patient can’t explain her behavior and refuses to change, it’s appropriate to discharge her from care. Before doing so, however, consider recommending that the patient work with another therapist, as there may simply be a personality conflict.
Keep in mind that patients will sometimes fire you!
There are, of course, always instances when patients will opt to fire you—and it’s generally nothing personal. Maybe they don’t vibe well with your personality, or perhaps they feel like they’re not progressing quickly enough. Sometimes, it’s simply a case of a long commute or some other outside factor. But getting fired happens, and it’s best not to take it personally.
Emily Kelly, PT, DPT, points out that this can be a good thing: “Sometimes it just isn’t a fit between me and a patient—and I think we should be okay with that as a profession.” She explains that PTs are people with unique personalities, just like all of our patients are unique—and we cannot be everything to every patient. So, we should allow patients to “fire us” without taking it personally. Furthermore, she says, these personality incompatibilities can sometimes cause the sort of friction that would eventually lead us to fire the patient: “If someone is not compliant, maybe we are not addressing their needs, or maybe the patient is not ready for what we are offering,” she explains.
What about you? Have you ever had to fire a patient from PT? Please share your stories in the comment section below!
Meredith Castin, PT, DPT, is the founder of The Non-Clinical PT, a career development resource designed to help physical, occupational, and speech therapy professionals leverage their degrees in non-clinical ways.