Attitudes and perceptions of pain physicians regarding patients terminated from practice

Between 10-60% of all patients exhibit “difficult behavior” demonstrating anger, mistrust and a tendency toward being argumentative and non-compliant. Although termination of the doctor-patient relationship by the patient is frequent, the reverse is rare. Enhanced knowledge of a patient’s potential for behaviors that are not compatible with maintaining a symbiotic physician-patient relationship in a chronic pain management setting may help pain physicians anticipate potential problems. The authors conducted a survey of pain physicians to determine an estimate of the annual rate of patient terminations from pain clinics, clarify the behavioral characteristics of terminated patients, and assess reasons for termination. A 34 question survey was sent to the physician members of the American Society of Interventional Pain Physicians. Most of the 188 respondents were non-academic practitioners. Most respondents (76.1%) terminated less than 20 patients per year. These patients were more likely to be males, between 25-45 years of age, who were on disability, and had been in the practice for less than 6 months. Nearly all physicians found prescription monitoring program (PMP) helpful to identify patients who were non-compliant with the mission of the clinic and provide objective evidence to support termination. The terminated patients frequently had a history of substance use or personality disorder. These patients were often treated simultaneously with ≥3 opioid medications. Terminated patients tended to present as needy but would soon exhibit aggressive or intimidating behavior, or continue to engage in negative health behaviors. The most common reasons for termination were violation of pain contract, positive urine test for illicit substance, and use of multiple prescribers. It may be useful to establish strict boundaries and have low tolerance to deviant behavior for patients who have at-risk characteristics. Regular review and discussion of data provided by PMP may improve physician confidence and patient compliance with management plan.