I am going to start off this article by saying that I am conflict avoidant in most instances that don’t involve my personal family or perhaps someone trying to get the last pineapple kombucha at the supermarket. I am that APP, you know, the one who will see you if you show up late. My medical assistants hate me some days, but we are specialty and I understand that a new patient may have trouble finding the office. There are times, however, that I will not hesitate to tell someone to find a new gastroenterology office to get their care from. Having to dismiss a patient from a practice is a difficult situation and in larger group practices may already be handled by scheduling. In smaller offices, the clinician is the one to make the decision. There are a few times I feel it’s necessary and within good, ethical practice to let a patient go. (Note: I have the blessing and backing of my physicians on this — so I advise before taking any of the below advice that APPs have the blessing of their supervising physicians.)
1) When Patients Exhibit Inappropriate Language or Behavior
If patients make innuendoes or crude remarks, are abusive in speech or action in ANY way toward me or the staff, or choose to defame us as clinicians online, they will be looking for a new GI office. It’s understandable if someone has had an issue with the practice, but it is not acceptable to trash talk us before bringing the issue up with us first in a professional manner. We are working hard seeing patients, dealing with insurance companies, and handling reports and results, and we are not OK with being sexually harassed or abused because a patient had a bad day and thought yelling at someone over the phone was the solution. Abuse and violence toward clinicians, especially APPs, is an ongoing issue, and one that we will not tolerate.
2) When Patients Shop Around
The second time it’s OK to part ways is when you find out the patient is shopping clinicians to get a “second opinion.” If I have done my due diligence and through diagnostics, labs, and imaging have determined a working diagnosis that a patient disagrees with, that is OK. I’m very open to discussing and educating on how I came to that conclusion. Sometimes I will even bring the physician in to also discuss it (I always discuss these things ahead of time with my doctors). What is not OK is when a patient goes to three other GI clinicians in the area and comes back to me a year later with the same symptoms. In the face of the same symptoms, my workup and diagnosis stands. I have taken time and used thoughtful decision-making to sort out the details of a condition; if I am correct and have relied on the evidence base, then it isn’t a problem that I’m questioned, it’s a problem that the patient went behind my back and doesn’t trust my judgment. In this instance, we can no longer be in a patient/clinician relationship.
3) When Patients Repeatedly Miss Appointments
Referrals are our bread and butter in speciality practices. We do have an open access plan for screening colonoscopy in GI, but most of my patients are either self-referred through open access for a problem, or they are referred by their PCP. When a patient is referred to GI, it is because their clinician is trying to help find out what the complaint is related to, and if it’s even an issue of the gastrointestinal tract. It really does range across the entire GI system if you’re an APP in a generalist GI practice. If a patient of ours doesn’t show up repeatedly (three strike rule), then they won’t be allowed to reschedule again. In the event that they continue to not show and reschedule, we’ll send letters to their PCP so they are aware. Scheduling is an issue at our office and nationwide, especially with physician shortages in gastroenterology. We do, however, pride ourselves on being able to get people in with little to no wait for health concerns. If a patient takes the spot and repeatedly does not show up, that just leaves someone else waiting.
4) When Patients Are Noncompliant with Monitoring and Follow-Up
I don’t often run into issues with patients being compliant with a treatment plan. Most people are thrilled to finally figure out what was causing their gastrointestinal problems. There are times though when we have to let a patient go because they just will not do required monitoring or follow-up endoscopic procedures that manage their disease. This happens most often with IBD, cirrhosis, or another chronic issue that requires follow-ups. We don’t monitor these diseases to make it harder on people; rather, we want to keep patients healthy and make sure we aren’t causing damage to end organs with medical treatments designed to keep chronic illness in remission.
For these patients we try to be very clear up front about what the disease monitoring looks like and what their time estimates will be. An example is an ulcerative colitis patient on a biosimilar drug to control their disease. We need to get blood counts, check liver function with certain drugs, review annual labs to refill their medications, and monitor issues related to flare-ups. Sometimes we may just need to schedule a repeat surveillance colonoscopy. If a patient isn’t coming in for monitoring, we can’t refill medications (insurance requires some of the labs annually), and we risk someone having increased cancer risk for their noncompliance. That may sound like defensive medicine, but it is considered good practice and is part of the guidelines for managing IBD.
5) When Patients Can’t Pay for Services
The last issue is a delicate one. I’ll try to plead my case, while not being insensitive to the costs associated with health care, insurance, medications, and imaging. In another article on Op-Med, I referenced the economy and poverty issues that create barriers to care in Tennessee. Those same barriers to care exist in this scenario. Copays for speciality are higher than PCP visits; procedures may be diagnostic and not as well covered by insurance as a screening colonoscopy is. We also see uninsured patients who have to pay cash. We do our best to offset their costs and allow all patients to make payments. At my former employer, patients were sent to collections often and it didn’t sit well with me. My current office is willing to work with people on their expenses to avoid this issue, but sadly, we have to refuse to see patients because they carry a balance and just don’t seem to be bothered by it or can’t pay it off. Maybe that’s a harsh view, maybe I’m jaded, but we aren’t a large hospital practice. We are small, with an endoscopy center on site. Our expenses have to be covered or people don’t get paid.
Ultimately, it is rare for me to make the call to let an established patient go. Sometimes they elect to see someone else and we dismiss them for change of GI clinicians. It may also be the call of our office manager and billing to deal with non-pay for services. I don’t step into firing a patient lightly and I don’t think you should either. I tend to try and give patients the benefit of the doubt and I will even call them to see if I can help address their complaint, while holding firm on my anti-abuse stance. Letting patients go is a big deal, and should only be done when the circumstances demand it. As the old saying goes, “Treat people as you wish to be treated.”
Have you ever had to let a patient go? Share the circumstances in the comments.
Allison Falin is a nurse practitioner in Maryville, TN. She enjoys weightlifting, hiking in her nearby Smokies, and just being outside. She has practiced as a NP for 11 years and RN for a cumulative 27. She and her husband have three adult children and four dogs. She is on threads as @alliefnp. Allison was a 2024–2025 Doximity Op-Med Fellow.
Illustration by April Brust
