Managing Your Practice: Answers to your questions about. . .

A patient who declines care

Q. I have a patient who is refusing a procedure that I believe she needs to have. What should I do to protect her health and to reduce my liability exposure?

Q. I'm an ob/gyn in search of a job. Should I sign up with a headhunter or is it better to apply directly for positions?

If you prefer to search without a recruiter, there are many good sources of information on available positions, including the classifieds in journals such as Contemporary OB/GYN and the "Ob/Gyn Employment" section of the ACOG Website ( http://www.acog.org/). Another option is to send a cover letter and your CV to the practices and hospitals in the geographic area you're targeting. Craft your letter and CV carefully and be sure they contain no typos, because they are your introduction, and they make a critical first impression on a prospective employer. In the cover letter, explain what type of position you are seeking and highlight your qualifications. Your CV should follow a well-established standard format, such as is available on the Web at http://about.com/ (go to http:// http://jobsearch.about.com/od/cvsamples/a/cvtemplate.htm for specifics).

If you're in your final year of residency, start your job search early, and ideally, no later than October. It's common for practices looking to add a young colleague to recruit between September and December.

Discharging a patient

Q. We occasionally encounter a patient whose attitude is so difficult that we feel it would be best not to have her in our practice. How do we discharge a patient with minimal offense to her and maximal protection for our practice?

To discharge a patient, I recommend the following, which is generally consistent with ACOG guidelines: First, notify the patient that you feel it's best for her to receive obstetrical/gynecological care from another practitioner. Do this via a certified letter similar to the one in Figure 2 that uses neutral language and does not specify a reason for the discharge. In the letter, stipulate that you will provide medical services to the patient for a period of 30 days and will see her for emergencies during that time period. In closing, refer the patient to an appropriate local medical society or hospital that can give her names of ob/gyns in the area who can assume her care. Make sure that your staff is aware of the discharge, and authorize them to make emergency appointments, but no other appointments, for the discharged patient until the termination date.

Send the patient two copies of the letter: one by registered mail with return receipt for proof of delivery, and the other by regular mail, in case your patient refuses to sign for the registered letter. Finally, document the letter and its mailing in the patient's chart and file the signed return receipt as well. Retain the chart in your records for the period required by law in your state (typically 7 years for a nonobstetric patient), or longer if you deem fit.