Michael J. Sacopulos, JD is the Founder and President of Medical Risk Institute (MRI) and is General Counsel for Medical Justice Services. He has devoted his near 20-year legal career to advising the healthcare community on where liability risks originate and how to avoid these risks.

Have you seen the GEICO Insurance ad where Kenny Rogers sings part of his famous song, “The Gambler?” Mr. Rogers, who is clearly no stranger to the world of aesthetic medicine, sings, “You have to know when to walk away and know when to run.” Sure, he is talking about playing cards, but the same holds true for treating certain patients.

Every cosmetic surgeon has a patient that he or she wishes they had never treated. Some are needy. Some are impossible to please. Others verbally abuse staff. Problems patients come in all shapes, sizes, and varieties of “difficulty,” but the effect is always the same. Physicians and staff dread interactions and worry that the patient is a liability.

Some doctors erroneously believe that they are essentially “stuck” with the tough patient. They've been warned against patient abandonment, and they believe that ending the patient relationship is even harder than dealing with the individual. In reality, ending the patient relationship is relatively straightforward. Below are strategies for complying with the law while avoiding ongoing problems for your practice.


The difficult patient is an inevitability in aesthetic practice. Don't wait until you become fed up with a patient to take action. Know the applicable laws and have the tools you need in place so that you can address any challenges as soon as they arise.

Have your attorney draft a standard patient discharge letter at the same time as all your other standard office forms and form letters. It should be brief (4-6 sentences) and clear. You do not want to run afoul of abandonment laws, and there is some jurisdictional variability in the requirements for patient discharge; your lawyer can advise on these. In general, discharging physicians are required to provide emergency care to the patient for 30 days and to provide the patient access to his/her records.

When you send the letter to the patient, do so via certified mail so that you can document receipt of the correspondence.

Place a copy of the letter and proof of receipt in the patient's chart for future reference.


Once you've made the decision to discharge a patient and provided the discharge notice, do not back down. Reversing the decision once a patient has received a discharge notice is a bad precedent. The standard office policy must be to not revisit or reconsider any discharge decision. Advise staff of this, and instruct them to use the policy as the standard response for the patient who may call to argue about a letter: “As a matter of policy, the practice cannot reconsider these decisions.”

If the patient engages you, the surgeon, be firm. Advise the patient that you don't believe you can meet his/her needs. Use their dissatisfaction with you to your advantage: “I realize you are not happy with me and my staff, why don't you see if another surgeon can better meet your needs?”

It's reasonable to establish standards for patient behaviors and to identify behaviors that trigger an automatic discharge letter. For example, patients who have been no-shows for four appointments or more, patients who fail to comply with care or refuse to take an active role in their care, or patients who have been sent to collections, may all be discharged as a matter of routine. These are all examples of disruptive behaviors or behaviors that establish an adversarial relationship that is best avoided.


The best course of action for a practice is to not provide care for any patient who may become problematic. Until you provide care, there is no doctor/patient relationship and therefore no need to move forward in any way with the patient. If you have any concerns about the patient during the consult, simply advise him/her that you don't believe you can provide them with the results they seek. Do not book any subsequent appointments and do not agree to perform any services or procedures.

Rely on staff to share their assessments of patients; they are a great barometer of patient experiences. Often they spend a good deal of time with the patient, and sometimes they see a different side of the individual than you do. Encourage staff to share concerns before you enter the exam/consult room.

Suppose you miss the vibes from a patient and schedule a procedure, but the minute the patient walks out, staff tell you about some odd things the patient said or did. It's not too late. You technically have no responsibility to the patient if you have not provided care. Simply modify your standard discharge letter to inform that patient that, upon further consideration, you do not feel you can adequately meet their needs and are therefore unable to provide the service requested.


It's been said that 10 percent of patients cause 90 percent of a practice's problems, and time and again this seems to be the case. Challenging patients exist, and you are bound to encounter them. Despite your best efforts to screen patients and avoid problems, you are also bound to treat a challenging patient from time to time.

Don't ever feel that you are “stuck” with a patient. When it comes to elective procedures, you have the discretion to refuse any services you feel are not appropriate.

You will inevitably have to discharge patients. With this reality in mind, you should work with your attorney to draft a standard discharge letter and develop a clear understanding of your rights and responsibilities to the patient. Follow the proper protocol, stand firm in your decision, and you can weed out the difficult patients and focus on enjoying the practice of medicine.

When taking on a new patient for aesthetic care, there is always a small chance he or she will turn into a nightmare patient. When faced with a difficult patient, remember what Kenny Rogers sang:

“Every gambler knows that the secret to survivin'/Is knowin' what to throw away and knowing what to keep.”

Some potential opportunities just are not worth the risk. In the world of elective care, patients and physicians choose each other. I wish you great success in choosing wisely.