How should you respond if a patient tries to extort free services, refunds, or special favors by threatening you with negative social media, medical board complaints, or malpractice suits?
This is a growing problem that many practitioners are experiencing but few are talking about, says Ericka Adler, a healthcare attorney with the Chicago-based law firm of Roetzel & Andress. It is time to end the silence.
When faced with this situation, most clinicians simply acquiesce and give the patients-turned-bullies what they want. Sometimes that’s the smart option, given the cost of a legal battle. But in some cases, it is right to fight, especially when your professional reputation or your license is at stake.
Practitioners need to be awake to this phenomenon, and prepared to prevent these situations from arising, says Adler, who works with hundreds of physicians and clinics large and small.
Know Your Vulnerability
Back in 2018, Jeffrey Segal, a neurosurgeon-turned-attorney sounded an alarm about this phenomenon in a newsletter post. He stated that, “it is legal to slam someone online, provided the account is truthful and not defamatory. And even if it is not truthful and is defamatory, slamming someone online is typically still not a criminal offense. But, once a person ties the threat of negative commentary online to a demand for money, wallah, that may be extortion.”
Nobody knows exactly how many such incidents occur each year, but Adler says based on what she and her colleagues are seeing, the phenomenon has surged in recent years.
“We represent thousands of different types of practices and medical professionals, so we probably hear a bit more incidence of this, but I would say it is happening quite a lot,” she told Holistic Primary Care, adding that she herself deals with several such incidents every month.
“A patient will say ‘I’m going to post something negative.’ And sometimes they do post things, and in order to get them to take it down, they demand that the doctor has to give them what they want—give them money back or do something for free. They post something and then refuse to take it down unless you do what they want.”
The bullying usually starts with repeated calls to the office, or relentless emails full of complaints and demands.
“What typically happens is a patient doesn’t get the result they want, or they don’t think the doctor was ‘responsive’ enough. Or they just simply want something for free. Surprisingly, that sense of entitlement is not as unusual as you might think.”
Patients who harass practitioners in this way are usually seeking financial gain in the form of refunds or free care. They may threaten to post bad reviews on social media, file medical board complaints, or even raise the specter of a malpractice suit. Some may try to defame a clinician’s character or behavior. Others may contend that the clinician failed to deliver on a “promised” or expected outcome.
Most commonly, the threat centers on social media. “A patient will say ‘I’m going to post something negative, I’m gonna let people know what you did you did.’ And sometimes they do post things, and in order to get them to take it down, they demand that the doctor has to give them what they want—give them money back or do something for free. They post something and then refuse to take it down unless you do what they want.”
She stressed that solo and small-group practices are especially vulnerable to this sort of patient bullying, as are cash-pay practices, and holistic or functional medicine practices that depend heavily on social media to draw and retain patients.
Clinics that focus on weight loss or physical appearance are at particularly high risk, because optimal outcomes are often subjective, and patients may have unrealistic expectations.
“Satisfaction” is Subjective
In some medical situations, the expected outcome of an intervention is fairly clear-cut. If a patient has a particular infection, and a doctor prescribes an antibiotic to which the pathogen is susceptible, it is reasonable to expect that the drug will kill the bug and the patient will feel better within a few days.
But other situations are more nuanced. What is a reasonable weight loss expectation when someone goes on a personalized diet program that you tailored? What’s a fair expectation for improvement when following a probiotic regimen to reduce symptoms of IBS and improve the gut microbiome? What’s an appropriate timeline for resolution of longstanding autoimmune disease when following a functional medicine protocol?
To a large degree, satisfaction or disappointment are in the eyes of the beholder. This is especially true in holistic and functional medicine. It attracts patients with complex disorders for which optimal outcomes and timelines are not always clearly defined.
Lab values and other quantitative measures can be helpful in showing that a given treatment had biological impact. But keep in mind that a patient’s desired outcomes may be quite subjective and difficult to quantify objectively. If someone is feeling dissatisfied or disappointed, no amount of lab data will likely change that.
Check Your People-Pleasing
Adler stressed that when these situations arise, practitioners almost always feel they are in the right, that they’ve done nothing wrong. More times than not, this is true.
But it’s also true that medical professionals have very strong “people-pleaser” tendencies. They’re often averse to confrontations, and anxious about reputational damage, malpractice suits, or medical board actions. This tendency to try to appease unhappy people leaves them vulnerable to manipulative patients.
Solo and small-group practices are especially vulnerable to this sort of patient bullying, as are cash-pay practices, and holistic or functional practices that depend heavily on social media.
Adler says it is common for practitioners to respond to disgruntled patients by politely inviting them to “discuss the issue.” Of course, that sounds totally reasonable. But too often, the underlying message is: “What can I do to make you happy?”
Unfortunately, there are people out there who are all-too-willing to take advantage of a practitioner’s goodwill and fear of conflict.
HIPAA Ties Your Hands
If a patient does make a negative social media post about you, do not respond by commenting directly on the post.
If you do so, you are publicly acknowledging that this individual is a patient of yours. And that, unfortunately for you, is a HIPAA violation.
“It does not matter if the patient has already given his name, and stated that he is a patient of your practice. You are not supposed to reveal this,” Adler stressed.
“A physician’s hands are tied,” she said, adding that in regard to social media, medicine is very different from other businesses.
“In the restaurant world, when someone posts something negative about a restaurant, you’ll sometimes see the manager respond with statements to the contrary. They’re acknowledging that the person did eat at their restaurant. In medicine, that could be a HIPAA violation.”
Some patient-bullies know this. “If a patient is the type that is manipulative enough to post something in order to gain an advantage, they usually post something that is not necessarily true. And the minute the doctor responds, they will file with the OCR (Office for Civil Rights) for a HIPAA violation. We’ve seen that happen.”
Though it was not intended to do so, HIPAA does hinder doctors and other medical professionals from being able to defend their names and their reputations on social media.
The First Step
Assuming that you’ve done nothing wrong, that the patient’s complaint is false or misleading, and that there are no reasonable grounds for the complaint, your first move is to contact the patient directly and request that the post be taken down.
If a patient makes a negative social media post about you, do not respond by commenting directly on the post. If you do so, you are publicly acknowledging that this individual is a patient of yours. And that, unfortunately, is a HIPAA violation.
If the patient has not already presented an extortionary demand in advance—and keep in mind that the “or else” threat usually occurs prior to the post—this is the point at which you’ll learn what the patient wants.
The question then becomes a sort of calculation about the costs of giving in versus fighting.
“Typically, what the patient is asking for, even if the doctor doesn’t agree and doesn’t think it’s legitimate, will cost the doctor less than incurring legal fees to either address the post or defend false allegations,” Adler told Holistic Primary Care in an interview. “It becomes a cost-benefit thing, just like doctors might settle a malpractice claim, even though they think they did nothing wrong,”
“We always talk it through with our doctors. We’ll say ‘We don’t think you did anything wrong. We think they’re manipulating you here. But it seems like it’s going to cost you a lot more to go down the road of fighting with them about this, than to just say “Here take your money back.”
If you do choose to settle, make sure that the terms and conditions for the settlement are stated clearly in writing, and that the patient agrees to a full deletion of all the negative social media posts, releases you of any further demands, and promises to refrain from posting the negative comments in the future. “We try and tie off that angle if we can,” Adler says.
When to Talk with a Lawyer
If a patient has not yet posted something about your practice, but is threatening to do so, it probably makes sense to talk with an attorney who can help draft a cease-and-desist request. In some cases, an “official” letter might be enough to dissuade someone from actually posting.
If the patient has already posted something and you’ve decided to acquiesce and settle, it may be valuable to talk to a healthcare attorney who can guide you in writing the terms of the agreement.
You’ll surely want to talk to a lawyer if someone has posted a false or defaming statement, or a personal attack, and is categorically unwilling to take it down. Slander, libel, and defamation could be grounds for taking legal action against the patient.
Though social media is the primary tool for patient-extortionists, some opt to go beyond social media, and threatens to file complaints with state licensing boards. If this happens—and again assuming the patient’s “charges” against you are false or unfounded–don’t delay in seeking counsel.
“No matter what kind of doctor you are, the board going to be interested in this complaint. They have the duty to investigate every complaint made, whether real, false, or otherwise,” Adler cautions. This can be a high-risk situation because it could impact your license to practice. Unless you yourself have a strong medicolegal background, it’s best not to try to navigate that by yourself.
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When to Consider Engaging an Attorney:
- You have received communication directly from an attorney hired by a patient
- A patient has made reports to a state medical board
- A patient has made social media posts using language that could reasonably be considered slander or libel
- A patient has posted statements that are blatantly—and provably—false
- A patient has made condemning posts and refuses to take them down despite reasonable attempts to address the complaint and resolve the situation
- The patient categorically refuses to delete an untrue negative social media statement
- You’ve opted to settle and meet the patient’s demand, and need help drafting the terms of the agreement
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Repeat Offenders
Adler is convinced that some of these patients are repeat offenders: they have a keen eye for spotting vulnerable practices, and they go from one to the next, working the same general scheme.
Though they’ll occasionally try to scam a large group practice, mostly they target solo docs and small groups, figuring that these practitioners do not have the resources or the will to engage in a legal battle.
“They know that some practices are very likely to just give them the money, or just give them what they want because they’re (the practitioners) so afraid. Once it works, they just do it again and again.”
For some people, this is basically a business plan. They know the profile of vulnerable practices, they know the HIPAA regs, they know about state licensure boards.
Are these patient-extortionists doing anything illegal? It’s certainly unethical, and in some cases—especially when a patient posts obvious untruths or unfounded personal attacks—it may be criminal behavior. But proving criminality will be difficult in many cases, especially in situations where subjective expectations and clinical nuances are in play.
“Usually, but not always, these are ‘difficult’ patients. They’re difficult when they come in, they’re difficult with your staff. They’re demanding. . The signs are all there.”
Spotting Trouble Before it Happens
Manipulative demands occasionally come from seemingly friendly and respectful patients. But more times than not, there are bright red flags and warning signs that arise early on in the clinical encounter.
“Usually, but not always, these are ‘difficult’ patients. They’re difficult when they come in, they’re difficult with your staff. They’re demanding. They’re sending lots of messages. The signs are all there that they’re going to be difficult, though it is not necessarily clear that they’re going to do something like this.”
It’s a sad truth that some people are very malcontented. They’re unhappy with everyone all the time. “You can never please them. These are the ones who stir up a lot of trouble.
And the more you give in to them the more their demands grow.”
Have a Termination Protocol
Adler says the healthcare attorneys at Roetzl generally advise all their medical clients—large and small—to develop clear patient termination guidelines and protocols, and to use them when necessary.
“You have to know when and how to terminate a patient,” she told Holistic Primary Care.
“You’re not required to keep a patient in your practice who is not following your policies, or is difficult and disrespectful. Obviously, you don’t want to terminate a patient for illegal reasons, like racial or gender discrimination, disabilities or whatever. But if they’re not showing up for their appointments, if they’re being rude and abusive to you or your staff, those kinds of things, you have the right to terminate the relationship. A lot of times, those are exactly the kinds of things we’re seeing in patients who try to extort physicians.”
The actual termination process involves sending a formal letter to the patient, citing the specific reasons for the termination, and making sure emergency care is provided for 30 days. “I usually like to include info about where they can call to find referrals for other clinics.”
Adler acknowledged that doctors are often really busy, so it’s a nurse or a practice manager that ends up dealing with abusive patients. “A lot of times the doctor may not even realize what’s going on with the particular patient until it’s too late.”
It’s very important to train your staff to recognize abusive or disrespectful behavior, and let them know that they do not have to tolerate mistreatment. It’s also wise to have periodic meetings to discuss difficult cases, and to work as a team to identify patients who are intending to cause trouble. “Having a (termination) protocol in place, and letting your staff know that we need to talk about patients that are exhibiting these signs, can help nip these problems in the bud.”
Of course, this does not mean that you deny the patient an opportunity to change his or her ways. “You can start by saying ‘Mr. Smith, this is a warning to you. You’ve been disrespectful, you’ve missed your appointment. You have you messaged us 25 times during the weekend. This is unacceptable.’ Then give the patient ample opportunity to respond and to make changes.
But too often, clinicians let abusive or manipulative behavior go on too long. “They want to make the patients happy. They feel like they can solve the problem if they’re just a little nicer, a little kinder, or they spend just a little more time.”
That’s natural, given that compassion and a desire to help are cornerstone character traits for people who choose careers in healing. But it seldom works. Clinicians need to face the reality that “there are people who just you cannot please. You need to recognize those signs early on, and cut them off.”
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