Over the past year, member calls to our Medico-legal Advisory Service (MLAS) about clinical patient relationships have increased nearly 14%.
Many doctors are grappling with how to balance their duty of care with concerns about patients’ wellbeing and professional liabilities. This is coupled with having to contend with patients who are aggressive or rude, or continually ignore advice and are non-compliant with treatment plans.
In general terms, other than in an emergency, if a doctor is unwilling to continue a treating relationship with a private patient, they are not compelled to do so. However, it is important to consider when and how to end a relationship to avoid a complaint and to facilitate continuity of care for patients.
An example* is a patient who had only attended a practice on a few occasions, but made a complaint that the practice had failed to ensure he was seen in the local hospital for vertigo. The practice repeatedly called the patient to discuss his complaint and explain the numerous contacts that had been made on his behalf, but he failed to return their calls. Shortly after, he presented at the practice and was abusive and aggressive towards the receptionist. The situation reached a point where another staff member had to come to her aid. The patient was asked to leave the practice and stormed out, swearing. The practice owner called the MLAS for advice on how to manage the relationship.
A plan of action
The cornerstone of the doctor-patient relationship is mutual trust and respect, so when there is a breakdown in trust it can impact your ability to deliver effective care. Sometimes, a conflict of interest can also be at the heart of the relationship breakdown. In these cases it may be in the interests of both you and the patient to transfer care to another practitioner.
In the first instance, you should explain your concerns to the patient to see whether this leads to any improvement in their behaviour or compliance to enable you to continue treating them. However, in some cases, as above, where the patient has been physically threatening, it may be necessary to end the relationship to protect the staff.
Avoid allegations of discrimination – take care that ending the relationship cannot be interpreted as based on reasons such as: gender, sexual preference, race, marital status, disability, age or HIV status.
How to end the relationship
It is not appropriate to end the doctor-patient relationship during the acute phase of an illness or a medical emergency. The patient is entitled to have appropriate continuity of care and failure to provide that may compromise the patient’s health. Depending on the circumstances, it may be necessary to wait until any health crisis is over before broaching the subject with the patient. In the case above we advised the practice manager to check with the patient’s doctor to ensure there was no outstanding or acute medical issues that required immediate follow up.
If you decide to end the relationship here are some suggested steps:
- In our experience it is preferable to speak to the patient in person. Be honest and explain your reasons, while remaining sensitive to the patient’s feelings. It may sometimes be appropriate to have someone else present, as a support person for the patient or to assist you.
- Follow this up with a letter to the patient. Consider using the sample letter in our factsheet: How to end the doctor-patient relationship. You can also send your draft letter to Avant for review before sending it to the patient.
- However, if as in the case above, the patient has been verbally or physically abusive or threatening, and you don’t wish to meet them in person, a telephone call followed by a letter is appropriate. The safety of you and the reception staff an important consideration.
- The patient is entitled to continuity of care. Failure to provide this care may compromise their health. It’s therefore important, if there are no safety issues, that you give the patient a reasonable time to find a new.
- Transfer the relevant documents to the patient’s new treating doctor, if requested, with the appropriate authority or to the patient directly. Provide the details of the local hospital in case emergency care is required.
Despite your best attempts to end the doctor-patient relationship in a reasonable way, some patients may still feel angry or abandoned by this decision. Therefore, you need to be prepared to respond to a complaint from a patient. Contact Avant for advice if this occurs.
- Sometimes the doctor-patient issues are insurmountable and the relationship should be terminated in the best interests of the doctor, practice staff and the patient.
- The safety of you and the practice staff is an important consideration.
- If you decide to end the relationship, follow the steps above to ensure the decision is clearly communicated with the patient, confirmed in writing and the patient receives continuity of care.
- Should the patient lodge a complaint, contact Avant.
If you require advice on ending a patient relationship, contact our Medico-legal Advisory Service on 1800 128 268 for expert advice, available 24/7 in emergencies.
*This example is based on a compilation of Medico-legal Advisory Service calls we have received.