- You can end the doctor-patient relationship if you consider it to be in the patient’s best interests or if the therapeutic relationship has become untenable for you.
- Ideally end the relationship in person and follow up the conversation with a letter restating your position.
- You have a continued professional obligation to treat the patient in an emergency.
Importance of the doctor-patient relationship
The doctor-patient relationship is fundamental to your ability to provide patients with clinical care. The nature of this relationship may vary within specialities, but the essential elements are openness, trust and good communication.
Typically, the relationship comes to a natural conclusion when the patient moves locations or no longer requires your care. It is more challenging when you, as the doctor, consider actively ending the relationship.
In general terms, if you are unwilling to continue treating a private patient you are not compelled to do so. However, before taking this step you should consider the patient’s best interests and have explored reasonable alternatives.
The key is to recognise when it is appropriate to cease treating a patient and to know how to do it without breaching your legal and professional obligations.
When to end the relationship
Some difficult patient situations evolve over time. This could be due to conduct towards you, drug-seeking behaviour or a patient repeatedly missing appointments or who is otherwise noncompliant. In the first instance, providing a verbal forewarning of ending the relationship or entering into a written agreement with the patient could help to address your concerns and set clear boundaries. Trialling such measures can avoid taking a patient by surprise and be evidence of your efforts if a complaint is made against you alleging an unreasonable refusal to treat.
In some instances you may also choose to end the relationship immediately after a single significant event such as a physical threat, sexual advance, deceptive behaviour such as falsifying a medical certificate, or stealing from the practice.
Patients have the right to complain about their care and this, of itself, may not be a reason to end the relationship. However, where a patient has proceeded with a formal claim it will be difficult to provide impartial treatment and you can terminate the doctor-patient relationship.
If you believe you do not have the expertise to continue to assist a patient, then in the patient’s best interests you might transfer care. However, avoid ending the relationship simply because a patient is challenging to deal with.
Before taking the step of ending a relationship with a patient, check that you do not have a contractual obligation to see certain patients at your place of work. Some workplaces will have a policy on how these matters should be handled.
You cannot refuse to treat a patient for a discriminatory reason such as on the grounds of gender, race, marital status, religion or disability.
How to end the relationship
Consider why the relationship is going wrong
Reflect on what has gone wrong and consider if there is anything you could have done to prevent ending the relationship. There may be learning opportunities in this situation.
When ending the relationship, you should initially aim to communicate in person with the patient. While it is not strictly required that you state your reasons, ideally you should. Be honest, while still being sensitive to the patient’s feelings.
Try to ensure the patient does not interpret the ending of the relationship as a personal rejection. You should explain that the doctor-patient relationship relies on mutual trust. When this has broken down, it can impact the effectiveness of patient care, so it is in the patient’s best interests to transfer to another practitioner.
Remember to remain calm and polite during all interactions.
Follow up your discussions with a letter to the patient ensuring that you have communicated your decision. If the patient requires review of their condition or medication within a certain timeframe, highlight this in the letter.
You may wish Avant to review the letter before you send it to the patient.
Inform other doctors involved in the patient’s care that you are no longer treating the patient but be careful with your explanation to avoid prejudicing the patient’s relationship with ongoing and future treatment providers.
Offer an alternative doctor if possible
Give the patient a reasonable deadline for finding a new doctor. You may wish to provide a list of practitioners in your community or refer the patient to the relevant medical college to find one who is acceptable. The need to assist arrangements for continuity of care may be greater for vulnerable patients such as those with complicated medical issues or restricted mobility, or patients in a rural setting where the availability of alternative medical practitioners is limited. In these situations, you may wish to seek advice from Avant.
Reassure the patient that you will – within an appropriate time frame – provide care for any necessary medical problems that arise before they find a new practitioner. In cases where the patient has not complied with treatment, in your letter explain the consequences should they continue to go without appropriate treatment.
Transfer the files to the new doctor or practice
To ensure continuity of care, advise the patient that you are happy to provide a copy of their relevant information to their new practitioner with their consent (note that it may be unwise to charge the patient for this service).
Continuity of care
Advise your practice staff that your relationship with the patient has ended and they should not make further appointments for the patient with you after a specified date.
Make sure all staff at the practice, including other doctors, are clear about what the termination means for the practice. There may be other doctors in the practice who are happy to treat the patient, or it may mean that no doctors in the practice will see the patient.
You may wish to place an alert on the patient file to ensure that all staff members, including new staff unfamiliar with the patient, are aware of the situation.
It is not appropriate to end the doctor-patient relationship during an acute illness. 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 of ending the relationship with the patient.
In an emergency you have an ethical and legal duty to provide assistance to your patients. This duty exists even where the person was not previously a patient or if you have recently ended the therapeutic relationship.
Before taking action
It can be useful to discuss the situation with senior colleagues or with Avant before officially ending the relationship.
Remember that the responsibility for ending the doctor-patient relationship rests with you, the doctor. Do not delegate it to another staff member.
If there has been a serious breakdown in the doctor-patient relationship, consider whether an incident report should be forwarded to Avant in case future complaints or claims are made.
Good Medical Practice: A Code of Conduct for Doctors in Australia 3.13 Ending a professional relationship.
Consider using the following letter template.
As discussed with you on [date] I regret that I am unable to continue as your treating doctor. I feel it would be in your best interest to transfer your care to an alternative practitioner.
I will of course continue to provide ongoing care until you identify your new practitioner. However, you should do this within a reasonable time. You may find the [RACGP] helpful in locating a practitioner who is able to meet your needs.
I am happy to forward a copy of your medical records and I have enclosed a form authorising the transfer of your records to your new practitioner.
Alternative paragraphs depending on circumstances
The overly demanding patient
I have considered your health care needs and I believe that it is no longer possible to continue to provide the level of service you might expect. Accordingly, I have decided that it is in your best interest to make alternative arrangements for future consultations at another medical practice.
I am aware that you have failed to follow the advice and recommended treatment that I believe are important for your wellbeing. While I acknowledge your right to refuse advice and treatment, I believe that it is not in your best interest to do so.
Bad behaviour or complaints
The events of [date] lead me to believe that you have lost faith in my care. As trust is the cornerstone of an effective doctor-patient relationship I feel it would be in your best interest to transfer your care to a new medical practitioner.
Medical practitioners have an ethical duty to maintain only a professional relationship with their patients. Your personal feelings expressed on [date] suggest that it would be in your best interest to find a new medical practitioner. As such, I will be unable to see you again except in the case of a genuine emergency.