At any point in a doctor's career, they may need to seek advice on how to manage the relationship with their patient.
More specifically, when the relationship has become untenable. Some examples include:
- a patient is verbally and physically aggressive
- a patient has been forging certificates
- a patient has consistently refused to follow treatment advice
- a patient sexually propositions the doctor
In general terms if a medical practitioner is unwilling to continue a treating relationship with a private patient they are not compelled to do so.
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 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.
Sometimes, a conflict of interest is at the heart of the relationship breakdown. For example:
- the patient unreasonably refuses to comply with treatment programs
- the patient displays threatening, rude or abusive behaviour (not related to an acute organic or functional disorder)
- the patient continually fails to pay their bills
- the patient has made a formal complaint against the doctor or has instituted legal proceedings
- the doctor may have already provided a medico-legal opinion on the patient, as an independent expert in legal proceedings
Before taking action
It can be useful to discuss the situation with senior colleagues or with Avant.
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.
Avoid allegations of discrimination – take care that ending the relationship cannot be interpreted as based on reasons such as: gender, disability, sexual orientation, age, race, HIV status, marital status.
When ending the relationship, you should initially aim to communicate in person with the patient if possible. While it is not strictly required that you state your reasons, ideally you should. If you do, be honest, while being sensitive to the patient’s feelings.
Try to ensure that the patient does not interpret the ending of the relationship as a personal rejection or affront. You should carefully explain that the doctor-patient relationship relies on mutual trust and when there is a breakdown in that relationship of trust it can impact on the effectiveness of patient care. In these circumstances, you believe it is in their best interests for you to transfer their care to another practitioner.
Of course, if it is because the patient was aggressive and they refused to modify their conduct, this should be the reason given.
Remember to remain calm and polite during any verbal exchanges.
Follow up your discussions with a letter to the patient ensuring that you have clearly communicated your decision, highlighting the importance of any ongoing care they may require.
You may wish to send a draft of your letter to Avant for review before you send it to the patient.
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.
Finding a new practitioner
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. Doctors in
rural settings, where the availability of alternative medical
practitioners is limited, face particular difficulties and 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
which 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
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 after a specified date.
Make sure all staff at the practice (including the other doctors) are clear on what the termination means for the practice. It may be that there are 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 (including new staff who may be unfamiliar with the patient) are aware of the situation.
However, your staff should also understand the extent of your ethical and legal obligations to render assistance in the event of an emergency, so as to prevent them inadvertently refusing the
patient access to you in the event of an emergency.
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).
Australian Medical Council. Good Medical Practice: A Code of Conduct for Doctors in Australia 3.13 Ending a professional relationship.