As medical practitioner, it is almost inevitable that throughout your practicing career, you will encounter numerous challenging or difficult patients. In these circumstances, you may wish to end the doctor/patient relationship, but you may be unsure as to how to do this appropriately and in accordance with your legal and ethical obligations.
We are regularly contacted by both doctors and medical defence organisations seeking advice in relation to this issue. Although each situation is unique, in this article, we discuss some general methods for managing challenging patients and how to appropriately end the doctor/patient relationship when it has become untenable.
There are numerous potentially challenging scenarios faced by medical practitioners in relation to their patients. Some specific examples we have seen in practice include:
- abusive or threatening patients (verbal and/or physical);
- drug-seeking patients (e.g. benzodiazepines or opioid medications);
- patients who are non-compliant with healthcare recommendations/advice;
- overly demanding patients;
- deceptive patients including falsifying medical certificates;
- patients who make a complaint about, or are unsatisfied with the healthcare provided by the practitioner;
- patients who make romantic/sexual advances or inappropriate comments to the practitioner;
- patients who repeatedly do not turn up to appointments; and
- a loss of mutual trust and/or respect between the practitioner and the patient.
In some circumstances, immediate cessation of the doctor/patient relationship may be warranted (such as abusive or threatening patients, deceptive patients and patients who make sexual advances), whilst in other circumstances (such as overly demanding patients or patients who fail to attend appointments) it may be worthwhile exploring whether the relationship can be salvaged with the communication of your expectations and the implementation of sufficient patient boundaries.
Effective communication and salvaging the doctor/patient relationship
As noted above, although you may have concerns regarding the relationship with your patient, in some circumstances it may be in the patient’s best interests to explore alternative measures to potentially salvage the relationship.
A key element of the doctor/patient relationship is effective communication. Sometimes, improving the communication between you and your patient can address the issues. Whether or not you decide to end the doctor/patient relationship, it is important to communicate openly with the patient. The Medical Board of Australia’s ‘Good medical practice: a code of conduct for doctors in Australia’ (Code) sets out what effective communication involves, including:
- listening to patients, asking for and respecting their views about their health, and responding to their concerns and preferences;
- encouraging patients to tell you about their condition and how they are currently managing it, including any other health advice they have received, any prescriptions or other medication they have been prescribed and any other conventional, complementary or alternative therapies they are using;
- informing patients of the nature of, and need for, all aspects of their clinical management, including examination and investigations, and giving them adequate opportunity to question or refuse intervention and treatment;
- discussing with patients their condition and the available management options, including their potential benefit and harm and material risks;
- endeavouring to confirm that your patient understands what you have said;
- responding to patients’ questions and keeping them informed about their clinical progress;
- taking all practical steps to ensure that arrangements are made to meet patients’ specific language, cultural and communication needs, and being aware of how these needs affect patients’ understanding; and
- familiarising yourself with, and using whenever necessary, qualified language interpreters to help you to meet patients’ communication needs. Government-funded and fee-for-service interpreter services are available.
Before ending the doctor/patient relationship, it may be appropriate to communicate your concerns with the patient and provide a verbal warning of your intention to end the relationship if the issues are not satisfactorily addressed. It may also be appropriate to provide the patient with a written agreement setting out your concerns and what needs to be addressed in order to continue the treating relationship. This can serve to avoid upsetting or angering the patient at the sudden cessation of the doctor/patient relationship. In both instances, it is important that you document what you have discussed with the patient thoroughly in the event the patient makes a complaint to a regulator (e.g. AHPRA). It is also important to remember that although there may be things you can do to ameliorate the situation, it is simply not possible to prevent a patient making a complaint.
Ending the doctor/patient relationship
There is generally no legal obligation on medical practitioners in private practice to see or continue seeing a patient, except in emergency situations or if the practitioner’s employment contract places an obligation on the practitioner to see certain patients (such as in an Emergency Department). It is also important to note that you cannot decline to see a patient based on unlawful discriminatory reasons such as race, ethnicity, gender identity, religion, sexual preference or disability. If you practise in a rural or remote area, you should consider the patient’s ability to access alternative care prior to making a decision to end the doctor/patient relationship. It is also inappropriate to end the doctor/patient relationship for patients with an acute illness. These patients have the right to appropriate continuity of care and depending on the situation, it may be necessary to delay ending the doctor/patient relationship until the acute illness is resolved or an otherwise appropriate time.
A question we are often asked is should you end the doctor/patient relationship if/when a claim is made against you by the patient. This must be assessed on a case-by-case basis. If the relationship has broken down irretrievably and there are options to transfer the patient’s care, then it is likely that it is appropriate to end the relationship. However, if there are no viable options to transfer the patient’s care to another practitioner or health service and you feel that you can continue to provide treatment to the patient, it may be appropriate to continue the relationship. In such circumstances, we strongly recommend that you do not discuss the claim with the patient.
If you are unsure whether you should end the doctor/patient relationship, we recommend consulting your medical defence organisation for advice.
When a relationship becomes ineffective, compromised or otherwise untenable, you may end it in accordance with the requirements set out in the Code, which provides that:
“Good medical practice involves ensuring that the patient is adequately informed of your decision and facilitating arrangements for the continuing care of the patient, including passing on relevant clinical information.”
Communicating your decision
It is preferable to initially explain your decision to the patient in person, followed by a letter to the patient.
When communicating your decision to the patient in person, you should:
- advise the patient that the doctor/patient relationship has irrevocably broken down and that it is in the patient’s best interests to seek ongoing medical care from another doctor;
- explain the reasons, if appropriate, for the breakdown of the relationship whilst being conscious of the patient’s feelings; and
- if possible, provide the patient with some options for alternative practitioners in the community they may wish to consult or, if you are not comfortable doing so, explain to the patient how they might identify a new doctor (e.g. internet searches or requesting a new referral from their referring doctor). It is generally appropriate to provide the patient with a reasonable amount of time to identify a new practitioner and to openly communicate this deadline to the patient. This requirement may be greater for vulnerable patients (including patients with particular medical issues or restricted mobility) or where it may be difficult for the patient to find a new practitioner (e.g. patients living in rural areas).
Your follow up letter to the patient should be sent as soon as practicable after you have verbally spoken with the patient and should:
- reiterate your decision to end the doctor/patient relationship and what you have verbally conveyed to the patient;
- highlight any outstanding clinical issues that require follow-up and the timeframes for these; and
- request from the patient the name of their new treating practitioner (when known) so that a copy or summary of the patient’s clinical records can be provided to the new practitioner to ensure continuity of the patient’s care.
We recommend that you consult with your medical defence organisation in relation to the wording of this letter.
Transferring care to another practitioner
It is important to appropriately transfer clinical care to the patient’s new doctor. This involves:
- informing the patient’s referring practitioner or other specialists, healthcare providers or hospitals involved in the patient’s care that you are no longer involved in the patient’s care (however, we recommend being careful with your explanation to avoid causing prejudice to the patient’s relationships with current and future practitioners);
- advising the patient and any referring practitioners or specialists involved in the patient’s care of any outstanding clinical issues that require follow-up and the timeframes for these;
- forwarding a copy or summary of the patient’s clinical records to the patient’s new practitioner (we generally recommend waiving your usual fees for this to avoid unnecessarily inflaming the situation further); and
- informing staff of your practice that the doctor/patient relationship has been terminated so that no further appointments are made for the patient. It may be necessary to remove reminders or create alerts on the patient’s file to ensure all staff members are aware.
It is good practice to keep a copy of information sent to the new practitioner, the patient and other practitioners involved in the patient’s care in case there are any later issues.
For GPs who decide to end the doctor/patient relationship, the Royal Australian College of General Practitioners (RACGP) has developed Standards for the transfer of care when ending the doctor/patient relationship. The Standards provide that when the practitioner requests transfer of care, the practice must facilitate the transfer of the patient to another practitioner or practice. The Standards include that GPs must take reasonable steps to ensure the person to whom they delegate, refer or hand over has the qualifications, experience, knowledge and skills to provide the care required.
If you are unsure as to whether or how to end a doctor/patient relationship, we recommend contacting your medical defence organisation or Barry Nilsson.