AAOS Bulletin - October, 2006

Defining and terminating the physician-patient relationship

By Richard A. Geline, MD

Every orthopaedic surgeon knows at least one “difficult patient”—the one who repeatedly refuses to follow recommended treatment, leaves the hospital or medical facility against advice, or fails to return for follow-up treatment. A difficult patient may refuse to cooperate; challenge your judgment and insist on acting as the doctor; or dispute fees that, to a reasonable person, appear just and normal. Such patients may appear severely disturbed or threaten a lawsuit.

More extreme and less common are patients who harass you and your staff; pose a physical threat to you, your staff and other patients; engage in fraudulent behavior such as stealing prescription pads, forging signatures and altering written prescriptions; exhibit drug-seeking behavior by seeing multiple providers; remain continually hostile; or seek secondary gain.

Confronted with this type of patient, many physicians simply choose to endure the difficulty and continue trying to provide good medical care. But remaining stoic in such circumstances can actually expose you to additional liability. On occasion, terminating a relationship with a difficult patient may be advisable and actually represent good risk-management practice.

What defines a physician/patient relationship?
Before discussing when and how to terminate the physician/patient relationship, a review of how the relationship is established may be helpful. Quite simply, the physician/patient relationship begins when the physician accepts, agrees to accept, or undertakes to render care to the patient.

This sounds simple enough, but the courts are continually clarifying and defining the situation. For instance, some attorneys claim that the relationship begins when the patient’s name is entered in the appointment book following a telephone call. Actually creating a chart represents a more advanced requirement for establishing the relationship. Courts have even held that a relationship exists if the physician has a capitated contract with a managed care plan, regardless of whether or not the physician has actually seen the patient enrolled in that plan.

The AAOS Code of Ethics and Professionalism for Orthopaedic Surgeons specifically addresses the physician/patient relationship in its first section. In addition to noting that the physician/patient relationship is the central focus of all ethical concerns, has a contractual basis and is based on confidentiality, trust and honesty, the Code discusses terminating the relationship as follows:

“1C. The orthopaedic surgeon may choose whom he or she will serve. An orthopaedic surgeon should render services to the best of his or her ability. Having undertaken the care of a patient, the orthopaedic surgeon may not neglect that person. Unless discharged by the patient, the orthopaedic surgeon may discontinue service only after giving adequate notice to the patient so that the patient can secure alternative care. Managed care agreements may contain provisions which alter the method by which patients are discharged. If the enrollment of a physician or a patient is discontinued in a managed care plan, the physician will have an ethical responsibility to assist the patient in obtaining follow-up care. In this instance, the physician will be responsible to provide medically necessary care for the patient until appropriate referrals can be arranged.”

Terminating care
An orthopaedic surgeon who chooses to terminate the relationship with a patient must carefully examine the circumstances. Some state medical licensing agencies consider terminating a patient with a recurrent or ongoing condition as patient abandonment and thus grounds for medical discipline.

A physician may disengage from a patient without liability under certain conditions, including the following:

  • When medical care is no longer needed
  • When the patient specifically withdraws from the relationship
  • When the care of the patient is transferred to another physician (At the patient’s request, the physician should provide any successive physicians with all information necessary to continue treatment.)
  • When the withdrawing physician gives ample notice to the patient—this may be as simple as notifying patients who do not have a current medical condition requiring care that the physician is withdrawing from the relationship and no longer wishes to provide care. The physician must provide sufficient written notification to allow patients with continuing medical problems to find a substitute physician or the physician must find a substitute and must remain responsible for care until that substitute is found.
  • When the physician is unable to provide care because of a lack of training or expertise or because of illness or incapacity so significant that the physician is unable to provide care

Steps in terminating a relationship
A physician who decides to terminate care of a patient must take certain steps. Typically these include the following:

  1. Give the patient written notice, preferably by certified mail/return receipt requested.
  2. Provide the patient with a brief explanation of why the relationship is being terminated. (This should be a valid reason such as noncompliance or failure to keep appointments.)
  3. Agree to continue to provide treatment and access to services for a reasonable period of time so that the patient can secure care from another physician. (The physician may want to extend the period for emergency services.)
  4. Provide resources and/or recommendations to help the patient locate another physician.
  5. Offer to transfer records to the selected physician with the patient’s signed authorization.

Special situations
Some restraints on termination may exist under certain circumstances. For example, it may be more difficult for the physician with a managed care contract to terminate patients enrolled in the program. Managed care contracts usually contain provisions governing termination of patient care. These provisions may differ for each carrier and generally obligate the physician to follow certain procedures prior to terminating care. A physician should read these provisions carefully before signing, lest he or she unwittingly signs away the right to terminate care. In addition, a specialist who wants to terminate care of a managed care patient referred by a primary care physician should contact the referring physician and arrange to transfer care to another participating specialist.

Patients referred by an emergency department are another special situation. The general rule that “you do not have to treat anyone you don’t want to” does not apply to this group of patients. Refusing to accept or treat these patients may place the physician in breach of the hospital’s medical staff bylaws. If you have privileges at the hospital, you are expected to abide by these bylaws, which may detail on-call obligations. An implied contract exists, and your failure to abide by the terms of the bylaws may constitute breach of contract, thereby jeopardizing your hospital staff appointment.

Patients with an ongoing medical problem constitute a third category of concern. Once you have established a physician/patient relationship, it should last as long as the patient needs care or until the patient reaches a logical endpoint to treatment. If the patient needs a series of treatments, you must complete the series before ending the relationship.

The law has been reluctant to define “continuing medical condition” and leaves the definition open to the professional judgment of the physician, as guided by the standard of care. Generally, the orthopaedic surgeon must ask, “Does this patient need ongoing medical care? What will happen if the patient does not have a physician to call for care?” If the answers indicate that the patient’s health may be in danger, there is indeed a continuing medical condition.

Individual rulings
Specific court rulings address the establishment of the physician/patient relationship and termination of care under special conditions. For instance, in one case, a physician who reviewed a coronary angiogram for a colleague was deemed to have created a relationship with the patient and was subsequently named as a defendant in a liability case.

Another area that courts periodically address is in the context of third-party examinations. In these cases, an employer or insurer initiates or requires an individual to undergo a medical examination. Two issues arise: first, whether or not this establishes a physician/patient relationship; and second, whether or not the physician incurs an obligation to use reasonable care and skill in attending to the examined individual.

The question has not been fully settled under law, with some courts holding that a physician/patient relationship exists, even if limited in scope and duration, while others finding no relationship exists. But the courts have concluded that a physician owes the individual a continued duty to use reasonable skill and care.

The unconscious patient is yet another special circumstance. This patient does not have the opportunity to select a particular physician or hospital, but a physician who accepts or undertakes to render care to an unconscious patient establishes a physician/patient relationship. Courts will be inclined to find that the relationship exists simply because of the overt conduct of rendering care by the physician.

In summary, terminating a relationship can be necessary and effective under select circumstances, but must be exercised with caution to avoid additional problems.

Richard A. Geline, MD, is a former member of the AAOS Medical Liability Committee.

References:

Much of the material for this article is excerpted from the following:

  1. Illinois State Medical Society Medical Legal Guidelines: Physician-Patient Relationship: Withdrawal or Termination, 1999.
  2. American Academy of Orthopaedic Surgeons, Code of Ethics and Professionalism for Orthopaedic Surgeons, 2004. www.aaos.org/about/papers/ethics/code.asp
  3. American Medical Association, Office of the General Counsel: Ending the Patient-Physician Relationship, 1998. www.ama-assn.org/ama/pub/category/print/4609.html
  4. LeBlang T, Basanta WE, Kane RJ. The Law of Medical Practice in Illinois, ed 2. Rochester, N.Y., Lawyers Cooperative Publishing, 1996.

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