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Insights

Managing and terminating patient-doctor relationships

Patients have rights, but what are my rights as a health professional? This question in the context of a call to the help line usually reflects a sense of powerlessness, fear and sometimes injustice accompanying the need to respond to a complaint. One right you do have, if you are working in private practice, is the right to end a professional relationship but it’s not absolute.



Ending the professional relationship to have a personal relationship is an absolute no. Ending the relationship because of a complaint is an absolute no. The right to complain is a fundamental right of all patients and this right is to be protected.


Guidance for doctors is available in a Medical Council statement released in March of 2021. That statement records a basic right of all health professionals to be safe in the workplace. It specifically provides that the relationship can be ended if the patient is abusive, violent or poses a significant safety risk to you or your colleagues. But what about the patients who don't quite meet that threshold but who are negatively impacting you?


The Medical Council guidelines[1] set out what you have to do to end a work relationship correctly and safely. You are required to go through a decision-making process - a bit like ending an employer-employee relationship. Think “BIKE


1. Behavior management: Are there ways that the relationship could be managed short of ending the patient-doctor relationship. For example, does the patient engage with a psychologist, drug addiction service, or receive another wrap around support, can challenges arising from noncompliance be managed or could you share the patient with someone else in the practice? Discuss the patient (anonymously) case you’re your colleagues and listen to their guidance.


2. Impact the guideline: This requires you to think about whether your decision may impact negatively on the patient and their family/whānau, such as limiting the patient’s options for, or access to medical care. In essence, as an ethical practitioner you need to weigh the harm to the patient and their community against the harm to you or your practice in continuing the relationship.


3. Kindness: If you have decided termination of the relationship is required, think about the most appropriate and culturally safe way to end the treating relationship. This requires kindness and care. The guidelines state, that this could include helping to transfer the patient’s care to another doctor or health professional. For some patients this is like being jilted so care needs to be taken.


4. End the relationship: Finally, the guidelines require that the communication around termination of the relationship is to happen in two stages. Firstly, explain your concerns or change in circumstances with the patient and the reasons you are considering ending the relationship. The act of termination can then follow.

[1] Ending a patient doctor relationship - https://www.mcnz.org.nz/assets/standards/e223e8f01b/ Ending-a-doctor-patient-relationship.pdf (mcnz.org.nz)



 

How to end the business relationship


You are required to consider the most sensitive way possible to convey the decision. The decision can be conveyed kanohi ki te kanohi (face to face) - this may be appropriate if there is a planned appointment (better not to charge for it). We advise to spend some time considering how best to convey the news and if too invite a third party if this would be accepted by the patient.


For example, “I have been thinking a lot about our last appointment and your health needs. I have done some hard thinking and decided that I do not have the resources to provide you with the care and time you need while meeting the needs of my other patients, so I need to arrange your transfer to another practice. While this is being organised, I will be available to look after you for any urgent need or emergency. There is also the afterhours service at xxx. I am happy to provide a list of practices that you can approach - this one is a walk in clinic, so you can go in without an appointment. I will quickly arrange transfer of your notes as soon as you let my practice nurse know where you want to transfer to. This is the card of my practice nurse so you can make contact to arrange the transfer.”


Please note that in this example we don’t go into the why in great detail such as “because you yelled at my staff or bully me, or are involving me in disputes with your family that I find stressful.” This only leads to arguments. This is not the time for a doctor to engage in a cathartic rant. It is more straightforward where the patient has made derogatory comments for example ”I have thought hard about your comment at our last consultation that you feel I don’t know what I am doing/I have failed to get you tests you need. This shows that you have lost confidence in me which means I can’t effectively look after you …”


The patient will feel rejected and is likely to feel hurt if not angry or both. Calling a patient in to end the relationship can feel more violating to some feeling the doctor has wasted their time bringing them in to reject them. Others feel it is less cowardly to others – that is they respect the doctor fronting up to the decision. We try to get it right for each situation but we cannot always be perfect.


Seeking guidance from your indemnifier’s legal/counselling service is a prudent step to take. Some other explanations personal to the patient have included:


  1. “Your (the patient’s) needs are beyond those which I/the practice have the resources to manage due to workforce issues”.

  2. “I feel compromised when trying to reach decisions made about how to best manage your care, and this has reached a point where I no longer feel able to offer you care in the way that meets the standards, I wish to provide to all my patients”.

  3. “Due to the length/nature of our relationship, we have reached a point where I feel that you would benefit from a fresh approach to your care.


The guidelines suggest you should assist in finding a new doctor. In some cases that may be appropriate, especially if you think you have a colleague who has a special interest that would benefit the patient. However, there are regrettably some patients who you would not wish on colleagues and those are the ones that more appropriately are given a list of possible doctors.



Retaining the Records


Retaining a copy of the notes is protective and increasingly easy with electronic records. As an alternative, you can provide the notes to the new practice on the basis that the file can be accessed later by you if needed.


Ending a patient doctor relationships is a significant and stressful step to take, however freeing yourself from a destructive professional relationship ultimately may keep you around longer, servicing the needs to many other patients that is servicing the greater good.