terminating the physician-patient relationship, part 1

WHAT EVERY PHYSICIAN NEEDS TO KNOW:

TERMINATING THE PHYSICIAN-PATIENT RELATIONSHIP

PART 1

1 INTRODUCTION

“The physician-patient relationship is the result of a contract, express or implied, between a physician and patient that is voluntary and arises when a patient requests and is supplied medical information/treatment.” – Fullbright and Jaworski. Texas Medical Jurisprudence. Fifteenth Edition. 2004.

1 INTRODUCTION

Medicine is a business that comes with an ethical duty to patients, but physicians are within their rights to end a relationship that is no longer therapeutic. However, the requirements for ending the relationship are complicated for physicians in order to avoid allegations of patient abandonment.

2 REASONSto terminate a patient

relationship

• Patient noncompliance• Failure to keep appointments• Rude or disruptive behavior to physician or staff• Non-adherence to practice policies

2 REASONSto terminate a patient

relationship

• Failure to pay outstanding balance• Patient commits prescription fraud• Patient filed a complaint with the state medical board

• Patient is beyond 28 weeks of pregnancy• Physician is on call • Physician is treating a hospitalized patient• Surgeon is treating a patient postoperatively

3 SITUATIONSthat may prevent or make

termination difficult

• Physician practices in a rural area where access to care is limited• Pediatric patients• Patient has mental health issues

3 SITUATIONSthat may prevent or make

termination difficult

4 OBSTETRICIANS & PREGNANCY

• It may be difficult to discharge a patient in the last trimester of pregnancy because it may not be feasible for these patients to find another physician who will accept them past 28 weeks.

• If transfer of care cannot be arranged, it is likely that a physician will need to continue treating the patient through the postpartum period.

4 OBSTETRICIANS & PREGNANCY

• Before terminating the relationship, physicians should consider if their call duties may eventually require them to deliver a baby for a patient who has been dismissed from the practice.

• A commonly asked question: When can an on-call specialist dismiss a patient? Generally, an on-call specialist in the ED must see the patient through the acute episode, including follow up, until the patient is stable. However, the specialist is not obligated to treat the patient for unrelated conditions.

5 ON-CALL PHYSICIANS

• Hospital call requirements normally do not allow an on-call physician to refuse care to a patient – even if the patient has previously been dismissed from the on-call physician’s outpatient practice.

• If an on-call physician treats a patient that has previously been terminated, it may be prudent to inform the patient that the hospital care does not re-establish the relationship once the patient has been discharged.

5 ON-CALL PHYSICIANS

• Physicians are encouraged to review the terms of their on-call contracts so they are familiar with their obligations and specific responsibilities for follow up.

5 ON-CALL PHYSICIANS

6 HOSPITALIZED PATIENTS &

POSTOPERATIVE CARE• Terminating the patient-physician relationship while the patient

is in the postoperative period or in an acute medical episode is not recommended.

• Physicians must care for their patients until they are stabilized or until another physician is found and can facilitate a seamless transfer of care.

6 HOSPITALIZED PATIENTS &

POSTOPERATIVE CARE• Surgeons have an obligation to see patients after surgery until

postoperative care is no longer required, the patient is stable, and can be discharged.

7 RURAL AREAS

• Rural providers may find it more difficult to dismiss patients due to a lack of available specialists. If a patient needs continued care and there are no other physicians to provide it, physicians may need to be flexible.

• Offering payment plans to patients facing financial hardship or continuing to treat noncompliant patients may be necessary.

8• Pediatric patients can be challenging because

noncompliance and nonpayment are not the patient’s fault or responsibility.

• Physicians are encouraged to try to work with the parents, and noncompliance should be well documented in the chart.

PEDIATRIC PATIENTS

8• If the parents’ noncompliance threatens the patient’s safety,

consider a call to Child Protective Services instead of terminating the relationship.

• If the relationship is not salvagable, it is reasonable to dismiss the patient from the practice.

PEDIATRIC PATIENTS

9 MENTAL HEALTH ISSUES

• Psychiatrists should avoid prescribing large amounts of medications around the time of termination. The most conservative approach is not to prescribe beyond the termination date.

• If a psychiatrist decides to prescribe or refill after termination, the termination date may need to be extended.

LAWSUITS & MEDICAL BOARD

COMPLAINTS• If a patient has filed a lawsuit or medical board complaint,

the physician cannot assume that the relationship has automatically ended. Ending the relationship will still require formal termination with a letter and appropriate notice.

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11 PROTECTION FOR A NEW ERA OF

MEDICINEABOUT TMLT:With more than 19,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. www.tmlt.org

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