Practice management: When it's time to part ways

Most doctor-patient relationships are built on collaboration and trust, often lasting years, even decades. But as in other relationships, sometimes, it’s not meant to be. The respect is not there or an incident takes place—and the relationship devolves into one of irreconcilable differences. In some cases, the ending is absolutely required, as when a patient is abusive to a physician or staff. At other times, the situation is subtler, and it may be hard for a doctor to know if the situation warrants severing ties and if it is even fair—given that we are currently experiencing physician shortages. Fortunately, the Canadian Medical Protective Association (CMPA) and provincial and territorial colleges outline the considerations and guidelines for physicians in such situations to ensure the well-being of their patients and themselves. “It’s about doing what is in the best interests of the patient, which is to have a healthcare provider they trust, respect, and will be able to collaborate with so that optimal care can be provided,” said Dr. Desai. “If the physician does not have this positive relationship with the patient, then it is unlikely or potentially impossible to provide care to a complex patient." The ‘why’ of severing ties Dr. Desai said that currently, the three main reasons physicians want to end relationships are: Patient behaviour—either verbal or physical abuse directed toward physicians and/or their office staff Complaints to colleges or legal actions Loss of mutual trust/respect within the doctor/patient relationship While abuse tops the list, this is not new. There has been a rise in reports of physicians being the target of harassment in recent years, Dr. Desai said there has not been a significant increase in calls to the CMPA from doctors wanting to sever relationships for that reason. “Although there may be an increase in members who feel harassed by patients, especially in view of the anti-science stance of some, we aren’t seeing a noticeable increase in calls regarding this issue over the last year or so,” he said. In the second case, pending complaints generally point to a strained relationship that would make it impossible for a physician to provide optimal care to the patient. The third case, Dr. Desai said, “is a situation where a patient may be simply unwilling to accept advice or recommendations from the doctor as they don’t trust the doctor’s skill or experience and would refuse to collaborate. As a result, the doctor may be unable to gather relevant information and unable to provide the standard of care expected of them.” Other circumstances Other circumstances that may lead to termination, according to the College of Physicians and Surgeons of Ontario (CPSO), are prescription-related fraud; the patient frequently missing appointments without appropriate cause or notice; and the patient accumulating and refusing to pay fees. At the same time, there are reasons considered unacceptable for physicians to end a relationship. For example, the CPSO states that: “Physicians must respect patient autonomy with respect to lifestyle, healthcare goals and treatment decisions, and not end the physician-patient relationship solely because the patient: does not follow advice (for example, with respect to smoking cessation, drug or alcohol use, or the patient’s decision to refrain from being vaccinated or vaccinating his/ her children); suffers from an addiction or dependence, or is on a high dose of a prescribed controlled drug and/or substance; or seeks treatment to which the physician objects on the basis of conscience or religious beliefs.” Trying to bridge the gap Ideally, according to the CMPA and colleges, the physician who is struggling with a patient should first try to resolve issues through open and honest communication. Providing active listening in a non-judgmental fashion may help to defuse the situation. However, physicians are not expected to tolerate abuse or threats of harm as part of their role as healthcare providers. “The key to a beneficial doctor/ patient relationship is the mutual trust and respect within that relationship. If this is lacking, the doctor may find it hard to accurately investigate and diagnose issues, and the patient may not heed any advice or suggestions provided,” said Dr. Desai. “But disagreement about treatment options is not synonymous with a breakdown in trust in respect. In only a small minority of circumstances would a disagreement imply a breakdown in the physician-patient relationship.” A mistake doctors make While trying to resolve conflict is recommended, more often physicians err on the side of tolerating bad behaviour. “At times, doctors may put up with a significant amount of abuse without wanting to push back, put anything negative in the notes, or in any way jeopardize patient care,” said Dr. Desai. “In the long run, the impact of this abuse may lead to the doctor becoming so traumatized, that it affects the care of this patient, and other patients in the practice also.” It comes back to doctors understanding that they always have the right to be treated with respect, said Dr. Desai, and should have zero tolerance for abuse and address it as soon as possible. What to do when it’s time The CMPA outlines specific steps to take when a physician feels it might be time to end a relationship (See “Ending the doctor-patient relationship”). High-level, general recommendations are: Attempt resolution if appropriate Check your college policies and requirements for terminating such relationships in your province or territory Take a compassionate approach Tell the patient in person if safety is not an issue (otherwise write a letter) Provide the patient with adequate notice, taking into account the patient’s circumstances and the availability of alternative resources Provide patient with specific information or instructions concerning the patient’s particular medical condition Advise on and facilitate getting a new physician Inform your staff and if warranted other allied healthcare professionals and arrange for confidential record transfers Keep careful records of incidents leading to the relationship termination, as well as the termination process Follow your college processes Document, document, document “The most important thing doctors should do when ending a physicianpatient relationship is to ensure accurate documentation,” said Dr. Desai. “If the issue is a sudden event (such as overt verbal abuse or physical threats), this needs to be charted at the time. If the issue develops over time, then it would be important to document the discussion the physician has had with the patient advising them of the issue and the steps the physician has taken to resolve it before it requires termination of the relationship.” While all colleges have similar guidelines and are consistent in their procedures, physicians are advised to review the specifics. For example, all accept that there needs to be mutual trust and respect within a doctor/ patient relationship, and use this as an underlying principle. But there may be slight differences in how doctors should approach these patients and document these issues. It should be noted that there are variations in thresholds for what is deemed to justify ending a relationship. Bottom line, says Dr. Desai, despite increased attention to difficult patient encounters given the stressful circumstances around COVID, “the overwhelming majority of physician/ patient relationships are positive. And many of those that aren’t can be remedied by open and non-judgmental communication.”

Practice management: When it's time to part ways

Register for free access or login.

Related Topics