“Relationships based on respect, openness, trust and good communication will enable you to work in partnership with your patients.”¹ The cornerstone to any doctor patient relationship is trust. This is a two-way street – the patient trusting the doctor and the doctor trusting the patient. Patients will change doctors if they feel they have a poor relationship with them. But what if it is the doctor who feels trust is missing? Can you or should you terminate the relationship?
MIGA receives many calls from practices and doctors questioning whether the relationship can be terminated and if so, how that should occur.
The Medical Board of Australia notes where the relationship between doctor and patient becomes ineffective or compromised, it may be appropriate to end the relationship. This involves adequately informing the patient of your decision and facilitating arrangements for continuity of care including passing on clinical information².
There are circumstances where the behaviour of the patient warrants immediate termination from care. The calls we commonly receive in this space are where the patient is abusive, threatening, forges sickness certificates or prescriptions, makes inappropriate comments to the doctor or staff at the practice and lying about medications.
Then there are those patients that are extremely difficult to manage. This can be for a variety of reasons including where the patient refuses to follow the recommendations of the doctor. Patient autonomy is vitally important so we are not referring to those patients that have made a fully informed decision to refuse certain treatments or management plans.
An example of a frustrating scenario is, a patient with a number of chronic medical conditions that are uncontrolled largely due to their non-compliance with the recommended treatment regime. The doctor recommends blood tests; the patient does not have them. The doctor recommends a GP management plan and the patient doesn’t attend to have this. The patient repeatedly books in but either cancels at the last minute or fails to attend the appointment. Here, the patient is unwilling to follow up on their own healthcare resulting in a loss of trust in the relationship. As an initial step, it would be appropriate for the doctor to explain to the patient the expectations of the relationship and advise the patient that if they do not follow up their healthcare then the relationship would be terminated and the patient would need to find another doctor. It is important to set the boundaries of the relationship when ‘red flags’ arise which should be documented in the medical records. Then if the patient fails, terminating the relationship may be appropriate.
We know that not all circumstances for terminating the relationship arise due to difficult patients. It may be appropriate to cease to treat when doctors are placed into a situation of conflicting interests between patients. In particular, this occurs where knowledge of one patient may potentially affect the management of another patient.
It is common for a GP to see all of the members of one family, parents and children, but what happens if the parents decide to separate? There is no hard and fast rule about this. As a starting point the continuity of care of the children should be a priority. If the relationship breakdown is not acrimonious it may be possible to continue to manage all of the family. If the breakdown is acrimonious it may be necessary to refer both parents to other doctors/practices.
We dealt with an interesting situation that occurred when a long term patient of a GP attended for advice on injuries sustained as a result of an alleged assault. Another patient of the GP attended for counselling in relation to mental health issues and it became apparent they were the alleged assailant. It became clear with the information the GP had about both patients, the GP’s ability to manage them was conflicted. The GP contacted MIGA for support and ultimately terminated the relationship with both and recommended to each they attend other practices.
Some interactions between patients and medical practitioners have the potential to result in a complaint to AHPRA by a patient. Terminating the relationship is no different. So when considering terminating the relationship, if you are in doubt, contact the MIGA Legal Services team to discuss.