How to begin and end the Doctor-Patient Relationship?

Doctors-patient relationships are complex relationships based on understanding by the doctors of the patients need and expectation and by the patient of the doctors capacity to respond. In addition, this relationship is of primary importance in the overall health care and to provide good quality service to the patient. Both must be willing to be open with each other. Actually, it is not possible to define the beginning of such a relationship precisely, though it tends to happen when a person contact the doctor to obtain help with a matter that seems health related and for which the doctor seems able to provide assistance. It does not always begin at the moment of calling for an appointment, nor on entering the office, nor do even these two people begin to discuss the health issue. On the other hand, it clearly has begun when the doctor agrees to undertake investigation and treatment, a process of health care to which the patient agrees. The relationship certainly begins sometime between those two stages, that period within which both individuals determine their ability and willingness to undertake the relationship. Once the relationship is establish, the doctors have a duty to safeguard the interest of the patient first and the doctors must practice competently, respect patient autonomy and confidentiality, maintain patient safety and protect the patients best interest. However, when circumstances affect the doctors ability to achieve this, the physician may decide to end the doctor-patient relationship. In some cases, it may be the patient who decides to end the doctor-patient relationship. Doctors are permitted to end the doctor-patient relationship under certain circumstances. Ending the doctor-patient relationship will usually have significant consequences for the patient, as he or she will need to find another health care provider. Doctors should always carefully evaluate any decision to discontinue care and should use reasonable efforts to resolve any issues affecting the relationship with the patient prior to any final decision. Reasonable efforts include discussing with the patient, when possible, the reasons affecting the doctors ability to provide quality care and/or the elements that are necessary for an effective doctor-patient relationship.

What situations can results in a decision to end the doctor-patient relationship? (i) When there is breakdown of trust and respect between the doctor and the patients Trust and respect are essential elements of an effective doctor-patient relationship. Doctors may find in the course of providing services to a patient that these elements break down to the extent that the doctor is no longer able to provide quality care to the patient. This may occur when there has been: Patient fraud, such as for the purpose of obtaining narcotics or other drugs; Serious threat of harm to the doctor, staff and/or other patients; Other forms of inappropriate behaviour towards the doctor, staff and/or other patients; 2 for example foul language, rudeness, argumentativeness, A conflict of interest that compromises the doctors duty to put the interests of his/her patients first; 3 A communication breakdown that makes it impossible to provide quality care. (ii) The doctors practice has become too large to manage In this situation it will increase the pressure on both doctors and patients. As a result, doctors may find on occasion that their practice has become too large to manage and that they must decrease the number of patients to whom they provide services. The College advises doctors in these situations to carefully consider the medical needs of their patients and to proceed in a manner that is fair, transparent and compassionate. Doctors should consider factors including: the vulnerability of the patient, the patients ability to find care in an appropriate timeframe and the consequences terminating the relationship may have on the health of the patient. On the other hand, there are certain conditions where it is inappropriate for the doctors to end the relationship. All of these are explained below:(i) Prohibited by legislation Doctors are prohibited from ending a doctor-patient relationship because the patient chooses not to pay a block or annual fee.5 (iii) As outlined in the regulation on professional misconduct Under the regulations of the Medicine Act, 1991, certain activities can give rise to allegations of professional misconduct. Discontinuing required services constitutes professional misconduct unless: The patient requests the discontinuation; Alternative services are arranged, or The patient is given a reasonable opportunity to arrange alternative services.6 (iv)The patient chooses not to follow the doctors treatment advice

Patients are entitled to make decisions about their health care. In general, they can make their own decisions about treatment and lifestyle, even if the doctor does not agree with those decisions. In general, a physician should not end a doctor-patient relationship because the patient chooses not to follow the doctors advice. Under the Health Care Consent Act, physicians are prohibited from administering treatment unless they have obtained consent from the patient or the patients representative, even if the treatment is beneficial. Patients are entitled to withhold consent to any proposed or ongoing treatment. If this occurs, it should be noted in the patients medical record; particularly if the recommended treatment is supported by evidence based practice or generally accepted standards of practice. (v) The patient requires urgent or emergency services not otherwise available Where care is needed on an urgent or emergency basis and there are no other services available, such as a walk-in clinic or local emergency room, physicians should provide the needed care. What should be done prior to termination a doctor-patient relationship? Decisions to terminate a doctor-patient relationship are difficult for both physicians and patients. In all circumstances, doctors must have a transparent and rationale for ending the physician-patient relationship. This should be shared with the patient when appropriate, and documented in the patients medical record. In most cases, it is appropriate and useful for the patient to understand the reasons why medical services are being discontinued. However, doctors may use their discretion in situations where there is a genuine risk of serious harm associated with communicating those reasons to the patient.7 The decision to terminate must always be communicated to the patient in writing. Ideally, doctors should also communicate the decision in person, but rare situations (such as where there is a genuine risk of serious harm) may warrant written communication only.

Case 1 A patient with Diabetes mellitus lives in a small town with only one endocrinologist. The endocrinologist has a full practice and is not accepting new patients. The patient has very bad diabetes and has a complex regimen that her family practitioner insists is beyond his scope of understanding. The patient shows up in the office and insists to the office manager that she be accepted. What should be done? Should the doctor accept the patient? DISCUSSION