Advice to the Profession: Ending the Physician-Patient Relationship

This advice document is intended to help physicians interpret the expectations set out in the Ending the Physician-Patient Relationship policy and to provide guidance about how these expectations can be met.

Where the patient ends the physician-patient relationship

This policy does not apply when the patient ends the physician-patient relationship.

When a patient wishes to end a physician-patient relationship, physicians may want to discuss with the patient why they are choosing to do so. These discussions can help the physician understand any concerns the patient may have about the care they are receiving and can help the physician resolve the situation.

The physician remains responsible for documenting in the patient’s medical record the patient’s reasons for ending the relationship (if known) and any steps they have undertaken to try to resolve the situation. To prevent confusion, physicians can also consider providing the patient with a written notification that their physician-patient relationship has ended.

Significant breakdowns in the physician-patient relationship

Physicians will need to use their professional judgment to determine what constitutes a “significant breakdown.” A breakdown in the physician-patient relationship can occur when trust and respect between a physician and their patient has been lost and/or the therapeutic relationship has deteriorated. Situations that can lead to a breakdown in the physician-patient relationship include, but are not limited to, those in which a patient:

• Commits prescription-related fraud;
• Behaves in an abusive, or disruptive manner towards the physician, other members of the clinical team or office staff;
• Frequently misses appointments without appropriate cause or notice; or
• Refuses to pay outstanding fees without providing a reasonable justification for non-payment.1

Resources for managing difficult patient encounters

Physicians have a right to be free from violence in their workplace. There are many challenging situations that may arise during physician interactions with patients, and ultimately physicians are permitted to end relationships where they feel their safety, or the safety of others, is threatened.

For information on ending the physician-patient relationship and managing challenging encounters, see the external resources linked below:

• When physicians feel bullied or threatened (CMPA)
• How to manage conflict and aggressive behaviour in medical practice (CMPA)
• Challenging patient encounters: How to safely manage and de-escalate (CMPA)
• Physician Safety: How to Protect Against Threats or Risk of Harm by Patients FAQ (OMA)

The Ontario College of Family Physicians also has a Peer Connect Mentorship program which supports physicians in skillfully responding to mental health issues and addressing substance use disorders and chronic pain challenges in their practice. Nonviolent Crisis Prevention & Intervention Training which focuses on prevention and teaching individuals how to safely de-escalate anxious, hostile, or violent behavior may also be helpful.

Patient Concerns

Patients may contact CPSO for help resolving an issue with their physician and/or to initiate a complaint. Depending on the nature of the issue, CPSO may call the physician to try to resolve the situation.

Often, patient concerns can be resolved when the issue is brought to the physician’s attention and are not indicative of a breakdown in the therapeutic relationship. Physicians need to consider the specific circumstances of each situation, the factors that may have led the patient to contact CPSO and/or make a complaint, and make reasonable efforts to resolve the situation, where possible.

If, however, a physician believes that a patient’s concerns or complaints indicate a broader loss of mutual trust and respect and they feel they cannot maintain an effective therapeutic relationship, it may be appropriate to end the physician-patient relationship.

Situations where physicians may no longer be able to provide quality care

There are many reasons why physicians may feel they can no longer provide quality care to a patient including, but not limited to:

• The patient has been absent for a long period of time; or
• The patient has relocated far from the physician’s practice and is unable to attend in-person appointments, where necessary.

Considerations for deciding to end the physician-patient relationship

There may be specific factors to consider and/or steps to take prior to ending the relationship, depending on a physician’s reasons for wanting to end their relationship with a patient. For example:

Where the patient has been absent from the practice for an extended period, the physician can:

• Consider how long the patient has been absent, and the likelihood that the patient has sought care elsewhere.
• Make a good-faith effort to determine whether the patient would prefer to maintain the relationship.
• Send a letter of inquiry to the patient’s last known address (residential or email).

Where the patient’s behaviour is abusive or disruptive, the physician can:

• Consider whether the patient’s behaviour is an isolated incident or a pattern of behaviour.
• Consider whether there are underlying factors that may be contributing to the patient’s behaviour (e.g., mental illness).
• Inform the patient of any expectations or clinic policies related to patient conduct.

Where the patient has refused to pay an outstanding fee, the physician can:

• Consider the financial burden that paying the fee could place on the patient.
• Consider waiving the fee or allowing flexibility with respect to repayment, especially if the patient is unable to pay due to personal circumstances.

Where the patient has relocated far from the physician’s practice, the physician can:

• Determine whether the patient is willing and able to travel to the clinic for necessary in-person care and/or whether care can appropriately be provided virtually.2
• Discuss with the patient how their relocation could impact their ability to receive the care they need.

Where the physician wishes to decrease their practice size 3, the physician can:

• Make sure to select patients with whom to end the physician-patient relationship in a fair, transparent, and compassionate way.
• Ensure that patients with high or complex care needs are not discharged disproportionately.
• Consider each patient’s medical needs and their ability to find alternative care in a timely manner.

Outside use and de-rostering patients

When patients who are part of a rostered practice seek care outside of that practice (e.g., by going to a walk-in clinic), there can be a financial impact on the physician. For this reason, some physicians may want to de-roster that patient and see them instead on a fee-for-service basis. This is distinct from ending the physician-patient relationship.

Physicians need to be conscious of the difference between ending a physician-patient relationship and de-rostering a patient, and make clear to the patient that if they are de-rostered, they will not lose access to care.

It would not be reasonable for a physician to end the physician-patient relationship solely because the patient sought care outside of their rostered practice. However, there may be instances where de-rostering is not possible, or where the physician feels that the patient continually seeking care outside of the practice has led to a breakdown in their relationship or has impacted their ability to provide quality care to the patient. In these circumstances, the physician needs to do the following before ending the relationship:

• Consider the factors that may have led the patient to seek care outside the practice (including the physician’s own availability),
• Provide the patient with clear information about the patient’s obligations within the rostered practice,
• Provide the patient with appropriate warning, and 
• Undertake reasonable efforts to resolve the situation in the best interests of the patient.

Providing written notification

Providing patients with a written notification indicating the reasons for ending the physician-patient relationship during an appointment, or sending the notification by registered mail or courier can help ensure that the patient has received it. It may also be appropriate and acceptable for a physician to inform a patient of their decision to end the physician-patient relationship using an online platform (e.g., patient portal or email) provided the physician typically uses this platform to communicate with the patient.

No matter how a physician provides written notification to their patients, they will need to ensure that patient confidentiality is maintained.

Sample termination letter

Physicians may use the following sample letter to inform their patients that they have ended the physician-patient relationship. Physicians can customize this letter to suit their needs and to help ensure that the patient can understand it.

Dear [patient’s name]:

As we discussed at your appointment on [insert date], my first obligation as a medical doctor is to provide quality care to all my patients. To do this, you and I must cooperatively and respectfully work together towards your health and well-being.

Due to [if appropriate, indicate reason], it is no longer possible for me to continue our physician-patient relationship.

I urge you to obtain another physician or primary health-care provider as soon as possible. With your consent, I will be pleased to provide them with a copy or summary of your medical records [include any additional steps, the process for obtaining a copy of their medical records and any associated fees]. I will also ensure appropriate follow-up on all laboratory and test results still outstanding and provide necessary medical services for [include time period here e.g., three months].

For primary care physicians: For assistance in locating another physician, you may wish to register with Health Care Connect which can refer you to a family physician or nurse practitioner in your area accepting new patients. You can also contact primary care clinics within your community to determine if any physicians are accepting new patients. Some physicians, including those who are new to an area or who are beginning to establish a practice, may advertise locally that they are accepting new patients.

Yours truly,

[Signature of physician]