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Advice to the Profession: Ending the Physician-Patient Relationship

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Advice to the Profession companion documents are intended to provide physicians with additional information and general advice in order to support their understanding and implementation of the expectations set out in policies. They may also identify some additional best practices regarding specific practice issues.

An effective physician-patient relationship is essential for the provision of quality medical care, and it forms the foundation of the practice of medicine. It is also a partnership which benefits from the mutual trust and respect of both the physician and the patient. While this relationship is of central importance to the practice of medicine, circumstances may sometimes arise which lead either the physician or the patient to end the physician-patient relationship.

This advice document is intended to help physicians interpret their obligations as set out in the Ending the Physician-Patient Relationship policy, and provide guidance for how these obligations can be effectively discharged.

This policy applies to all physicians, regardless of speciality or area of practice

The expectations of this policy apply to specialist physicians and physicians practising outside of primary care, however, only when ending the physician-patient relationship prior to reaching the “normal” or “expected” conclusion of the patient’s treatment or assessment (for example, as the result of a conflict with the patient that makes the continued provision of care impossible).

When, in the normal course of providing care, a specialist’s involvement with a patient reaches its natural or expected conclusion (for example, because the treatment or assessment have concluded, and/or the patient’s care has been transferred back to their referring physician), this policy does not apply.

The patient’s best interests are paramount, even when there is conflict or disagreement

Physicians have a professional responsibility to act first and foremost in the best interest of their patient, and the policy establishes expectations which reflect this responsibility.

This responsibility is not altered simply because a conflict or disagreement has arisen with the patient.1

Patient complaints

In circumstances where a patient has filed a complaint against their physician, the primary consideration is whether the mutual trust and respect that are essential to an effective physician-patient relationship are undermined, and if so, whether the relationship can be repaired.

The policy expects that ending the physician-patient relationship will not be an automatic response to a complaint, but that physicians will make a determination with consideration for the specific circumstances of each situation, exercising their professional judgment, and in keeping with the principles and expectations of the policy (for example, by considering the factors that may have led to the complaint with an open mind, and by undertaking reasonable efforts to resolve the situation whenever possible).

Sample notification letter

The policy requires physicians to notify each patient in writing when the physician-patient relationship has been discontinued.

The following is a sample letter for situations where there has been a significant and irremediable breakdown in the physician-patient relationship.

Physicians can customize this letter to fit the specific circumstances of each case, and to help ensure that the letter is written in a way that the patient can understand.

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 of my patients. In order to do this, you and I must cooperatively and respectfully work together towards your health and well-being.

It has become clear that because of [if appropriate, indicate reason], our physician-patient relationship has broken down, and this has made it difficult for me to continue providing quality care to you.

Despite taking the following steps to resolve the situation [if appropriate, list the steps undertaken to resolve the situation in advance of ending the relationship], I therefore regret to inform you that I will not be in a position to provide you with further medical services after [enter the date -- this time will vary from community to community, but you should give sufficient notice].

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. I will also ensure appropriate follow-up on all laboratory and test results still outstanding.

For assistance in locating another physician, you may wish to contact your local Community Health Centre, which is an organization that provides primary health care and prevention programs through physicians and a variety of other health professionals. A list of community health centres in Ontario is available on the Ontario Ministry of Health and Long-Term Care website. You may also wish to contact your local hospital to see whether any physicians on staff are accepting new patients. Lastly, some physicians, including those who are new to an area or who are beginning to establish a practice, will advertise that they are accepting new patients

Yours truly,

[Signature of physician]

Endnote

1. It is important to note that in situations where the patient poses a genuine risk of harm to the physician, the physician’s staff, or to other patients, physician may end the physician-patient relationship immediately, and are not obligated to engage directly with the patient.