• Patient-Physician Relationship

    Physicians have long recognized that the health and well-being of their patients depend upon a collaborative effort between the patient and physician.

    Establishing the Patient-Physician Relationship

    A patient-physician relationship exists when a physician serves a patient's medical needs. It is established as a result of a mutual intention to contract, express or implied, that the doctor will treat the patient with proper professional skill.

    The Texas Medical Association (TMA) Office of General Counsel states: Physicians' legal responsibilities to their patients begin with the creation of the patient-physician relationship and continue as long as that relationship exists. A physician is potentially liable for medical professional liability only where there is a patient-physician relationship.

    The TMA Office of General Counsel provides additional guidance on Creation of the Patient-Physician Relationship.

    Also, refer to the below FAQ section for policy and info regarding some specific situations.

    The American Medical Association (AMA) Code of Medical Ethics also provides guidance Opinion 1.1.1 Patient-Physician Relationships.


    Prospective Patients

    Physicians have an ethical obligation to provide care in cases of medical emergency. Physicians also must uphold ethical responsibilities not to discriminate. However, physicians are not required to accept all prospective patients and may decline to establish a patient-physician relationship in certain limited circumstances.

    See the AMA Code of Medical Ethics under Patient-Physician Relationships Opinion 1.1.2 Prospective Patients.


    Rights of the Patient

    Physicians can best contribute to a mutually respectful alliance with patients by serving as their patients' advocate and by respecting patients' rights.

    See the AMA Code of Medical Ethics under Patient-Physician Relationships Opinion 1.1.3 Patient Rights.


    Ending the Patient-Physician Relationship

    Sources: AMA Council on Ethical & Judicial Affairs, Texas Medical Association, Texas Medical Liability Trust (TMLT)

    The patient-physician relationship is wholly voluntary in nature and therefore may be terminated by either party. A physician is responsible for providing reasonable notice of the intent to terminate the relationship to allow sufficient time for the patient to make alternative arrangements for care. A physician is not required to state a reason for termination.

    However, physicians also have an ethical obligation to support continuity of care in certain circumstances. For example, an OB patient who is eight months pregnant may not be able to find another physician willing to accept responsibility for her care. The physician who wants to end the relationship may need to wait until after providing delivery and postpartum care.

    To terminate a relationship without providing reasonable notice could put a physician at risk for a patient complaint and possible disciplinary action by the Texas Medical Board for patient abandonment.  Physicians are encouraged to review possible termination on a case-by-case basis; one policy may not fit all when it comes to ending a relationship.

    Dismissing a patient is always difficult, but practice guidelines can be developed ahead of time to make the situation less stressful. TMA e-Tip: Create practice guidelines for dismissing patients.

    TMA General Counsel provides guidance in the whitepaper Termination of the Patient-Physician Relationship.

    The TMA Board of Councilors provides an Opinion on Termination of the Patient-Physician Relationship.

    The AMA Code of Medical Ethics also provides guidance Opinion 1.1.5 Terminating a Patient-Physician Relationship.

    TMLT advises Terminating patient relationships - how to dismiss without abandoning.

    TMLT also has published an excellent article that discusses the risks, difficult situations, steps, sample letters, and more. Please refer to Terminating the patient-physician relationship - navigating appropriate notice, difficult patients, closing a practice, and more in The Reporter 2017 Quarter 4, beginning on page 2.

    Also, see the below FAQ section for guidance in some specific situations.

    Below is a brief look at the physician's requirements when dismissing a patient:

    – Terminate the relationship in a manner that avoids allegations of patient abandonment and facilitates patient care.
    – Print the termination letter on office letterhead and send it to the patient by both regular and certified mail, return receipt requested. Keep a copy of the letter and return receipt in the patient's chart.
    – TMA has a Sample Letter for Terminating Relations.  TMLT also has developed several addt'l Sample Termination Letters
    – A physician is not required to state a reason for termination. In fact, in many situations, it may not be advisable. It may be more advantageous to exclude specific reasons or to include only neutral statements.
    – Agree to treat the patient for a reasonable length of time, such as 30 days, to allow the patient time to secure care from another physician. Clearly state in the letter the date on which the termination will be effective.
    – Provide resources to help the patient find a new physician (e.g., the patient's health insurance plan or a referral service), but do not make a specific physician referral.
    – Offer to send a copy of the medical records to the patient's new physician upon receipt of a signed authorization (include the authorization form with the termination letter). When it's the physician ending the relationship, he/she may wish to forego any copying fees for the medical records to avoid giving rise to additional bad feelings.
    – A physician may not withhold a copy of the patient's medical records because of an outstanding account balance. 


    Frequently Asked Questions:

    The Texas Medical Liability Trust (TMLT) has many Risk Management FAQs helpful to your practice.

    On-Call Physicians Source: TMA Board of Councilors Current Opinions

    If the on-call physician provides care to the patient, such provision creates a patient-physician relationship. Because of the creation of the patient-physician relationship, the physician should provide or arrange follow up care to the patient. The physician is not, however, obligated to treat the patient for a condition that is unrelated to the condition for which the physician initially treated the patient in the emergency room.

    Do appointments establish a patient-physician relationship?  Source: TMA E-tip

    Generally, an appointment to see a physician, in and of itself, is not sufficient to establish the contract - expressed or implied - that underlies a patient-physician relationship. A patient demonstrates consent to the relationship by seeking medical services. Physicians consent by diagnosing, treating, or otherwise providing care. Although the law in this area is not cut and dried, generally it holds that the physician has the option to reject the patient-physician relationship at this first appointment.

    An exception to this might be if a specialist refuses to treat a patient who has an appointment for a specific procedure that is vital to the patient's health. What if a prospective patient lists specific symptoms when calling the physician's office, then asks for an appointment? In that case, your staff person on the phone should make clear that the purpose of the appointment is to evaluate the patient so the physician can determine if he can accept him or her as a patient - not necessarily for treatment.

    I discharged a patient from my practice for noncompliance. Later I saw him in the ER, but he needed follow-up in the office. Must I now 're-terminate' the patient if I do not wish to provide further care?  Source: TMA E-tip

    Yes. By treating the patient in the ER without advising him of the limits on that relationship, you established a new patient-physician relationship, and you must formally terminate that relationship.

    If I terminate my contract with an insurer, must I also notify patients covered by that insurer that I am terminating the patient-physician relationship? Source: TMA E-tip

    No, your patients can continue to receive services from you even if you do not accept the contract offer from their insurance company. Termination of an insurance contract is entirely separate from the termination of the patient-physician relationship. You may want to inform patients that they can continue to see you on an out-of-network basis.