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 provides guidance on Creation of the Patient-Physician Relationship (members only).
TMA states that 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 American Medical Association (AMA) Code of Medical Ethics also provides guidance Opinion 1.1.1 Patient-Physician Relationships.
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. Refer to the AMA Code Opinion 1.1.2 Prospective Patients.
Physicians can best contribute to a mutually respectful alliance with patients by serving as their patients' advocate and by respecting patients' rights. The AMA Code provides information on Opinion 1.1.3 Patient Rights, as well as Opinion 1.1.4 Patient Responsibilities.
When a new patient makes an appointment with my office, does that establish a patient-physician relationship?
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. However, the law is not cut and dried and there is an exception to this. See TMA for more details.
If an on-call physician provides care to a patient, does that create a patient-physician relationship?
Yes, such provision creates a relationship. As such, the physician should provide or arrange follow up care. The physician is not, however, obligated to treat the patient for a condition that is unrelated to the condition treated in the emergency room. See the TMA Board of Councilors Opinion On-Call Physicians.
Terminating the Patient-Physician Relationship
The patient-physician relationship is wholly voluntary in nature and therefore may be terminated by either party. However, physicians have an ethical obligation to support continuity of care for their patients.
The Texas Medical Association (TMA) Board of Councilors Opinion on Termination of the Patient-Physician Relationship continues by stating it is unethical for a physician to unilaterally terminate the relationship without first providing an adequate medical attendant or reasonable notice under existing circumstances of the physician's intent to terminate the professional relationship.
The American Medical Association (AMA) Code of Medical Ethics states that, when considering withdrawing from a case, physicians must notify the patient long enough in advance to permit the patient to secure another physician and facilitate transfer of care when appropriate. Refer to Opinion 1.1.5 Terminating a Patient-Physician Relationship.
Termination of patient care without providing reasonable notice (TMB rules 190.8(1)(J) Violation Guidelines) could put a physician at risk for a patient complaint and possible disciplinary action by the Texas Medical Board (TMB) for potential patient abandonment. A reasonable notice is one that would allow sufficient time for the patient to make alternative arrangements for care.
The Texas Medical Liability Trust (TMLT) provides guidance in the article Terminating patient relationships - How to dismiss without abandoning.
The physician is not required to state a reason for termination of the relationship. TMLT states that, in general, risk managers advise against including a reason unless it can be stated in a brief, clear, and objective way.
TMLT risk managers also recommend that physicians develop a standardized process for dismissing patients. As a first step, the physician may go through a counseling process with the patient, particularly if the patient is noncompliant. This would allow the physician an opportunity to understand the cause of the patient's noncompliance. A similar counseling process can be employed for patients who regularly miss appointments or exhibit rude behavior.
Although a patient can be dismissed for nonpayment of fees, this situation must be handled carefully. The physician should closely evaluate the need for continuity of care, and TMLT strongly recommends that dismissal for this reason only be used as a last resort.
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. Prior to termination, the physician should evaluate the specific case to ensure the patient is not in an acute phase of care, will be given appropriate notice, and has the opportunity to find another physician.
The TMA Office of General Counsel provides guidance in the whitepaper Termination of the Patient-Physician Relationship (members only) that includes answers to some FAQs.
TMLT has informative slides on What Every Physician Needs to Know: Terminating the patient-physician relationship Part 1 and Part 2 that cover some specific situations and the need to proceed with caution.
TMLT also has published an excellent article that discusses some difficult situations, handling risks, and appropriate steps to take. Refer to Terminating the patient-physician relationship in TMLT's The Reporter, Quarter 4 2017, beginning on page 2.
Dismissing a patient is always difficult, but creating practice guidelines (TMA) ahead of time can make the situation less stressful.
Below is a brief look at the physician's responsibilities when dismissing a patient
- Terminate the relationship in a manner that avoids allegations of patient abandonment and facilitates patient care.
- 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.
- If the physician is part of a group practice and the other physicians in the group would prefer not to see the patient, then the termination letter should clearly state that the relationship is ending with both the physician and group.
- Print the termination letter on office letterhead and send it to the patient via both certified mail/return receipt requested and regular mail. Keep a copy of the letter and return receipt in the patient's chart. (Note: Sending the letter by certified mail/return receipt provides the necessary documentation; sending it also by regular mail provides backup in case the patient is not home to sign for the certified letter and/or fails to pick it up at the post office.)
- TMLT has developed several Sample Termination Letters (pdf). TMA also has a Sample Letter for Terminating Relations. (members only)
- Be sure to inform staff, especially the appointment scheduler, of the dismissal and effective termination date.
Frequently Asked Questions:
In addition to those below, the TMA General Counsel whitepaper Termination of the Patient-Physician Relationship (members only) provides answers to even more FAQs.
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?
Yes, a new patient-physician relationship will have been established by the act of treating the patient in the ER unless the limits were clearly established in that interaction. However, all the factors listed above pertaining to proper termination of the patient-physician relationship are still applicable, so you must formally re-terminate that relationship. (TMA General Counsel)
A patient arrived for her initial appointment. The patient was rude and abusive because she felt she had waited too long, so I decided not to take care of her. Do I have to send her a termination letter?
Generally no, because a patient-physician relationship was not formed. However, it is the policy of some offices to regard all people as "patients" at the time the first appointment was scheduled. In that case, the physician may have voluntarily assumed a duty the law has not yet imposed. A letter reciting that you have not agreed to be her physician may be advisable. (TMA General Counsel)
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?
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 would want to inform your patients that they can continue to see you, but that it would be on an out-of-network basis.
I was "deselected" by a managed care plan. Do I still have to provide care to managed plan enrollees even though I may not be paid for that care?
Insurance status has no bearing on whether abandonment has occurred, so enrollees are still patients until the patient-physician relationship is properly terminated. Also, the managed care plan contract may require that care be continued until a particular course of treatment is completed, or the plan finds that patient another physician. Check your plan contact for details. (TMA General Counsel)