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 (members only). And refer to the below FAQ section for information regarding some specific situations.
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.
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, as well as Opinion 1.1.4 Patient Responsibilities.
Terminating the Patient-Physician Relationship
Sources: AMA Council on Ethical & Judicial Affairs, TMA, TMB, 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 not required to state a reason for termination, but he/she 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.
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.
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.
Termination of patient care 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.
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, that includes answers to some FAQs.
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 informative slides on What Every Physician Needs to Know: Terminating the patient-physician relationship Part 1 and Part 2 that provide information on some specific situations and the need to proceed with caution.
TMLT has published an excellent article that discusses some difficult situations, risks, steps, and more. Refer to Terminating the patient-physician relationship in TMLT's The Reporter, Quarter 4 2017, 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 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.)
- Be sure to inform staff, especially the appointment scheduler, of the dismissal and effective termination date.
- TMLT has developed several Sample Termination Letters. TMA also has a Sample Letter for Terminating Relations. (members only)
Frequently Asked Questions:
In addition to those below, the TMA General Counsel whitepaper Termination of the Patient-Physician Relationship provides answers to even more FAQs.
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.
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 General Counsel)
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.
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 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/she can accept him or her as a patient - not necessarily for treatment.
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? (Source: TMA General Counsel)
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.
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? (When You Drop Your Patients' Insurance ... 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 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? (Source: TMA General Counsel)
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.