‘I think we should see other people’: How to divorce your patient

• Doctors sometimes cannot effectively treat a patient and adequately meet the needs of their other patients.
• A number of steps are required before ending the patient–doctor relationship, including consideration of the range of potential impacts on the patient.
• Doctors are required to consider the most sensitive way possible to convey the decision to end the professional relationship.

This is not the time for a doctor to engage in a cathartic rant

On 9 March, the RNZCGP released results on GP burnout and intended retirements.¹ Contributors to a growing challenge to front-line GP services were identified: increased patient complexity with particular reference to the needs of older people and those with mental health issues; the Government funding model of 15-minute consultations, this being inadequate for complex patients; and follow-up requirements consuming two additional hours each day.

Thirty per cent of survey participants reported high scores on the burnout scale. One-third of GPs reported an intention to retire in five years, and 49 per cent in 10 years. In such circumstances, doctors may find some patients become intolerable, due to personality, sense of entitlement or their tendency to create “fear, despair or even downright malice in their doctors”.²

Maybe it’s the time of year, but the most common reason for seeking advice on the Medicus helpline lately has been doctors who feel they cannot manage a particular patient or family while adequately meeting the needs of their practice’s other patients.

Given practice resources are so stretched, you might think that, at this time, your ability to “choose for the greater good” would be a recognised or enhanced right – a choice that allows you to manage your practice so you can effectively treat the greatest number rather than be overwhelmed by one patient.

However, coinciding with increased pressure, stricter impediments have been enunciated for ending the patient–doctor relationship. This reflects the tension in giving effect to a patient’s right to continuity of care and the reality there are groups of patients who have difficulty accessing that care.

The December 2020 guidelines from the Medical Council recognise your right to end the patient–doctor relationship in certain circumstances, including if you want to downsize, relocate or close your practice; the patient is abusive, violent or poses a significant safety risk to you or your colleagues; or the patient–doctor relationship breaks down.³ However, steps are required to achieve the divorce.

Ending the relationship can be fraught, even for reasons not personal to the patient. Just closing your practice itself can be contentious.

Years ago, I was counsel in a case before the Human Rights Review Tribunal where the plaintiff was among a strongly vocal group opposed to their doctor’s decision to move away and sell the practice to another group. Events around this, including a public meeting attended by representatives of the DHB, PHO and new owners, gave rise to complaints to both the health and disability commissioner and the privacy commissioner.

That the tribunal case was resolved with a significant order of costs against the complainant/patient did not address the stress of prolonged litigation.

So, how can you safely end the relationship for reasons personal to the individual concerned?

You are required to go through a decision-making process a bit like a judge exercising a statutory discretion. The following are the steps the Medical Council says you “should” undertake. The order set out in the guidelines is:

1. Explain your concerns or change in circumstances with the patient and the reasons you are considering ending the relationship.
2. Think about whether your decision may impact negatively on the patient and their family/whānau, such as limiting the patient’s options for, or access to, medical care.
3. Assess the impact on the patient, where treatment may be incomplete, acute or ongoing unless their treatment has been transferred to another doctor or health professional.
4. Think about the most appropriate and culturally safe way to end the treating relationship. This could include helping to transfer the patient’s care to another doctor or health professional.
5. Consider seeking advice.

I suggest carrying out “step 1” last. There is no point causing upset to the relationship unless you have thought through the other considerations.

Steps 2 and 3 require you to consider the impact on the patient if the relationship is ended. This is where, in my experience, doctors feel most conflicted. Good doctors whose practice is instilled with the ethic of service usually get to a point, by the time of ringing me, where the situation has become impossible for them.

That the patient may feel rejected, have their confidence in medical care challenged or react with violence are all factors the doctor has ruminated on, along with the reality of limited alternative medical practices. When talking with the doctor, I record these factors in a note so the doctor has a confidential record to access should the ultimate decision be challenged by a subsequent complaint.

Surprisingly, the guidelines have a pretty much all-or-nothing approach. Despite this, my discussion with the doctor will traverse options short of ending the relationship, such as the doctor setting out expectations. This can be effective in dealing with challenges such as drug-seeking behaviour, being disrespectful of time, non-compliance with recommendations (recorded agreements either to comply or to absolve the doctor from liability, while respecting the patient’s wishes), family conflicts on accessing health information, and aggressive behaviour.

Having canvassed these options and considered the problems the patient will encounter, the doctor will reach a view with strong reassurance that it’s okay to prioritise the doctor’s own needs, mental health and obligation to serve a large community of less demanding but equally needy patients.

You are required to consider the most sensitive way possible to convey the decision. The guidelines could be read as expecting the decision will be conveyed kanohi ki te kanohi, (face to face). This may be appropriate if there is a planned appointment (better not to charge for it).

On the advice line, we spend some time considering how best to convey the news, ideally with a nurse present if this will not be inflammatory to the patient. For example:

“I have been thinking a lot about our last appointment and your health needs. I realise I am the third doctor you have enrolled with in the last year. I think this shows how hard it is to look after you and, at the same time, all the other patients in the practice when there are not enough doctors.

“I have reached the decision that I can’t effectively meet your needs, so we need to arrange your transfer to another practice. While this is being organised, I will be available to look after you for any urgent need or emergency. There is also the after-hours service at…

“I have here a list of practices you can approach – this one is a walk-in clinic, so you can go in without an appointment. I will quickly arrange transfer of your notes as soon as you let my practice nurse know where you want to transfer to. This is the card of my practice nurse so you can make contact to arrange the transfer.”

Note, in this example, we don’t go into the “why” in great detail – for example, because you yelled at my staff or bully me, or are involving me in disputes with your family that I find stressful. This only leads to arguments – this is not the time for a doctor to engage in a cathartic rant. The patient will feel rejected and is likely to feel hurt, if not angry, or both.

Calling a patient in to end the relationship can feel more violating to some, who may feel the doctor has wasted their time bringing them in. Others feel it is less cowardly; they respect the doctor fronting up to the decision.

Seeking guidance from your indemnifier’s legal/counselling service is a prudent step to take. What is also absolutely prohibited is ending a patient–doctor relationship in order to have a sexual relationship with the patient.

Some other explanations personal to the patient include:

• “Your needs are beyond those which I/the practice have the resources to manage due to workforce issues.”
• “I feel compromised when trying to reach decisions about how to best manage your care, and this has reached a point where I no longer feel able to offer you care in the way that meets the standards I wish to provide to all my patients.”
• “Due to the length/nature of our relationship, we have reached a point where I feel you would benefit from a fresh approach to your care.

These are broad suggestions. Any letter should be tailored to the individual case. It is also advisable to seek advice from your medical indemnity organisation for assistance with a letter that meets the needs of your specific case. See also the Medical Council’s guidelines.

These suggest you should assist in finding a new doctor. In some cases, that may be appropriate, especially if you have a colleague who has a special interest that would benefit the patient. However, there are, regrettably, some patients who you would not wish on colleagues; those are the ones who more appropriately are given a list of possible services.

Retaining a copy of the notes is protective and increasingly easy with electronic records. Alternatively, you can provide the notes to the new practice on the basis you can access the file later if needed.

Ending a patient–doctor relationship is a significant and stressful step to take. However, freeing yourself from a destructive professional relationship may ultimately keep you around for longer, servicing the needs of many other patients – so don’t beat yourself up.

Gaeline Phipps is a barrister with Lambton Chambers in Wellington. If there is an issue you would like addressed in this column, email gphipps@professionallaw.co.nz

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