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    What is the correct way to terminate a patient-physician relationship?


    David Goldberg, M.D., J.D.
    Dr. Derm has taken care of an increasingly disgruntled man for many years. Last year, the patient presented with cellulitis of his lower leg. The visit did not go well. The doctor took an hour to see the patient, and the patient declared that the medical assistant working for Dr. Derm was clearly incompetent. When the patient was finished seeing Dr. Derm, he told the receptionist he wanted a refund on his $10 co-pay. The receptionist refused.

    When the patient returned one week later with a worsening infection, he threatened to go online and destroy Dr. Derm's reputation unless he agreed to not charge the $10 co-pay as well as give his wife a free botulinum toxin injection. He also threatened to sue if his demands were not met.

    Dr. Derm was furious, refused to see him, and demanded he leave the office. Unfortunately, the patient's cellulite progressively worsened; he ultimately became septic. The patient did survive, but he subsequently filed a medical malpractice lawsuit as well as a complaint against Dr. Derm with the state medical board. Doesn't Dr. Derm have a right not to see an abusive patient? What did he do wrong?

    Abandonment issues

    It is clear Dr. Derm abandoned his patient. Although he certainly has a right to refuse the patient's demands, and he has the right to terminate the patient-physician relationship, he does not have the right to "abandon" his patient.

    Abandonment occurs when a doctor severs the physician-patient relationship while the patient still actively needs care. The termination also happens without adequate notice that would reasonably allow the patient to look elsewhere for care. Such a termination of care clearly can be the basis for a complaint to the state medical board, and if the patient can prove that he or she suffered an injury as a result, it can be the basis of a medical malpractice claim.

    The proper way to discharge a patient is to reverse each step that formed the doctor-patient relationship: The patient came to Dr. Derm for treatment of his cellulitis, so the relationship can only be terminated when the patient is no longer actively in need of care for this problem.

    The patient also sought care with Dr. Derm rather than going to another doctor. The doctor-patient relationship can only be ended by giving the patient time to find another physician. Dr. Derm's prior relationship with this patient allowed the patient to reasonably believe he was his doctor. This can only be terminated by the physician laying out clear statements that make such a belief unreasonable. Of note, the separation does not have to be mutual – in fact, it can be entirely unilateral on the part of Dr. Derm, even if the patient strongly objects.

    Dr. Derm has the following obligations. 1) He cannot terminate the relationship during a time when it is necessary that care be continuous unless there is an immediate transition to another physician. 2) He must give adequate notice (a minimum of 30 days in most states) to the patient of the termination so that the patient will have the time to set up alternative care. 3) He must provide reasonable patient support during the time of the transition. 4) He must provide coverage for emergency treatment during the specified transition period.

    In the end, the physician-patient relationship is only terminated when the doctor or the patient discharges the other. There is no de facto termination by other methods.

    Termination no-nos

    As important as it is to note what can be done to terminate a patient-physician relationship, it is equally significant to understand what cannot be done. There are a few specific things that do not terminate the physician-patient relationship, even though a doctor might think otherwise. The patient running up a significant unpaid bill does not end the relationship. Even if the patient sues his physician, the relationship is still there; the defendant doctor remains obligated to see the plaintiff patient. The patient having no contact with the office for a long time has no impact on the obligation to see and take care of the patient.

    Patient noncompliance may be bothersome, but in itself does not end the physician obligation. And even if the patient changes coverage to an insurer you do not accept or the patient's managed care plan "deselects" you, this does not terminate the obligation.

    None of the above severs the relationship because whether someone is your patient is not looked at by courts and administrative boards in terms of what you thought the relationship was, but in terms of what the patient reasonably perceived it to be. None of the aforementioned scenarios is incompatible with the patient continuing to believe that he or she is still under your care.

    In the end, Dr. Derm is not required to keep any patient in his practice, but he must formally discharge them. Even what seems to be a clear situation — the patient firing his physician — deserves appropriate attention to avoid it turning into an abandonment action.

    If Dr. Derm had a signed letter from the patient discharging him, he could rely on that. However, a verbal agreement to terminate the patient-physician relationship will not stand up in court. Unfortunately, Dr. Derm appears to have abandoned his patient.

    David Goldberg, M.D., J.D., is director of Skin Laser & Surgery Specialists of New York and New Jersey; director of laser research, Mount Sinai School of Medicine; and adjunct professor of law, Fordham Law School.

    GoldbergDavid.jpg
    David J. Goldberg, M.D., J.D.
    Dr. Goldberg is Director of Skin Laser & Surgery Specialists of New York and New Jersey, Director of Mohs Surgery and laser research, ...

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