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Physician Patient Relationship Termination of the Physician-Patient Relationship The physician-patient relationship is grounded upon the personal relationship which exists between physician and patient. When that relationship becomes untenable for either party, dissolution of the relationship may become necessary. This article discusses the general legal and ethical issues related to termination of the physician-patient relationship. Q: May a physician lawfully terminate his or her relationship with a patient at any time? Q: How should notice be given to the patient? Q: How much notice is required? Q: What other considerations are relevant in composing the notification letter to the patient? A: The physician may suggest the names of other physicians the patient may contact but is not required to do so. It is not necessary to state reasons for the decision to terminate. The physician should offer to forward copies of medical records to another physician, with proper authorization. However, physicians may not legally or ethically withhold a copy, narrative or summary of the patient's medical record from another physician (or the patient) because of an 3 outstanding account balance. The physician may specify that any treatment during the notice period will be provided on a cash basis unless an emergency. However, it may be prudent to treat even the patient who cannot pay cash rather than possibly be required to defend a lawsuit charging abandonment. Q: What should the physician do when the patient terminates the relationship? Q: I lost contact with a patient I treated several years ago. If the patient calls for an appointment, am I still obligated to see the patient? Q: A patient will not pay an outstanding balance for services rendered. Does that mean the physician-patient relationship has been terminated? Q: A patient of mine left the hospital "against medical advice." Later the patient wants to make an appointment with my office. Am I obliged to treat the patient? Q: I discharged a patient from my practice for non-compliance. Later I saw him in the emergency room, but he needed follow-up in the office. Is it now necessary to "re- terminate" the patient if I do not wish to provide further care? Q: A patient filed a medical malpractice suit against me. Now the patient wants to make an appointment. Am I still obligated to take care of the patient? Q: A woman arrived for her initial appointment. She 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? Q: I need to terminate my relationship with a managed care patient. What considerations apply? Q: I was "deselected" by a managed care plan. Do I still have to provide care to managed care plan enrollees even though I may not be reimbursed for that care? Q: I want to close my practice. What problems can arise if I do not give proper notice? A: Physicians who close their medical practice without sufficient notice can encounter legal problems. For example, in Korn v Ohio State Medical Board, a physician disappeared from his medical practice for more than two months. The medical board disciplined him because "he was unable to practice medicine according to acceptable and prevailing standards of care," and placed him on five years probation. On appeal, the court found that the evidence supported a finding that he was irresponsible in the manner in which he left his practice and patients. Violations of his duties were not excused by the fact that "others picked up the 5 pieces." Also, Texas State Board of Medical Examiners Rule 165.5, which is printed below and can be found on the Internet at http://www.tsbme.state.tx.us/rules/rules/165.htm#1655, imposes certain requirements on physicians who relocate or close their practices: 165.5. Transfer and Disposal of Medical Records. (a) Required Notification of Discontinuance of Practice. When a physician retires, terminates employment or otherwise leaves a medical practice, he or she is responsible for: (1) ensuring that patients receive reasonable notification and are given the opportunity to obtain copies of their records or arrange for the transfer of their medical records to another physician; and (2) notifying the board when they are terminating practice, retiring, or relocating, and no longer available to patients, specifying who has custodianship of the records, and how the medical records may be obtained. (3) Employers of the departing physician as described in §165.1(b)(6) of this chapter are not required to provide notification, however, the departing physician remains responsible for providing notification consistent with this section. (b) Method of Notification. (1) When a physician retires, terminates employment, or otherwise leaves a medical practice, he or she shall provide notice to patients of when the physician intends to terminate the practice, retire or relocate, and will no longer be available to patients, and offer patients the opportunity to obtain a copy of their medical records. (2) Notification shall be accomplished by: (A) publishing notice in the newspaper of greatest general circulation in each county in which the physician practices or practiced and in a local newspaper that serves the immediate practice area; (B) placing written notice in the physician's office; and (C) sending letters to patients seen in the last two years notifying them of discontinuance of practice. (3) A copy of the notice shall be submitted to the Board within 30 days from the date of termination, sale, or relocation of the practice. (4) Notices placed in the physician's office shall be placed in a conspicuous location in or on the facade of the physician's office, a sign, announcing the termination, sale, or relocation of the practice. The sign shall be placed at least thirty days prior to the termination, sale or relocation of practice and shall remain until the date of termination, sale or relocation. (c) Prohibition Against Interference. (1) Other licensed physicians remaining in the practice may not prevent the departing physician from posting notice and the sign. (2) A physician or physician group should not withhold information from a departing physician that is necessary for notification of patients. (d) Voluntary Surrender or Revocation of Physician's License. (1) Physicians who have voluntarily surrendered their licenses in lieu of disciplinary action or have had their licenses revoked by the board must notify their patients, consistent with subsection (b), within 30 days of the effective date of the voluntary surrender or revocation. (2) Physicians who have voluntarily surrendered their licenses in lieu of disciplinary action or have had their licenses revoked by the board must obtain a custodian for their records to be approved by the board within 30 days of the effective date of the voluntary surrender or revocation. (e) Criminal Violation. A person who violates any provision of this chapter is subject to criminal penalties pursuant to §165.151 of the Act. Q: Can a physician be liable for abandonment when a patient fails to return for treatment? A: Ignoring a physician's advice to return for treatment may be negligence on the part of the 6 patient that would defeat a professional liability action. Further, there is no abandonment if a patient terminates the physician-patient relationship by voluntarily choosing not to return for 7 treatment. Thus, a patient who ignores advice to receive needed treatment at some point constructively terminates the physician-patient relationship and no abandonment occurs. Q: Suppose I treat a patient in the emergency room, and that patient needs to be transferred to another hospital. Another hospital and treating physician are found, and the patient is loaded into the ambulance for transport. Am I discharged from that patient's care when the patient leaves the hospital? A: No. In order for a transfer to be "appropriate" under the federal Emergency Medical Treatment and Active Labor Act, the transferring hospital and physician are responsible for providing medical treatment within its capacity which minimizes any risks to the patient's health during transfer. They are also responsible for ensuring that proper transportation equipment, personnel and life support measures are used during the transfer. However, the transferring physician's responsibility ends once the transferred patient is received by the 8 receiving hospital. REFERENCES 1. King v. Fisher, 918 S.W.2d 108, (Tex.App.-Fort Worth, 1996). 2. Lee v Dewbre, 362 S.W.2d 900, 902 (Tex Civ App -Amarillo 1962, no writ). 3. American Medical Association Council on Ethical and Judicial Affairs, Annotated Current Opinions of the Council on Ethical and Judicial Affairs, Chicago, Ill, American Medical Association, 1992, Sec 7.01, p 58. 4. Terry K. When health plans don't want you anymore. Medical Economics. May 23, 1994, pp 138-145. 5. Korn v. Ohio State Medical Board, 573 NE2d 1100 (Ohio Court of Appeals, 1988). 6. Eoff v Hal and Charlie Peterson Foundation, 811 SW2d 187, 191 (Tex App -San Antonio, 1991). th 7. Knapp v Eppright, 783 SW2d 293 (Tex.App-Houston [14 Dist.] 1989, no writ). 8. 42 USC 1395dd(c)(3). Prepared by: Office of the General Counsel Revised January 14, 2005 NOTICE: PLEASE CHECK THE TEXAS MEDICAL BOARD WEBSITE (www.tmb.state.tx.us) FOR CURRENT UPDATES ON ITS RULES AND POLICIES WITH RESPECT TO THIS ISSUE. NOTICE: The Office of the General Counsel of the Texas Medical Association provides this information with the express understanding that 1) no attorney-client relationship exists, 2) neither TMA nor its attorneys are engaged in providing legal advice and 3) that the information is of a general character. You should not rely on this information when dealing with personal legal matters; rather legal advice from retained legal counsel should be sought. Sample letter terminating physician-patient relationship Dear Mr/Mrs : Please be advised that I will no longer be able to treat you as a patient. I find it necessary to conclude our relationship because (specify reason[s], if desired). Since your condition (describe condition)(may/will) require further medical attention, I suggest that you select another physician without delay. As I indicated, I will be available to treat you for only _____ days following your receipt of this letter. I will be glad to forward information from your medical records to any physician or other person you designate. Please complete and sign the enclosed authorization form. Thank you and best wishes. Sincerely, , M.D. Authorization to release medical records Dear Dr. : This letter will authorize you to provide a copy, summary, or narrative of my medical records (as indicated by the checkmark below) Complete record Records of care from ____ to _____ only Records of care concerning the following condition(s) to the following person: Name Street City State Zip The reasons or purposes of this release of information are as follows: I understand that you will provide this information within fifteen (15) days, and that a reasonable fee for furnishing this information may be charged. Signed: Patient (or person legally authorized to consent on patient's behalf) Date: |