The patient-physician
relationship
Prof. MAM Ibnouf
The patient-physician
relationship
Built on:
1- Trust
2- Honesty and openness in the relationship, and its
therapeutic implications for patients.
3- Ensuring continuity over time
4- Physicians must also be committed to maintaining
appropriate relationships, given the power
imbalance between physicians and patients and
the inherent vulnerability illness can bring to
individuals.
Dependence on the Dr.
Although physicians have obligations to
patients from the outset, those obligations
become even stronger over time as the patient
comes to depend on the physician. That is
particularly true if dissolving the relationship
would harm the patient.[1]
1- Austad CS. The forum. Ethics & Behavior. 1992;2(3):215-226.
Dr. withdrawal
• In ethics and the law, a physician may not abandon
a patient[1]. Abandonment has been defined as the
physician's unilateral withdrawal from the
relationship without formal transfer of care to
another qualified physician.[2]
1- American
College of Physicians. Ethics Manual. Fifth edition. Ann Intern Med. 2005;142:560-582
2- Pellegrino ED. Nonabandonment: an old obligation revisited. Ann Intern Med. 1995;122:377-378.
Limits of relation
The ethical obligation of the physician to maintain a
relationship with a patient is not without limits. [1] Experts
have argued that a physician may refuse to continue
caring for a patient when, for example, continuing that
relationship may harm other patients or the physician, as
in the case of a patient who threatens physical violence. [2]
Likewise, a physician is not required "to violate
fundamental personal values, standards of medical care or
ethical practice, or the law[3]" in providing patient care.
1- Thieman S. Avoiding the claim of patient abandonment. Missouri Med. 1996;93:634-635.
2- Gordon HL, Reiser SJ. Do physicians have a duty to treat Medicare patients? Arch Intern Med.
1993;153:563-565
3- American College of Physicians. Ethics Manual. Fifth edition. Ann Intern Med. 2005;142:560-582.
Justifiable without harm
A physician may discharge a patient from the practice
after concerted attempts to resolve the matter have failed,
if adequate replacement care is available and the patient's
health is not jeopardized in the process. But the physician
must ensure that the reasons for discharging a patient are
justifiable and ethical.[1,2,3,4]
1- American College of Physicians. Ethics Manual. Fifth edition. Ann Intern Med. 2005;142:560-582
2- Austad CS. The forum. Ethics & Behavior. 1992;2(3):215-226.
3- Gordon HL, Reiser SJ. Do physicians have a duty to treat Medicare patients? Arch Intern Med.
1993;153:563-565.
4- Tapper CM. Unilateral termination of treatment by a psychiatrist. Can J Psychiatry. 1994;39:2-3
Discrimination
• An ethical and legal matter, physicians must make sure that
discrimination plays no part in any patient discharge decision. A
doctor may not discriminate against a class or category of patients. [1]
The Disabilities Act prohibits physicians from refusing to care for
disabled patients. A number of cases have arisen, for example,
involving physicians who have refused to care for HIV positive
patients.[2,3]
1- American College of Physicians. Ethics Manual. Fifth edition. Ann Intern Med. 2005;142:560-582.
2- Smolkin, D. HIV infection, risk taking, and the duty to treat. J Medicine Philosophy. 1997;22:75-88.
3- Daley J, Forrow L. Ethical issues. Primary Care. 1992;19:203-216
•
Economical reasons
Discharging a patient because of economic
concerns or reimbursement levels is ethically
objectionable.
Pt wishes
Both the patient and physician should discuss their
concerns and expectations for ongoing care. The
physician should try to understand the patient's
wishes and beliefs, make a serious attempt to
resolve differences, and document all these efforts
before considering discharge and transfer of the
patient's care.[1]
•
American College of Physicians. Ethics Manual. Fifth edition. Ann Intern Med.
.
2005;142:560-582
Documentation
• Letter should be sent via certified mail return receipt requested, to
the second physician[1] and discharging physician should have a
conversation with the patient about the end of their relationship. He
should ensure that patient’s medical records are released to his new
physician in a timely manner. If the ending of the patient-physician
relationship is necessary, by adhering to these standards, The
discharging physician can ensure that the transition the patient
medical care to another physician is as smooth as possible and that
he is conforming to the ethical principles of nonmaleficence, the
duty to do no harm, the physician's obligation to promote the good of
the patient and to act in the patient's best interests.
•
Santalucia C, Michota FA. When and how is it appropriate to terminate the physicianpatient relationship? Cleveland Clin J Med. 2004;71:179-183.