When the doctor-patient relationship breaks down

Ms Dee Duffy advises on how to proceed when a doctor’s relationship with a patient reaches a point of no return

Good medical practice is based on a relationship of mutual respect and trust between a patient and doctor. Unfortunately, as in all walks of life, that relationship can break down. Most doctors, regardless of specialty, can think of at least one situation where they felt concerned about the quality of the therapeutic relationship with a patient to the extent where it was difficult to continue to provide effective care.  

We regularly hear from our members seeking advice on how to proceed in these situations. It may be possible to restore the doctor-patient relationship where there is a breakdown by facilitating an open discussion with the patient regarding the reasons for the deterioration in the quality of the relationship and the impact it has on the care to be provided. Other times, unfortunately, a doctor-patient relationship can stretch to breaking point.  

Reasons for the breakdown in relationship

There are numerous reasons for the breakdown in a doctor-patient relationship including:

• Patients displaying aggressive or threatening behaviour or presenting a risk of violence to doctors or staff members; 

• Patients behaving inappropriately/intrusively towards their doctor;

• Patients refusing to comply with medical advice; or

• Patients exhibiting serious drug-seeking behaviour, to the extent that treatment cannot be effective.

Your ethical duty when the relationship breaks down

The Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (2019) states:

“36.2. If you are unable to continue to care for a patient or group of patients either as an individual practitioner or as part of a team or group, you should tell the patient(s) and make arrangements for another doctor or service to take over their care. Until care has been taken over by another doctor or service, you are responsible for your patients. This means that you must provide emergency services and any care or treatment that your patients may need. When alternative medical care is in place, you should facilitate the transfer of the patients’ medical records without delay.”

“36.5. If you feel unable to continue to provide effective care for a patient because the therapeutic relationship has broken down, you should get the patient’s consent to send all of his or her medical records to another doctor of your or the patient’s choice. You should document this in their medical records.”

Therefore, making the decision to terminate the relationship with a patient or remove a patient from your practice, should never be taken lightly. It is very important to adopt a fair, balanced, and unbiased approach to manage a potential breakdown and to remain objective at all times.  

The Medical Council ethical guide also acknowledges that some patients may pose risks to the health and safety of those caring for them. It states that doctors are not obliged to put themselves or others at risk of harm when assessing or treating patients, but that reasonable efforts should be made to conduct appropriate clinical assessment and treatment, taking appropriate measures to protect the doctor and others. The personal safety of doctors and their staff should be a priority in any situation where a patient has been violent.

It is important that you do not discriminate against a patient and the decision to terminate a doctor-patient relationship should never be based on issues such as race, gender, civil or family status, religion, disability, age, sexual orientation, or appearance, to name but a few.

Recommended steps before ending the relationship

The following steps should be borne in mind when faced with a potential breakdown in the relationship: 

• Consider explanations for the patient’s behaviour. In some circumstances, there may be a clinical reason for inappropriate or aggressive behaviour, such as mental illness, dementia etc. This may require further exploration with the patient and/or their other healthcare providers.

• Consider the timing of ending the relationship. For example, if a patient is in the immediate post-operative stage, it would not generally be advisable to terminate the relationship in the absence of any extreme circumstances. 

• Communicate clearly your views. It is generally best to have a face-to-face meeting with the patient or a phone conversation, calmly informing them that you are considering ending the relationship. Reasons should be provided as to why you believe it may be in the patient’s best interests to have their care transferred to another doctor and that you do not believe that in light of the breakdown in the therapeutic relationship you can provide effective and safe care. 

• Insofar as possible, efforts should be made to restore the relationship. It is a good idea to ask the patient for their interpretation of the situation and whether there is a misunderstanding that can be cleared up easily. Some patients and doctors will jointly agree at this stage that the issues will improve, and the relationship can continue. In other circumstances, a doctor may wish to provide the patient with a written warning after this discussion, referring to how it was set out that if the relationship does not improve, it may be necessary to end the relationship.

• Make a note of the discussion in the patient’s medical records, outlining the reasons for the warning as explained to the patient.

Ending the relationship

If there is no improvement in the therapeutic relationship after the steps above have been taken and the doctor decides they can no longer provide good clinical care, consideration should be given to writing to the patient informing them of this, unless doing so would cause harm to the patient’s physical and mental health. The letter should explain that regrettably, the doctor feels the doctor-patient relationship, which must be based on mutual trust and confidence, has irretrievably broken down, and it would be best for the patient to attend another doctor. It is important for the patient to understand that taking this step is in their best interests.

In the case of a GP, the letter should urge the patient to find a new GP as soon as possible and in the case of GMS patients, a letter should also be sent to the HSE/Primary Care Reimbursement Service (PCRS) asking that a new GP be assigned. It is advisable when writing to the HSE/PCRS to ask that the contents of the letter be kept confidential, pursuant to the GMS contract. Until the patient has transferred, the original GP retains responsibility for the patient and emergency care must be provided to the patient during that period. When a new GP is allocated, it is important to transfer the patient’s medical records as soon as possible in accordance with patient consent.

For doctors from other specialties, it would be advisable to arrange for a referral to another similarly-qualified specialist either via the patient’s GP or directly. It is important to discuss options for referral with the patient and, in particular, for some patients whether any issues with health insurance arise. Patients may need time to make the relevant enquiries with their health insurance providers. The patient and their GP should be advised of any important clinical follow-up required and on foot of appropriate consent, records transferred to a new specialist. It is a good idea to indicate willingness to discuss any clinical issues with a new provider to ensure smooth transition. Under the ethical guide referenced above, until care has been taken over, a doctor remains responsible for the patient and must provide any emergency care needed. 

Records

Contemporaneous records of consultations and interactions with patients will be important if any decision to end a relationship is later questioned or criticised. Records should be objective and factual, remaining professional in nature, and avoiding subjective descriptions likely to offend.  

Conclusion

The breakdown of a doctor-patient relationship can be very stressful for all involved. It is important to approach it in a measured way, and where possible, having an open dialogue with the patient to see if the relationship can improve. We recommend seeking advice from your indemnifier when considering how to proceed regarding a challenging doctor-patient relationship.