GUIDELINE: Patient-Physician Relationships

The patient-physician relationship is a unique relationship based on trust, honesty, respect and a mutual desire to improve health outcomes.   There must be a mutual and collaborative understanding of the patient's needs and expectations, and the physician's capacity to respond. Relationships based on openness, trust and good communication will enable the physician in partnership with the patient, to address the patient's individual needs.   It is necessary for the physician in the patient-physician relationship to be honest, considerate and polite, and treat patients with dignity and as individuals.  It is also important to respect patient's privacy and right to confidentiality, to support patients in caring for themselves to improve and maintain their health, and to encourage patients who have knowledge about their condition to use this when making decisions about their care. It is equally necessary for the patient to be honest and open in providing pertinent communication to enhance the value of the interaction.  As well, the patient should be mindful of the advice or treatment recommendations provided by the physician. The patient/guardian is ultimately responsible for selection of the preferred option for medical care and follow through. If possible, they should strive to incorporate physician advice and recommendations into the patients' health and lifestyle situations.

Establishing a patient-physician relationship

When the physician is meeting a patient for the first time, the physician should identify the patient's needs and expectations, disclose to the patient information about their area of knowledge, skills, limitations of practice and mode of after-hours operation, and determine whether the terms of the relationship (partnership) are mutually acceptable. The physician must be mindful of human rights issues. The Canadian Medical Association Code of Ethics says:

17. In providing medical service, do not discriminate against any patient on such grounds as age, gender, married status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status. This does not abrogate the physician's right to refuse to accept patients for legitimate reasons.

18. Provide whatever appropriate assistance you can to any person with an urgent need for medical care.

19. Having accepted professional responsibility for a patient, continue to provide services until they are no longer required or wanted, until another suitable physician has assumed responsibility for the patient, or until the patient has been given adequate notice that you intend to terminate the relationship.

The first contact with a new patient may occur at a visit which some refer to as a meet-and-­greet visit.  The physician may use this visit to identify the patient's needs and expectations, and disclose information about their knowledge, skills, and limitations of practice, along with the organization of their practice, such as the mode of after-hours operation.   It is essential that physicians pay attention to the Code of Ethics, especially Section 17, in order not to be challenged on the basis of human rights if they decline to accept a patient to their practice.  It is also important for physicians to understand that in Saskatchewan at the present time, the Medical Services Branch does not recognize the meet-and-greet visit as an insurable service and the visit should not be used to review the medical history of the patient or otherwise provide medical services.

It is also important for physicians to understand that in an emergency situation the physician must provide emergency care if no other suitable physician is available unless there is real and imminent threat of harm or violence to the physician, clinic staff or others present.

The patient-physician relationship encountered most frequently will be that of a patient to their primary care provider.  When the care provider is a specialist, consulted to provide specific care, the guideline remains pertinent until such time as the specialist has appropriately discharged the patient in writing back to the care of the primary care provider.  In circumstances where a specialist decides to terminate a patient-physician relationship prior to the condition specific discharge criteria being met, then the specialist remains responsible for the management until he/she transfers care to an accepting specialist of the same specialty or back to the care of the primary provider for referral to another specialist.

Occasionally there will be some patient-physician relationships that for one reason or another do not work.  Either party may decide to terminate the relationship.  A physician may ethically decide not to continue to see a patient, as long as there are valid reasons and the patient is not in immediate need of medical care.

When ending a patient-physician relationship, the College recommends the following:


1) The decision to end the relationship should be clearly communicated to the patient. The initial decision may be communicated verbally if appropriate.  A follow-up letter sent by registered mail is recommended.  Be as compassionate and supportive as possible.  State the reason(s) for the decision. Document any discussion and place a copy of the letter in the patient's file.

 

2) Give the patient a "reasonable" period (minimum of one month, unless there is a real and imminent threat of harm or violence to the physician, clinic staff or others present) of time to find another physician. This will obviously vary according to location and circumstances.

3) State that you will give or arrange for care until that date, and that you will respond to a request for care in an emergency situation.  If ongoing care is needed, ensure that the patient is aware of this.

4) Be helpful to the patient in finding a new physician and transferring records (see guideline on Transfer of Patient Records) and ensure that there are appropriate arrangements in place to ensure that there is follow up of outstanding investigations and consultations.


A physician must not discharge a patient:

1) Based on a prohibited ground of discrimination including age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or economic status.

2) Because a patient makes poor lifestyle choices (such as smoking).

3) Because a patient fails to keep appointments or pay outstanding fees unless advance notice has been given to the patient and the patient has been provided with the opportunity to address the concerns.

4) Because the patient refuses to follow medical advice unless the patient is repeatedly non-adherent despite reasonable attempts by the physician to address the non-adherence.

5) Because the physician relocates his/her practice to a new location/setting to which current patients could be reasonable expected to follow.

6) Because the patient requests access to services that the physician has a conscientious objection to.

7) If discharge significantly hampers access to a physician due to remoteness or lack of local physician resources in the community.  For example, only one physician or one clinic in the community.

 

Sample of a letter with suggested wording is as follows:

Dear (patient’s name):

The patient-physician relationship is fundamental in providing and receiving excellent care. The patient-physician relationship must be based on trust, honesty, respect and a mutual desire to improve health outcomes. This can only be done in the context of a satisfactory patient-physician relationship in which both partners participate willingly.

{Use the next paragraph to describe your reasons for withdrawing from the patient-physician relationship, such as breakdown in interpersonal relationship, disagreement with relatives, etc.)

 In these circumstances, I do not believe it is in your best interest for me to continue to serve as your physician.  I therefore regret to inform you that I will not be in a position to provide further medical services after (date? This time will vary, but you should give at least one month's notice.).

Until that date, I will provide services to you or provide an alternate arrangement. After that date I will not provide elective services to you, only emergency services in a life-threatening situation, when there are no other physicians to provide the required care.

I urge you to obtain the services of another physician as soon as possible.  I will be pleased to provide a summary of my care while you have been my patient and with your consent will arrange to have a copy of your file transferred.

Sincerely,

 

The office visit

Effective communication between patients (or their patient advocate) and physicians is essential to the ideal delivery of care.  The goals of communication are to exchange information, to develop a common understanding and build trust, and to reach a mutually satisfying decision.

The physician’s obligation with respect to communication with a patient is to:

1) Commit full attention to the patient;

2) Create an environment that preserves the patient's dignity;

3) Foster candor in the disclosure of confidential, intimate information;

4) Convey genuine concerns for the patient's wellbeing; and

5) Respect the role of the patient advocate and/or caregiver.

The patient's obligation with respect to communication with the physician is to ensure that they are open and provide pertinent information. In advance, it is sometimes helpful if the patient:

1) Prepares a list of questions and concerns they wish the physician to address;

2) Makes the physician aware of these questions and concerns at the beginning of the visit;

3) Shares their medical histories as completely and accurately as possible;

4) Clearly designates a patient advocate or caregiver and defines their role in the care process; and

5) Establishes a single point of contact for providing information to family members.

Improving patient-physician communication should improve patient adherence to recommended therapies, improved patient self-care, and improved comprehension of the information given by the physician, increased patient satisfaction, and increased physician satisfaction.

It is important for physicians to retain control over their scheduling and timeliness in offering appointments to patients. Office visits should be used as an opportunity to assess illnesses/ medical conditions, review care plans, pharmacological therapies, potential drug-to-­drug interactions, or review any new medications added by additional caregivers.  It is appropriate for a patient to be able to provide the list of problems for which they are seeking assistance, and for the physician and patient to go through the list and determine what requires urgent attention and what can be deferred to another appointment.

Physicians should continually evaluate their scheduling systems for effectiveness.

Leaving Practice

When a physician leaves practice for any reason, whether it be to relocate or retire, there must be assurance of continuity of patient care and preservation of the patient's record, including appropriate arrangements for timely access to the patient's record.

Patients should be informed at the earliest opportunity that the physician is leaving in order to give reasonable notice.  The length of notice to assist with "continuity of care" will vary.  When there is a physician coming to replace the leaving/retiring physician, notice can be somewhat shorter than in cases where the practice will be left without a physician. If possible, the length of notice should be at least three months before the expected date of departure.

Patients should be informed personally if possible and advertisements should be placed in the local newspaper(s) to notify patients who seldom attend the office.  The advertisement should include a statement with respect to date of departure, where the patient records will be located, and information about a replacement physician if appropriate. A statement thanking the patients for the privilege of being involved with their care is also appropriate.   If a physician's discrete patient population can be identified, a personal letter addressed to the individual patient is an acceptable manner of notification. A notice posted in your waiting room and examination rooms containing the same information as your advertisement is also recommended.

Colleagues and referring physicians should also be informed with as much advanced warning as possible that a physician is leaving.

Arrangements must be made for physician/patient records to be stored and for patients to have reasonable access to copies of their records.  Depending on the practice arrangements for the "ownership" of the record, a colleague may undertake this responsibility, or other independent arrangements must be made.  The College of Physicians and Surgeons of Saskatchewan must be notified of the location of the records and how they can be accessed by patients and/or other healthcare professionals with the patient's consent.

If at all possible, assist patients in their search for a new physician or provide information where the patient can access a list of physicians in their geographic area who are accepting new patients.  (Some regional health authorities maintain such a list.)   If a new physician is taking over the practice, some provision of introductory information would reassure patients that they may stay within the practice if they wish and that their records will be retained by the practice or a copy of their records forwarded to a new physician of their choice.

When retiring or relocating, specialists should notify their referring base of family physicians. Specialists who are unable to honor a commitment to see a patient prior to their leaving should alert the family physician to the options for seeing a new specialist if a new specialist is taking over their practice, or allow the family physician to make a second referral to a different specialist, or agree to the departing specialist arranging a referral to a specialist colleague.

It is the expectation that a patient under active treatment will be transferred to a colleague who accepts agreement to continue the care of that patient.   All outstanding laboratory tests or investigations must be reviewed and acted upon, and it is imperative that the physician who is relocating or retiring has a mechanism to ensure that the new physician accepting the care of this patient is aware of outstanding investigations and those agencies such as the Lab and/or X­ ray facilities are aware that those reports should be forwarded to the new physician.

A physician who is relocating or retiring must leave a forwarding address with the College of Physicians and Surgeons of Saskatchewan. Additional notification is required concerning other agencies,  such  as  the  Canadian  Medical  Protective  Association,  the  Canadian  Medical Association, the Saskatchewan Medical Association, the Regional Health Authority, the Cancer Clinic, and the Medical Services Branch.  This notification should include the date of departure, your forwarding address and the name and address of the person to whom correspondence and reports should be sent.

 

STATUS:

APPROVED

Approved by Council:

April 2007

Amended:

September 2016

To be reviewed:

September 2021