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The Doctor Patient Relationship

Risk Manager's Insight

At its most elemental level, the doctor-patient relationship is established when the patient seeks, and the doctor agrees to provide, care. Many experts point out that the doctor-patient relationship imposes legal as well as clinical obligations on the provider. It is equally important, however, to recognize that the patient too has obligations within the partnership. First, the doctor uses his or her education and experience to treat the patient. At the same time, the patient should share essential health information, participate in the treatment planning process, and comply with whatever treatment plan on which the doctor and patient have agreed. Without this partnership, the doctor may be unable to provide satisfactory treatment and the patient’s oral health may deteriorate.

 

Formalize the Relationship

In any interaction between a doctor and a patient, it is important to determine the relationship, and therefore the duty a doctor might owe to a patient. Without formal processes for establishing the relationship, the doctor and patient may have different perceptions of whether or not the partnership really existed. If no doctor-patient relationship exists, then the provider has no duty to the patient. Things can be more complicated when it is unclear whether or not a doctor-patient relationship exists. This can occur, for example, when a third-party health insurer assigns a patient to a doctor’s patient list without informing the doctor of this transaction. The new patient may call, assuming that she can access care, and be told that she’s not officially associated with the practice. This type of assignment can be particularly challenging for the dentist if this new patient has complicating health conditions and his or her first interaction occurs because the patient requests an emergency appointment.

Another example of the challenge associated with informal doctor-patient relationships can occur when the office receptionist, who has been trained to help patients book appointments, attempts to squeeze a non-patient into the schedule. If this person then receives an appointment, is he or she now a patient of the practice?  It depends on how the doctor wants to handle the situation.

Based on interactions with the patient, the doctor may agree to see the patient on a continuing basis. On the other hand, if the experience is less than pleasant or if the patient may be better off receiving care from another provider, the doctor may decide not to see this patient again. This is perfectly acceptable–once the doctor has addressed the patient’s acute dental need and complied with any discharge requirements.

 

Discharging a Patient  

In circumstances such as these, a doctor may opt to discharge a patient. The doctor must remember, however, that patient care is of the utmost importance and that there could be legal ramifications for improperly discharging a patient, including a claim of abandonment.

Typically, the dentist should formally notify the patient that the relationship has been severed. Two copies of the discharge letter should be sent to the patient: a) one copy via regular USPS and b) the other using a return receipt requested format. Because copies of the letter will be retained in the patient’s file, it will be more difficult for the patient to allege abandonment by the dentist.

However, sometimes the relationship between the doctor and the patient can complicate the discharge. For example, a patient seen on only an emergency basis may need an explanation that, since the emergent work was completed, he or she is being discharged. The doctor should recommend that the patient establish himself with another dentist for his ongoing oral health needs.

It is best to be clear about the discharge since some patients never go to the dentist except for acute care. Unless otherwise informed, the emergency care patient may assume that he is now the doctor’s regular patient. And it will be this office that he calls when he wants to be squeezed into the day’s schedule or treated on a Sunday evening. This patient may inconvenience other patients, the dental staff, and the dentist.

Additionally, if the doctor wants to discharge a patient who has been assigned through an insurance agreement, he needs to follow the process set forth in the insurer’s contract. Because a third party was involved in the establishment of the doctor-patient relationship, the third party’s expectations must be taken into consideration if the doctor wishes to terminate the relationship.

 

Patient Noncompliance

Certain patient behaviors threaten the continued functionality of the doctor-patient relationship. If the patient fails to comply with office policies or is continually noncompliant with treatment plans, then it is possible that the lack of cooperation signifies the patient’s desire to terminate the doctor-patient relationship. A classic example of this is the orthodontic patient who “disappears” during the course of treatment. Repeated attempts to schedule the patient fail, phone calls are not returned, and the orthodontist eventually sends a discharge letter to the patient warning about the consequences of not having the bands removed, not having his or her teeth cleaned, and encouraging the patient to seek further dental care as soon as possible.

Through noncompliance, the patient has broken the partnership. If possible, the doctor should attempt to re-establish the formal relationship by discussing the noncompliant or unacceptable behavior with the patient. A verbal discussion that reinforces boundaries and asks for the patient’s partnership can sometimes be effective to this end.

When that does not work, sufficient documentation will clearly show that it was the patient who abandoned the treatment plan – to which he had freely agreed. At this point, the doctor may have no other recourse other than to formally discharge the noncompliant patient.

 

Conclusion

The patient’s need for ongoing dental care is an important factor in the decision to discharge a patient. If the patient’s need is best served by having the patient obtain care from a different dentist–one the patient respects and whose advice he will follow–then it is definitely in the patient’s best interest for the existing doctor-patient relationship to be ended. The formal termination of the doctor-patient relationship may ultimately have positive clinical results for the patient and reduce the risks of litigation for the dentist.

 

* Ms. Roman is Risk Management Education Leader, Medical Protective, Indianapolis, IN.

 

 

  1. Ethical Decision Making.  Ethics Handbook for Dentists.  American College of Dentists, 3rd ed., 2008.  

 

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