The Doctor Patient Relationship
Risk Manager's Insight
Kathleen M. Roman, MS*
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
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.
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.
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
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.
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.
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.
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.
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.
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
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.
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.
Roman is Risk Management Education Leader, Medical Protective, Indianapolis, IN.
Decision Making. Ethics Handbook for
Dentists. American College
of Dentists, 3rd ed., 2008.