Abandonment is considered a breach of duty and is defined as unilateral termination of the physician-patient relationship without providing adequate notice for the patient to obtain substitute medical care. The patient-physician relationship must have been established for abandonment to occur. This patient-physician relationship becomes established when a physician affirmatively acts in a patient’s care through the patient's diagnosis and/or treatment. This relationship is also established if the physician agrees to diagnose and/or treat the patient. A physician-patient relationship is often created when the “professional services of a physician are rendered to and accepted by another person for the purposes of medical or surgical treatment,” which was further established by the Cygan v. Kaleida Health court case in 2008.[1]
There are certain circumstances in which a patient-physician relationship may be implied.
Furthermore, there is a court case in 2015 where Pizzo-Juliano vs. Southside Hospital upheld that a physician-patient relationship can be implied between an on-call physician and patients whom the on-call physician has never once met in the past. In this particular case, a two-year-old boy was bit by a dog and was brought to the Southside Hospital emergency room. At this time, the hospital's on-call plastic surgeon was not available. The on-call plastic surgeon determined that a physician assistant would suture the young boy's facial laceration. This procedure led to the patient's facial scarring, pain, and suffering, and subsequently, this patient sued the plastic surgeon for malpractice. The plastic surgeon stated that a physician-patient relationship was not established because he never examined or treated him before.[3]
To avoid these implied relationships, at initial evaluation, a physician can provide a written statement to the patient stating that the initial visit does not guarantee entry into the physician's practice. The written statement may state that the visit is only for evaluation purposes and does not establish a physician-patient relationship. Additionally, when a physician works in limited examination settings such as at community exercising events, at health fairs, or on websites (providing informal health advice), a physician can provide a disclaimer that an examination or the information provided does not establish a physician-patient relationship.[4]
Before dismissing a patient from practice, the clinician should evaluate whether all efforts have been made to ameliorate the relationship. For instance, when a patient is noncompliant with treatment and scheduled follow-up appointments, the physician can consider having a conversation about the patient's needs and expectations. The physician and patient together may attempt to establish reasonable goals. If the patient has unrealistic expectations, the physician can attempt communication to reconcile differences. All efforts made should be documented by the physician.[5]
According to American Medical Association (AMA) guidelines, a doctor may lawfully dismiss a patient for various reasons: Patient's repeated noncompliance with treatment and follow up appointments that were previously agreed upon, disruptive or threatening behavior, unreasonable failure to pay for services, and a physician's closure of his/her practice or retirement. Other acceptable reasons or situations to dismiss a patient from a medical practice include when patients are misleading about their past medical history, chronic drug-seeking behaviors, displaying threatening or seductive behavior toward staff members or physician, and a sentinel event such as violence, blatant sexual advances, theft, verbal threats or any criminal behaviors at the office. Such a sentinel event may require immediate intervention by security and/or law enforcement.[6]
Patient abandonment can be either intentional or inadvertent. An example of intentional abandonment is the refusal to see a patient after, for example, failure to pay for the received medical services. Miscommunication regarding call coverage or negligence that occurs through errors in the scheduling system are examples of inadvertent abandonment. When patient injury or negligence results from a misunderstanding regarding the call schedule, the primary and/or covering provider may be held liable for damages.
If a physician is unavailable for long periods of time, a patient can be inadvertently abandoned, for example, if the physician takes an extended vacation or sabbatical without notifying the patient or arranging for emergency coverage for the patients. Additionally, being unresponsive to patients' questions in an email or phone calls, failure to follow up with a patient after surgery, or after the patient has started a new medication can be considered inadvertent abandonment.[7]
The following are recommendations when health professionals terminate the patient-provider relationship.
[1] | Farber NJ,Jordan ME,Silverstein J,Collier VU,Weiner J,Boyer EG, Primary care physicians' decisions about discharging patients from their practices. Journal of general internal medicine. 2008 Mar; [PubMed PMID: 18176852] |
[2] | Jerrold L, Patient abandonment. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. 2005 Feb; [PubMed PMID: 15750549] |
[3] | Nicol GH, What is patient abandonment? Today's FDA : official monthly journal of the Florida Dental Association. 2009 Jan; [PubMed PMID: 19402245] |
[4] | Blake V, When is a patient-physician relationship established? The virtual mentor : VM. 2012 May 1; [PubMed PMID: 23351207] |
[5] | Bronshtein O,Katz V,Freud T,Peleg R, Techniques for terminating patient-physician encounters in primary care settings. The Israel Medical Association journal : IMAJ. 2006 Apr; [PubMed PMID: 16671364] |
[6] | Lippman H,Davenport J, Patient dismissal: the right way to do it. The Journal of family practice. 2011 Mar; [PubMed PMID: 21369554] |
[7] | McMullen L, Terminating the patient-physician relationship. Abandonment of the patient: what it means and how to avoid it. Journal of the Mississippi State Medical Association. 2007 Sep; [PubMed PMID: 19292120] |
[8] | Senderovitch H, The Ethical and Legal Dilemma in Terminating the Physician-Patient Relationship. Health law in Canada. 2016 May; [PubMed PMID: 27476245] |
[9] | Torres A,Wagner R,Proper S, Terminating the physician-patient relationship. The Journal of dermatologic surgery and oncology. 1994 Feb [PubMed PMID: 8113508] |
[10] | Gallagher TH,Levinson W, Physicians with multiple patient complaints: ending our silence. BMJ quality & safety. 2013 Jul [PubMed PMID: 23576772] |