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I suggest you ask the Toronto Star, the chest thumping publication that sees itself as the champion of demonizing doctors in this province, all in the name of selling more papers.
No doctor ever takes this decision lightly and often agonizes over this in the context of a broken (for whatever reason) doctor-patient relationship for a long time before the decision is made.
It should be noted that patients are free to leave their doctor whenever they want for whatever reason.
For what it’s worth, your current policy is more than adequate but I am sure that you will be coming back with something much more harsh with more limitations thus further abrogating any of the few rights that we physicians have left.
I agree with the comment; indeed, many physicians agonize about the decision to end the doctor-patient relationship.
I recently encountered a situation that led me to review this policy, and contact the Physician Advisor Service through the CPSO for advice, as I was about to end a relationship with my patient. (Of note: This service was quite helpful, and I encourage physicians to use it).
With my decision finally made, the rationale appropriate, and a colleague to take over care, I subsequently wrote and memorized my speech, and proceeded to the patient encounter to end the relationship.
I did not go through with it. I spent weeks agonizing over the potential harmful distress and embarrassment the conversation would have for the patient, in the face of very distressing diagnosis (the issue was actually about a family member).
I also became concerned about a potential CPSO complaint, which could arise from ending this relationship. I admit – my own psychological distress was becoming a burden to my well-being.
The mandate of CPSO is to establish policies and healthy relationships to ensure public trust in our health care. I do have a specific comment about the policy as it currently is written:
In this progressive culture of perceived patient entitlement, and their apparent self-permission to bully and defame physicians, I wonder if CPSO will be willing to acknowledge this reality for physicians, the consequences of these experiences, and strategies to reduce the trauma and harm for physicians and our families? We cannot provide good care if we are not well.
In Canada and in within the legal system of Common Law, there is a term called “At will employment”. This is used to mean that an employer has the right to terminate an employee for any reason, as long as the reason is not a discriminatory one with recognized protected areas (religion, gender, age, etc) and a notice or severance package in lieu of is paid. This is because it is recognized that an employee has the right to quit and leave at any time as well, so should the employer. The exceptions are when there are definite contracts, individual or union.
The doctor-patient relationship is, in essence, an employment relationship as well. The patient is the employer and the physician is the employee. Both should have the right to terminate the relationship at will if they entered the relationship at will. Of course notice would be required so the patient can find another replacement employee (doctor). Physicians have many patients so chance of them economically suffering from one or a few patients leaving without notice is zero, so traditionally physicians seldom ask for a notice of termination from patient though a cancellation without notice fee is an example of such a thing.
-I think,Doctor-Patient relationship is more complex than,employee-employer relationship.The basic principles of Altruism&Compassion,in providing care to the needy,can not be defined in legal or contractual terms.Often,doctor,because of his professional bacvkground, will kinow much more about the nature&needs of patient`s illness,than patient himself& hence carry overriding professionalðical&fiduciary responsibility,in keeping with best interests of a patient(which the patient may not be aware).
-I remember terminating my relationship,on more than one occasion,because of various reasons,including non-compliance,substance abuse inspite of warning,refusing prescribed treatment,multi-doctoring&multiple prescriptions,prescription drug abuse inspite of warning,disruptive behaviour&threats etc.
-With these terminations,I remained rational&peaceful.with the awatreness,that I did the best,what all I possibly can,to remedy the situation,but to no avail.and continue to wish the patient well&hope to receive the care he needs.
“At will employment” is an American labour concept, not a Canadian one; Canadian courts have made it abundantly clear that it won’t fly here, and Canadian employers must give a reason before they fire someone (after the first 3 mths). What the Canadian laws & courts do say over and over again is that no one should be forced to keep employing someone. Even if the employer is totally in the wrong, payment of lost wages is the only thing that can be recouped (loss of reputation/employability can’t be, except through punitive or Wallace monetary damages). And there are alternatives to continued employment e.g. welfare or a different source of income, so it’s not like employees are totally dependent on one employer for their very lives – unlike with a physician, who by law is the gatekeeper for all medical services the province pays and licenses (through CPSO) the physicians to provide.
That said, no one is saying a physician must continue to provide services to a patient, regardless of the fear-mongering that many physicians are doing on this site about being “forced” to accept patients or continue in a physician-patient relationship. I can understand why physicians themselves fear more regulations/policies, as everyone would like total freedom to do as they in their judgment see fit, but the College isn’t the OMA.
All that this CPSO policy is doing is saying that physicians must have a good reason to stop as per their fiduciary duty of care. To do otherwise would be like saying a parent or trustee can fire their kids, wards, etc. without any reason whatsoever, and abandon their responsibilities without any repercussions at all.
The “contract” here is between the CPSO and the physicians it licenses.
What the policy doesn’t spell out is the fact that it is actually in the physician’s interest to cover their own posteriors in writing a discontinuance letter and giving a reason. The purported reason doesn’t actually have to be true in fact, it just has to be a defensible reason that puts the doctor and profession in a good light, and possibly put the onus or blame on the patient. Then, if the patient has deep pockets, a lawyer might take on the case and the taxpayer-funded malpractice lawyer (acting for the physician) has added documentation to help him/her win the dispute.
At will employment is not just an American concept. It is rooted in the legal system of Common law. It is used in the Canadian Legal system as well. It is about equality, free will and fairness.
I believe the current policy is satisfactory and no changes are required.
As a patient, if for whatever reason your doctor wanted to terminate you from their practice, don’t you think it would be in your best interest if they just went ahead and did it rather than keep you as a patient against their will? Perhaps subconsciously they may not be providing you with the best possible care.
For this reason, I think a doctor should be able to dismiss a patient from their practice for any reason having respect for the human rights code and the patient’s ability to secure alternative care.
If there exists an irreconcilable breakdown of trust or respect in the doctor-patient relationship, I think both parties benefit long-term from parting ways. I think a simple letter that does not go into too many details suffices if a face to face chat is not feasible.
As much as a doctor should always be courteous and show respect to their patients, so should patients to their doctors.
I completely agree with this comment. I have never followed through this patient termination process, although there were multiple times in my practice when I should have done this. As the person stated above, it is not in the patient’s interest to continue receiving care from a physician when the trust is broken down or there is lack of respect, etc. There are multiple reasons for the reluctance, but the number one is fear of retaliation from the patient – CPSO complaint. I wish that CPSO policy would trivialize this process in a way that it would be clear to patients that the relationship they have with their MD can be terminated easier and with less probability of implications for the MD. The patients are well protected by this policy as it is written.
I believe that there needs to be huge changes to guidelines. My father is a diabetic with a range of other health issues, so when he gets acutely ill and can’t get in to see his doctor, he would like to be able to go to another urgent care/walk-in clinic rather than be told that he will be dropped as a patient unless he waits for an appointment with his physician or visits the emergency room instead. What kind of money-hungry doctor says that? Why tell your patient to use up emergency resources when there are other clinics in the community for situations like this. All because his physician belongs to a private ‘health group’ that charges the physicians in said groups each time their patients are seen elsewhere. This is completely unacceptable especially given how hard it is to find a family physician in Ontario.
Perhaps a question of clarification on how to reduce the size of a practice would be helpful. There are times when physicians will need to reduce their work load such as illness, family circumstances, burn out etc. but not have a desire to leave practice totally. How do you trim a practice of inoffensive , nice patients, who have medical needs , especially in jurisdictions of physician shortages, without contravening College principles? This is not retirement, nor relocation, nor “serious illness”. Leaving things up to attrition may not be fast enough. For many physicians patients have trumped self and family for much of their professional lives (likely because of never developing a good work/life balance from the onset). When time comes that this must be reversed will the College be supportive and understanding enough without placing physicians under more duress to prove no malice or willful neglect when a selection of who to “de-roster” must be made?
I believe initiating the conversation in a face-to-face meeting should happen when possible. With the doctor clearly outlining his reasons.
The appointment after my first gynaecological exam, my family doctor suggested I see a different doctor without any sufficient reason. I was switching cities anyway shortly after that appointment but to this day, I continue to have trust issues with my current doctor when it comes to gynaecological exams because I worry the same thing will happen. Even though I’m an RN and know that there was probably more to his thought process.
Needless to say, I believe a face-to-face factual discussion needs to initiate the ending of a relationship before anything else.
Those are my thoughts,
Well, this is certainly interesting as my husband and I do not trust our family practitioner any more. He is not attuned to the needs of an aging couple . when he met my husband about 10 yrs ago, he told him that he would likely get prostate cancer, odds were high. And he didn’t recommend a digital exam or a psa blood test as they would only find cancer at a later stage! And then he told my husband that treatment would only give him about 10 yrs of life and without treatment he would expect to live about 10 yrs longer anyway. So no PSAs for hubby.
Two years ago, this young physician told me that at age 63 I did not require any further pap tests done as I had the same partner( for over 40 yrs) and cervical cancer was sexually transmitted and it wasn’t necessary for me to have tests done!
These kind of comments have been unhelpful and do not give us confidence in this person. We cannot get a new Dr in the health team in which we are registered………… a very unsatisfactory situation all in all.
I would like to know what follows after you decide that you require a new physician . what are the options? Here in Rural Huron County we are lacking doctors so we muddle along hoping that our health stays good and if we have issues a specialist will follow our care.
This young dr. calls us regularly since my husband had a blood clot a year ago for followup but he is being seen by a Dr [Name ommitted] in London who is renowned and we certainly trust his advise. The local dr tried to change the dosage last year and we had to be firm in telling him that we would not be seeing him for his followups but rather the specialist. It appears as though it is a money grab for an appointment!
My father was a GP for over 50 yrs. I have a son who is an advanced Paramedic . So I am quite trusting of good medical advice and since our own GP retired about 10 yrs ago, we have gone through this journey with two doctors in the clinic, one left after 6 mos, (we were told she was on vacation) and then we met the new one and were interviewed by him and accepted. If I knew then what I know now. I would have enquired about a different doctor. Very frustrating.
No where do the guidelines address the most common reason in a psychiatric practice – that of missed appointments. In psychiatry, we have 20 or 50 minute appointments and when patients miss that time and end up owing hundreds of dollars, at what point is it reasonable to say it is enough?
Regarding ‘Ending the Patient-Physician Relationship’ policy, I find there is need to address the circumstance of a patient being unsuited to the form of treatment which is offered by the physician, and for which the physician is specifically trained. For example, a GP Psychotherapist who is trained as a psychoanalyst receives interest from all manner of patients seeking help for their perceived emotional or psychological problems. These patients do not usually have an understanding of the type of therapy they need or are looking for, nor do they typically understand the differences in modality or of therapeutic style of the practitioner. It may be of little meaning to the patient whether the physician is a CBT practitioner, a hypnosis practitioner, or a psychoanalyst. It is also not necessarily clear to the practitioner at the assessment stage whether or not any particular patient is suited to or able to benefit from the type of therapy practiced by this physician.
It may be only after some time that it becomes apparent that the particular patient is fitting this description, and to continue the work indefinitely is not likely to be productive, and also deprives another, more suited patient, the opportunity to access a service that is very difficult for them to find.
This dilemma may pertain to other fields of practice as well, and should, i believe, be addressed in this policy. Thank you.
Good morning –
A concern that I have had from many patients is that they will get fired from a family practice if they “deroster” from a FHO, for example. This truly happens. Patients need to be derostered to go on the provincial HealthCareConnect list. The CPSO policy should be clear to say that roster status is an unacceptable criteria for ending the physn-pt relationship.
There is an inherent discrepancy and unfairness here. There is a relationship here, namely a doctor-patient relationship. It appears that one party (the patient) is being empowered to be able/allowed/free to terminate this relationship at any time, without notice and without reason. However, the other part of the relationship (the physician) is being dis-empowered at fear of losing one’s license status and thus livelihood, by being denied the freedom to end the relationship.
However you want to spin this, it is unfair. In any relationship, if both parties enter at will, both parties should be able to leave at will, or leave based upon an already agreed upon contract. This happens in all other types of business and personal relationships. Perhaps the College can come up with a doctor-patient contract to show what the termination clause is, so that once the relationship is terminated, there is no hard feelings.
You and others arguing on the basis of the “contract” frame are miscategorizing the problem-space as if the two parties are equals, and should have exactly the same rights. However, they aren’t equals: that’s why contract law is not commonly used in medical situations but trust law is. Trust law and the fiduciary “duty of care” recognizes that the patient is not an equal, but a more vulnerable party to whom the physician has superior power over their very lives, and thus have superior obligations to patients than the latter have to them.
It’s sad that this hasn’t stopped physicians and MOHLTC from trying to force contractual obligations onto the patient (with the physician being the beneficiary of these new obligations) with the provincial rostering “Agreement”. Don’t believe it: it is not an agreement at all if we’re expected to sign it *before* even getting a chance to meet the doctor, as we are expected to do. It is a de facto “contract” the way so many medical receptionists are explicitly calling it, and it spells out limitations to a patient switching doctors, our obligations to the rostering doctor, and physician rights to terminate the patient if the dr. determines that the patient has broken the terms of the “agreement” with him/her. Essentially, we are expected to give up all power and trust to someone we don’t yet know through this contract; amongst the terms is the explicit section of us “agreeing” that all of our past and future doctor-patient encounters can now be “shared” between the dr. and the MOHLTC by virtue of our signing the “agreement”. Thus, in exchange for medical care, we’re expected to give up all privacy rights to our medical metadata.
You decry how patients are being being “unfairly…empowered” to end the relationship without needing to give a reason, yet the MOHLTC’s manual makes it abundantly clear that the physician can do this without giving a reason and without being required to even tell the patient he or she is being derostered. Try reading the manual: http://www.health.gov.on.ca/english/providers/pub/primarycare/proces_enrolment/proces_enrolment.pdf Hint: page 15 states, “If the physician has terminated the enrolment, please ensure the patient
is notified that enrolment has ended.” Note that there’s no penalty or sanction if the physician chooses to not tell the patient, and keep treating them for higher FFS rates than what they’d receive if the patient remained rostered. I had to find out from the Ministry that I’d never been rostered at all with the one doc I signed the agreement with. The entire text of the contractual “Agreement” is “Appendix A” in this Manual.
Sorry, but I suggest you have a choice: either educate yourself on the facts or stop making posts like this one that is itself propagandist “spin” as it distorts the facts. It’s also a pie-in-the-sky fantasy: as if one party can terminate another and there’ll be “no hard feelings”! For a physician to terminate a patient, or not enrol/de-enrol them without informing the patient, is a failure to honour the physician’s “duty of candour” to the patient, and you expect a simple contract can prevent hard feelings?!
Somehow I don’t believe CPSO was complicit in the way this contract is being misused by physicians. I suspect that the MOHLTC consulted the OMA about it during their contract talks, and contracts are always written for the benefit of the writer with the help of the more powerful parties’ lawyers.
The CPSO is responding by trying to clean up the mess with a policy aimed at softening the worst manifestations of the existing de facto contracts. Policies, of course, will always have less force than the laws, courts and signed contractual “Agreements” stamped with provincial logos and thus governmental power. So rest assured: physicians are *not* getting the short end of the stick in this relationship.
To work and function as a physician, one requires to be in a healthy state of mind. In other words the physicians needs to be mentally fit to be able to care for patients’ problems. In all areas of medicine where face to face encounters with patients occur, particularly in psychiatry, addiction medicine and family medicine, physicians are given monumental tasks of dealing and improving large numbers of social and psychiatric problems presented to them daily.
When a physician becomes the subject of abuse, whether verbal, emotional or both by a patient, the physician must have a way to deal with this. Many physicians have been made so scared of firing patients that they put up with such abuse until it gets very severe. While this may avoid a complaint, repetitive abuse by a patient can cause physicians depression, anxiety, other mental problems and even suicide.
How can society expect us physicians to help them so much, society wants offers us very little support and protection?
We as physicians take so much abuse from clients it’s almost become a way of life. Even a fraction of same amount of abuse directed at other members of society is dealt with very severely. Consider verbal abuse toward a police officer, judge, flight attendant, or any authority figure. Those situations would land the abuser in an arrest or other dire consequences.
We are not even asking that we be offered the same protections as offered to those professions, but a little compassion toward the very people that you expect so much compassion from would be only fair.
The College should reassure physicians about their rights about not being subjected to repetitive abuse. Physicians should not fear losing their license and livelihood over firing a verbally or emotionally abusive patient.
Current policy is adequate. Please do not make things more complicated than need be. Physicians are not against their patients. What is the real need to keep on bringing more draconian rules? especially when the current rules are considered adequate by most of the profession.
I think the current policy is good in theory but there should be a mechanism in place at the CPSO to recognize and quickly deal with vengeful complaints arising from disgruntled patients after they have been dismissed.
As a physician I have very occasionally made decisions to terminate patients from my practice only after much deliberation and it has never been an easy decision. I have only ever dismissed patients due to egregious or repetitive abusive behaviour towards myself or my staff and I followed the policy as written including communicating my decision in writing, giving the patient amply opportunity to find alternative care etc. Nonetheless, I have twice been subject to investigations by the College investigating complaints arising from the same abusive patients I dismissed, thereby allowing the patient to continue their abuse via the College complaints process. Both complaints eventually got dismissed but the first only after a lengthy, stressful but meritless investigation. The second was dealt with much more expeditiously but still dragged on for months. As there is really no deterrent for patients to lodge a complaint and the College is obligated to investigate virtually every complaint, the whole College complaints process is really a deterrent for a physician to dismiss a patient, even if they follow the policy, opening them up to continual abuse by the same patients that are abusive in the first place. Until the College is free to use their common sense in recognizing and quickly dealing with such complaints, this policy will be nothing more than good in theory without much real world pull.
Thank you for this comment.
Any policy on this issue is pretty meaningless, because the patient still can and likely will file a complaint dragging the doctor through mud for many sleepless months.
In Ontario more than 99% of the population are covered by OHIP thus there is no cost to see another doctor, and if there is another doctor available to take over the care of a patient, there is no harm and financial burden to the patient. If there was either of harm (no other MD available to take over the care) or cost involved, one could justify that there should be barriers to ending the relationship. Otherwise, any barriers really amount to abuse of the professional.
Information and Privacy Commissioner of OntarioResponse in PDF format.
OMA Section of Addiction MedicineResponse in PDF format.
Professional Association of Residents of OntarioResponse in PDF format.
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Ontario Medical AssociationResponse in PDF format.