Ending the Physician-Patient Relationship – Update: Policy Approved

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    Stakeholder feedback

    View the feedback we received to our online survey

    View the comments posted to our online discussion page

    View the accompanying FAQ,which elaborates on key principles and expectations of the policy.

    Our Process

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    The College’s Ending the Physician-Patient Relationship policy received final approval from Council on May 26, 2017, and is now an official policy of the College of Physicians and Surgeons of Ontario.

    We would like to thank all those who submitted their feedback and contributed to this policy review. While not every comment or suggested edit was incorporated into the final policy, all comments were carefully considered in light of current practice issues, the values and duties of medical professionalism, and the College’s mandate to protect the public.

    Below is a brief summary of the policy review process, including an overview of the feedback received and revisions undertaken.

     

    people

    Who we heard from

    • 104 submissions were received in response to this consultation.
    • Feedback was primarily submitted by physicians, but we also heard from members of the public and the following organizations: the Ontario Medical Association, the Ontario Medical Association Section on General and Family Practice, the Professional Association of Residents of Ontario, and the Information and Privacy Commissioner of Ontario.
    View the feedback: Survey reportWritten Comments

    What we heard

    Other important considerations

    • Generally speaking, respondents expressed support for the draft policy.
    • In particular, respondents agreed that the draft policy was clear and comprehensive.
    • Respondents were most divided with respect to whether the expectations articulated in the draft policy were reasonable. Of those who were critical of the reasonableness of the draft policy, feedback mainly focused on two key issues: expectations with respect to patients who have unpaid fees, and patients who have sought care outside of a rostered practice.
    • Of those respondents who provided constructive criticism or suggestions for how the clarity, flow, and technical accuracy of the draft could be improved, the following are representative comments:
        • The draft policy should emphasize the role that patients play in maintaining an effective physician-patient relationship.
        • The application of the draft policy to specialist physicians practising outside of primary care should be make more clear.
        • The draft policy’s positions with respect to situations where a patient has failed to pay an outstanding fee or has sought care outside of a rostered practice are unreasonable. Respondents interpreted the draft policy to mean that physicians were never permitted to end the physician-patient relationship in these circumstances, which was not the intent of the draft policy.
    • In addition to the feedback, we considered a wide range of other information while developing the final policy. This included:
        • Policies and guidelines of other organizations, including other Canadian medical regulators.
        • A review of relevant legislation.
        • A review of the literature related to health human resource availability and access to care; access to care of marginalized and vulnerable populations; and the impact of ending the physician-patient relationship on patients.

    How we responded to your feedback

    • The revised policy retains the central positions and key principles of the previous policy.
    • Revisions were made to the policy to enhance both clarity and comprehensiveness:
            • Additional content has been added with respect to general expectations for physicians when considering ending the physician-patient relationship;
            • The section pertaining to situations which may lead to ending the physician-patient relationship has been expanded; and
            • The section pertaining to actions a physician must take when ending a treating relationship has been refined.
    • Some specific examples of revisions undertaken in response to feedback are set out below, along with one instance where a revision was not made.
    Policy decision Rationale
    • The policy now includes a reference to the fact that the physician-patient relationship can be thought of as a “partnership”, and that this partnership benefits from the mutual respect of the physician and the patient.
    • This revision recognizes stakeholder feedback which emphasized the important role that patients play in maintaining an effective physician-patient relationship.
    • The policy more clearly articulates the policy’s application to specialist physicians, and emphasizes that the policy applies only when ending the physician-patient relationship prior to reaching the normal or expected conclusion of the patient’s treatment or assessment (for example, as a result of a significant conflict with the patient).
    • Some physician respondents to the consultation were unclear as to the actions specialist physicians were expected to undertake when ending the physician-patient relationship, and the circumstances in which specialist physicians would be required to formally end the relationship in accordance with the policy.
    • The policy now includes more specific expectations with respect to unpaid fees, and is more explicit about which situations may be appropriate grounds for ending the physician-patient relationship.
    • Stakeholder feedback suggested that this area of the draft policy was not clearly understood.
    • The policy now includes specific expectations for situations where a patient has sought care outside of a rostered practice, and is more explicit about which situations may be appropriate grounds for ending the physician-patient relationship
    • Stakeholder feedback suggested that this area of the draft policy was not clearly understood.
    • No revisions were made in response to feedback that specialists should not be required to send written notification directly to the patient when ending a relationship prior to reaching the normal or expected conclusion of the patient’s treatment or assessment. These respondents suggested that it should be sufficient for the specialist to send written notification to the patient’s referring physician, who could then communicate the situation to the patient.
    • While serious consideration was given to this suggestion, it was ultimately decided that the requirement that all physicians notify each patient in writing be retained, as the interest of the patient being notified promptly and clearly is the paramount consideration.

    The final policy

    • The Ending the Physician-Patient Relationship policy received final approval from Council on May 26, 2017, and is now an official policy of the College of Physicians and Surgeons of Ontario.


    Read the Final Policy

    • Frequently Asked Questions document has also been developed, which provides elaboration on key issues grounded in the principles and expectations of the policy.

     Key messages of the final policy:

    1)    The expectations of the policy apply to all physicians, regardless of specialty or area of practice.

    2)    In all cases, physicians must apply good clinical judgment and compassion to determine whether it is appropriate to end the physician-patient relationship.

    3)    Physicians must undertake reasonable efforts to resolve the situation affecting their ability to provide care in the best interests of the patient prior to ending the physician-patient relationship (for example, by considering whether a particular incident or behaviour is an isolated example, or part of a larger pattern).

    4)    Physicians must respect patient autonomy with respect to lifestyle, health-care goals, and treatment decisions, and not end the physician-patient relationship solely because a patient chooses not to follow their advice, or seeks treatment to which the physician objects on the basis of conscience or religious beliefs.

    5)    Even where the physician-patient relationship has been discontinued, physicians must ensure the provision of necessary medical services while the patient seeks a new health-care provider.

    6)    In situations where a patient poses a genuine risk of harm to the physician, the physician`s staff, patients, or colleagues, physicians are under no obligation to attempt to resolve the situation with the patient directly prior to ending the physician-patient relationship.