How can GPs best end a therapeutic relationship?

‘Many worry about the embarrassment of terminating a therapeutic relationship. My concerns are more for self-preservation.’
 
That’s GP and Melbourne University associate professor Chris Hogan.
 
Over his career, Dr Hogan has had to learn the difficult art of how to end a therapeutic relationship when there is unacceptable patient behaviour.
 
To deal with challenging patients, Dr Hogan introduced a new patient booklet outlining acceptable and unacceptable patient behaviour.
 
Soon, he had to use it.
 
One patient kept disappearing into the toilet, where he would drink alcohol until he became aggressive. By the time the police arrived, he was in rapid atrial fibrillation and needed an escort to hospital.
 
Another, a survivor of childhood abuse, was unfortunately prone to violence. He sucker punched one of Dr Hogan’s colleagues because they superficially resembled his abuser. Another patient kicked someone else’s child in the waiting room.
 
Each time there were safety concerns, Dr Hogan ended the therapeutic relationship.
 
Dr Hogan told newsGP that the killing of Melbourne GP Dr Khulod Maarouf-Hassan in 2006 by a patient still resonates with GPs.
 
‘Her death affected us all. Our days of innocence were lost,’ he said.
 
For patients, ending the relationship is relatively easy – they can simply walk away from their GP.
 
But having a conversation to end the doctor-patient relationship is something many GPs dread.
 
It’s one of the most common reasons GPs seek advice from their medical defence organisation, according to Dr Sara Bird, a medicolegal expert at MDA National.
 
Dr Bird told newsGP that the topic was perennial, with her organisation issuing a guide in 2015.  
 
‘Some GPs don’t realise they can actually end the doctor patient relationship,’ she said.
 
‘It can be difficult. By the time GPs phone us, they’ve tried every strategy to preserve the relationship. Now it’s the end of the road.’
 
Dr Bird said ending the relationship can be straightforward – particularly in larger cities with many other practitioners. But in small towns with no doctors nearby, finding a way to hand over care can be challenging.
 
Dr Bird said safety is a key reason why GPs act to sever the relationship.
 
‘The most common reason is unacceptable patient behaviour,’ she said.
 
‘If threats have been made, if a patient is abusive to practice staff, if a patient has forged a script or sickness certificate – that means the doctor can no longer trust the patient. For many doctors, you can’t overcome it once they’ve done that.’
 
Dr Bird said another common reason is if a patient falls in love with their doctor – or vice versa.
 
GP Dr Genevieve Yates, who also works as an educator for MDA National, told newsGP that GPs do not legally need to continue to see a patient in a private general practice, barring emergencies, and assuming there is no discrimination behind the decision. 
 
She said that GPs are responsible for facilitating handover of care, but did not have to directly find a new doctor for the patient. 
 
‘You should try to ensure they are not immediately at risk during the transition period,’ she said.
 
‘Sometimes a patient will simply be noncompliant with advice, so you can say I don’t think I’m the right GP for you and it might be in your best interest to see another GP.’
 
GP and health blogger Dr Edwin Kruys told newsGP it is best to plan ahead if GPs feel a relationship is deteriorating.
 
‘Ending a therapeutic relationship with a patient can indeed be challenging, but there are situations when care has been compromised and as a result we simply are not the best doctor we can be for that particular patient,’ he said.  
 
‘In the early days of my career I once abruptly advised someone that our therapeutic relationship had ended when it became clear to me that I could no longer trust the patient.
 
‘Although the reason was valid, looking back on it now I should have better prepared myself, as the case dragged on for quite a while. So it is important to take some time to think about how you are going to inform the patient and what steps need to be taken to follow due process.’
 
Dr Kruys said the message should be delivered in a calm and clear way. 
 
‘Care and any outstanding issues should be safely handed over to the next doctor. Emergency care must be provided regardless of the therapeutic relationship,’ he said.
 
‘The RACGP Standards are helpful and I recommend a phone call to your medical defence organisation to make sure all medicolegal boxes are ticked and any pitfalls avoided. The MDO can also assist with drafting a follow-up letter, which can be sent after the patient has been advised about the termination of the doctor-patient relationship.’
 
The Standards state that GPs have the right to end the treatment of a patient, other than in an emergency.
 
‘Situations in which this could occur include when the practitioner thinks they can no longer give the patient optimal care, or when the practitioner no longer considers it appropriate to treat the patient (eg when a patient has behaved in a threatening or violent manner, or where there has been a significant breakdown in the patient–practitioner relationship),’ the Standards state.
 
To transfer care, the Standards state a practice must ‘facilitate the transfer of the patient to another practitioner or practice’ by following these steps: 
 
• informing the patient (at a consultation, or by phone or letter) as to the reason for the decision to transfer care
• taking reasonable steps to ensure the person to whom you delegate, refer or hand over has the qualifications, experience, knowledge and skills to provide the care required
• facilitating arrangements for the continuing medical care of the patient, including the transfer or appropriate management of all patient records.

medicolegal patient behaviour patient misconduct professional boundaries therapeutic relationship