Challenging behaviour from patients and their families has become an unwelcome staple of modern general practice. But there are helpful ways to manage it, as Shannon Doogue, Case Manager at Medical Protection, finds out.
Most doctors will, at some stage of their career, experience a doctor-patient relationship that becomes tense, demanding and, overall, emotionally exhausting. In particular, pandemic-influenced behaviour has led to a striking increase in GPs requesting advice on dealing with difficult patients and seeking advice on how to remove a particular patient (or families) from their lists.
Removing any patient from the practice list is an emotive issue that can create potential for criticism. In order to mitigate this where possible, it is worth reviewing the regulatory guidance, considering best practice and using a bit of old-fashioned common sense.
When considering removing a patient from your list
As you are likely aware, GPs are entitled to end their professional relationship with a patient. However, they must adhere to the professional and ethical standards set out by the Medical Council when considering and seeking to remove a patient.
In the Medical Council’s guidance1 it is emphasised that “many patients value having their own GP or being treated by the same doctor or team during the course of an illness, as this helps them to develop relationships with their clinicians”. However, there may be occasions when a doctor is unable to continue to care for a patient, either as an individual practitioner or as part of a team, and doctors are advised:
“…You should tell the patient(s) and make arrangements for another doctor or service to take over their care. Until care has been taken over by another doctor or service, you are responsible for your patients. This means that you must provide emergency services and any care or treatment that your patients may need. When alternative medical care is in place, you should facilitate the transfer of the patients’ medical records without delay.”
The Medical Council also advises:
“If you feel unable to continue to provide effective care for a patient because the therapeutic relationship has broken down, you should get the patient’s consent to send all of his or her medical records to another doctor of your or the patient’s choice. You should document this in their medical records.”
This can be a challenging scenario and may involve a difficult conversation with the patient. However, honesty is important, and the Medical Council expects doctors to be co-operative with patients in arranging the safe transfer of their care to a new GP and providing care, especially in emergency situations, in the interim period.
Case study
Patient A telephoned his GP practice to make an appointment with Dr C. He was off work with anxiety and depression, having recently lost a family member to COVID-19. The practice was busy and the phone line was jammed with calls trying to get through. Patient A was a healthcare worker himself and knew the pressure that was being put on clinics, so he decided to try the practice again later.
After an hour, he called the practice again a few times, but received no answer. He became increasingly annoyed and anxious with every call attempt. By the time he got to speak with the receptionist, Patient A had called eight times and he launched into an argument, telling the receptionist how long he had tried to get through on the telephone and that he felt ignored, and he asked to speak to Dr C. The receptionist Ms B remained calm and apologised to Patient A for the delay, confirming first that he did not need emergency care before explaining that Dr C was consulting with another patient, but would call Patient A back in a few hours. Patient A calmly and quietly stated that “it was not good enough,” and slammed down the phone.
Ms B was upset with Patient A’s manner and told the practice manager, Mrs D, what had happened. Mrs D then relayed the situation to Dr C in-between consultations and naturally, he empathised greatly with Ms B. He had never experienced this type of behaviour from the patient before and, from the retelling of the conversation, Patient A appeared to have got aggressive and abusive towards Ms B.
Dr C decided that the patient’s behaviour warranted removal from his practice list and he proceeded to write to the HSE, as the patient was a public patient, asking to have him reassigned to another GP’s practice list, and providing a description of the events leading to the request for removal from his list. He decided to inform Patient A when he called him that afternoon.
Patient A was very upset to learn that Dr C had removed him from his list when he was still unwell and after all the years that he was a patient with him. He denied being aggressive towards Ms B and expressed disappointment that Dr C did not call to discuss the incident before taking action.
Four weeks later the practice received a letter of complaint from Patient A. He described being extremely upset by his conversation with Dr C and after reflection, he felt that he had not spoken to Ms B the way he should have. He asked Dr C to pass on his apology to Ms B. However, he had received a copy of Dr C’s correspondence to the HSE and felt that the account was exaggerated and incriminating of his interaction with Ms B. He asked Dr C to reconsider his removal from the list, since he felt that the account was inaccurate and that he had been removed unfairly. After seeking an account directly from Ms B, Dr C met with Patient A to discuss his complaint and agreed that he could remain a patient of the practice.
Learning points
This situation highlights the many pitfalls that can occur when there is an absence in detailed guidance and the practice does not have an appropriate and fair procedure in place.
Firstly, proactively communicating with patients regarding any potential issues as and when they arise is always a good first step. Dr C did not sufficiently investigate the incident between Patient A and Ms B, and the situation appears to have been slightly over-dramatised by Mrs D. It is important to remember that there are several sides to every story. As Dr C failed to do in this circumstance, GPs should always consider whether there are reasonable grounds for removing the patient. Practitioners should also consider whether the reasons for removing the patient are fair and not discriminatory, flippant or made in haste.
It is also important for doctors to consider whether the patient’s behaviour, or the incident in general, may have been caused or exacerbated by their illness. It would not be appropriate to remove the patient for being difficult if they were likely suffering from their illness and in need of care. The Medical Council advises doctors that
“the health of vulnerable patients may be harmed when their care is interrupted, or when other clinicians take over their care without adequate knowledge of their history and needs. You should do your best to make sure that the care of vulnerable patients is not disrupted”.
On the other hand, it is equally important to recognise incidents and circumstances where immediate removal of a patient could be justified, such as circumstances where a patient may be threatening or violent, or where your staff members' and other patients’ safety is at risk.
In a situation where you feel unsafe, or feel that the practice staff are unsafe, then it may be justifiable to write to the patient, rather than engaging in face-to-face discussion, informing them of the practice’s decision and the steps they need to take. You may also consider contacting the Gardaí for support should there be a risk of anyone's safety being impeded or of violence.
As there is a lack of detail within the regulatory guidance in this area, it is interesting to note how the UK regulator, the General Medical Council (GMC),2 addresses the issue of ending a professional relationship with a patient and offers a process to do this fairly. Although the GMC has no jurisdiction in Ireland, their guidance is sound and practical, and GPs might consider incorporating it when navigating matters such as these. The guidance states that:
“In rare circumstances, the trust between you and a patient may break down, for example, if the patient has:
• been violent, threatening or abusive to you or a colleague
• stolen from you or the premises
• persistently acted inconsiderately or unreasonably
• made a sexual advance to you.”
It also offers a clear step by step process when considering ending your doctor-patient relationship. Doctors are advised to consider whether there are any alternatives to ending the professional relationship, and whether the doctor-patient relationship might be restored:
“Before you end a professional relationship with a patient you should:
1. warn the patient that you are considering ending the relationship
2. do what you can to restore the professional relationship
3. explore alternatives to ending the professional relationship
4. discuss the situation with an experienced colleague or your employer or contracting body
and you must be satisfied that your reason for wanting to end the relationship is fair and does not discriminate against the patient.”
If the doctor-patient relationship cannot be salvaged, they advise the following:
“If you decide to end your professional relationship with a patient you must:
1. make sure the patient is told of your decision to end the professional relationship, and your reasons for doing so; where practical, the patient should be told in writing
2. follow relevant guidance and regulations
3. record your decision to end the professional relationship – information recorded in the patient’s records must be factual and objective, and should not include anything that could unfairly prejudice the patient’s future treatment
4. make sure arrangements are made promptly for the continuing care of the patient, and you must pass on the patient’s records without delay
5. be prepared to justify your decision.”
Are there other steps you can take?
In summary, before practitioners consider whether to end their professional relationship with a patient, it is important to consider whether a discussion with the patient or other steps can be taken to restore the relationship. Steps may include providing the patient with a warning, ideally followed up in writing, that they may be removed from the practice list if their behaviour persists, for example if they are persistently rude to reception staff.
If this option has been considered and there is no alternative, then you should ensure that you follow the Medical Council guidance on ending your professional relationship. You should inform patients that you are unable to continue to provide care for them and the reason why, and transfer their medical records, without delay, once they have provided consent for you to do so.
It is important that practitioners document their reasons for ending their professional relationship and any actions taken to resolve this matter in detail, separately from the patient's medical records. This will demonstrate that they have carefully considered this situation, reviewed the relevant guidance and have come to an informed decision regarding the matter. In a practical sense, there is less scope for criticism if practitioners have considered the guidance in this area and document their decision and reasoning for the removal.
Regardless of the particulars of each circumstance, incidences or relationship with any patient, it can be a very stressful and emotional experience to deal with. Above all, try to remain professional when dealing with the issue, continue to provide your patients with the best care possible and try to act rationally – even when it’s tough.
References
1Guide to Professional Conduct and Ethics for Registered Medical Professionals. 8th edition. (May 2016)
2Ending your professional relationship with a patient (summary). General Medical Council