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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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36. Patient-Practitioner Relationship
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The art of medicine has three factors, the disease, the patient, and the medical practitioner. The medical practitioner is the servant of the art. The patient must participate with the medical practitioner in combatting the disease.
~ Hippocrates
Abandonment Affliction
The Case of the Abandoned Patient
Dr. Sarah Richards was a highly respected practitioner in her community, known for her expertise in treating patients with chronic illnesses. However, her reputation was put to the test when one of her patients, Mr. John Smith, filed a lawsuit against her for patient abandonment.
Mr. Smith had been under Dr. Richards’ care for several years, during which time they had established a strong patient-practitioner relationship. Mr. Smith had a chronic heart condition, and Dr. Richards had been closely monitoring his health and prescribing appropriate treatments to manage his symptoms.
One day, Mr. Smith received a letter in the mail from Dr. Richards stating that she was terminating their patient-practitioner relationship immediately, with no explanation or referral to another provider. Mr. Smith was shocked and confused by the sudden termination, and he was unable to find another provider to take over his care in a timely manner.
As a result, Mr. Smith’s health deteriorated rapidly, and he ended up in the emergency room with a life-threatening complication related to his heart condition. When he learned that Dr. Richards had not provided him with the necessary medical records and information to continue his care, he decided to take legal action.
During the trial, it became clear that Dr. Richards had violated her ethical obligations as a practitioner by failing to provide Mr. Smith with proper notice of the termination of their relationship and failing to facilitate the transfer of his medical records to a new provider. Her actions constituted patient abandonment, a form of medical malpractice that can result in legal consequences.
The case served as a stark reminder of the importance of the patient-practitioner relationship and the ethical principles that guide it. Dr. Richards learned a valuable lesson about the significance of patient autonomy, trust, and communication, and she made changes to her practice to ensure that such an incident would never happen again.
The case of the abandoned patient is a cautionary tale for all healthcare providers, highlighting the need to prioritize patient-centered care and maintain a strong patient-practitioner relationship. By adhering to ethical principles and legal requirements, healthcare providers can ensure that their patients receive the best possible care and avoid the pitfalls of patient abandonment.
Abstract
The patient-practitioner relationship is a critical component in creating a patient-centered approach that prioritizes the patient’s best interests, values, and goals. Autonomy is a fundamental aspect of this relationship, as the patient should be empowered to make informed medical decisions based on effective communication with the practitioner. Trust and reflective understanding in the practitioner are crucial for building this relationship, and ethical principles of beneficence and nonmaleficence guide the practitioner’s actions to maximize the patient’s best interests. Public policy also plays a role, as patient abandonment is considered a form of medical malpractice and can result in legal consequences. In order to maintain the trust of the medical community and ensure patient well-being, proper instructions and medical records must be transferred if the patient-practitioner relationship is terminated. Understanding the importance of this relationship is essential for all medical providers.
**
Think
[36:1] The patient-practitioner relationship is the cornerstone for establishing a patient-centered relationship that maximizes the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities.
Assess
Patient: 1) Autonomy
[36:2] Autonomy (informed consent) is based on the liberal notion that the patient knows their own goals, values, and priorities better than anyone else. Therefore if the practitioner can communicate clearly and effectively, then the patient will be the best person to determine what medical choices will maximize their best interests.
[36:3] The patient-practitioner relationship is essential for patient autonomy. Trust in the practitioner’s confidentiality and privacy is necessary for the patient to disclose protected health information (PHI). Trust in the practitioner’s medical knowledge, skill, and competence are essential for believing that the practitioner’s diagnosis, prognosis, and risk-benefit analysis for various treatment options are reliable.
[36:4] Being able to communicate with reflective understanding, empathy, and compassion are necessary to effectively:
- 1. attain an accurate patient history, lifestyle, and description of the physical symptoms, and
- 2. describe using language appropriate for the patient’s developmental age and education the: diagnosis, prognosis, treatment options, risks, benefits, and address any questions the patient may have.
[36:5] Effective communication is central to attaining autonomous informed consent as it empowers the patient to provide autonomous informed consent authorizing the practitioner to provide treatments that maximize the patient’s best interests.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[36:6] Central to the professional responsibility of all medical professionals are the moral principles of beneficence (do good) and nonmaleficence (do no harm), with the prime directive being the maximization of the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities. Everything the practitioner does as a professional is to attain the prime directive of the patient’s best interests.
Public Policy: 4) Justice
[36:7] Federal and state laws have legislated that patient abandonment is a form of medical malpractice. Patient abandonment is a legal claim when a practitioner terminates the patient-practitioner relationship without reasonable notice to the patient.
[36:8] Inadvertent abandonment occurs when a patient becomes “lost in the system” due to a computer glitch or some other type of mismanagement. Even though there was no practitioner intent to abandon, this argument has consistently failed in the courts.
[36:9] Transfer without proper instructions is another cause for patient abandonment malpractice. The termination of the patient-practitioner relationship must not only be done with proper time for the patient to find an alternative practitioner, but it also must be done in the proper manner in which all the medical records, notes, and information necessary for proper medical care are transferred to the new practitioner. The practitioner must actively facilitate the patient by finding an alternate caregiver if needed.
[36:10] The medical profession is built on patient and community trust. Any medical provider’s actions that weaken that trust is considered to be professional misconduct, morally inappropriate, and possibly illegal.
Conclude
[36:11] Understanding the importance of the patient-practitioner relationship and the social-contract that becomes established once such a relationship has been established is of vital importance. Patient abandonment is a form of medical malpractice. If a patient-practitioner relationship is terminated, then there must always be ample time for the patient to find alternative care.
[36:12] In summary, the significance of the patient-practitioner relationship cannot be overstated, as it forms the basis for effective medical care and decision-making. Practitioners must prioritize patient autonomy, trust, and communication to facilitate informed consent and act in the best interest of their patients. It is essential for medical providers to recognize the importance of this relationship and adhere to legal requirements, ensuring that patients are not abandoned or left without proper care. By fostering a strong patient-practitioner relationship, healthcare providers can create an environment that respects patient autonomy and maximizes their well-being.
**
36. Review Questions
1. Autonomy (informed consent) is based on the liberal notion that the patient knows their own goals, values, and priorities better than anyone else.
2. Trust in the practitioner’s confidentiality and privacy is necessary for the patient to disclose protected health information (PHI).
3. The prime directive of the patient-practitioner relationship is to maximize the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities.
4. Patient abandonment is a legal claim when a practitioner terminates the patient-practitioner relationship without reasonable notice to the patient.
5. Inadvertent abandonment occurs when a patient becomes “lost in the system” due to a computer glitch or some other type of mismanagement. This argument has always worked well in the courts.
6. Transfer without proper instructions is a failure to provide all the medical records, notes, and information necessary for proper medical care and is cause for patient abandonment malpractice.
7. Medical providers’ actions that weaken the public trust in the profession are generally types of professional misconduct.
**
CORRECT! 🙂
[36:1] The patient-practitioner relationship is the cornerstone for establishing a patient-centered relationship that maximizes the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities.
Wrong 😕
[36:1] The patient-practitioner relationship is the cornerstone for establishing a patient-centered relationship that maximizes the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities.
CORRECT! 🙂
[36:1] The patient-practitioner relationship is the cornerstone for establishing a patient-centered relationship that maximizes the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities.
Wrong 😕
[36:1] The patient-practitioner relationship is the cornerstone for establishing a patient-centered relationship that maximizes the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities.
CORRECT! 🙂
[36:6] Central to the professional responsibility of all medical professionals are the moral principles of beneficence (do good) and nonmaleficence (do no harm), with the prime directive being the maximization of the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities. Everything the practitioner does as a professional is to attain the prime directive of the patient’s best interests.
Wrong 😕
[36:6] Central to the professional responsibility of all medical professionals are the moral principles of beneficence (do good) and nonmaleficence (do no harm), with the prime directive being the maximization of the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities. Everything the practitioner does as a professional is to attain the prime directive of the patient’s best interests.
CORRECT! 🙂
[36:7] Federal and state laws have legislated that patient abandonment is a form of medical malpractice. Patient abandonment is a legal claim when a practitioner terminates the patient-practitioner relationship without reasonable notice to the patient.
Wrong 😕
[36:7] Federal and state laws have legislated that patient abandonment is a form of medical malpractice. Patient abandonment is a legal claim when a practitioner terminates the patient-practitioner relationship without reasonable notice to the patient.
CORRECT! 🙂
[36:8] Inadvertent abandonment occurs when a patient becomes “lost in the system” due to a computer glitch or some other type of mismanagement. Even though there was no practitioner intent to abandon, this argument has consistently failed in the courts.
Wrong 😕
[36:8] Inadvertent abandonment occurs when a patient becomes “lost in the system” due to a computer glitch or some other type of mismanagement. Even though there was no practitioner intent to abandon, this argument has consistently failed in the courts.
CORRECT! 🙂
[36:9] Transfer without proper instructions is another cause for patient abandonment malpractice. The termination of the patient-practitioner relationship must not only be done with proper time for the patient to find an alternative practitioner, but it also must be done in the proper manner in which all the medical records, notes, and information necessary for proper medical care are transferred to the new practitioner. The practitioner must actively facilitate the patient by finding an alternate caregiver if needed.
Wrong 😕
[36:9] Transfer without proper instructions is another cause for patient abandonment malpractice. The termination of the patient-practitioner relationship must not only be done with proper time for the patient to find an alternative practitioner, but it also must be done in the proper manner in which all the medical records, notes, and information necessary for proper medical care are transferred to the new practitioner. The practitioner must actively facilitate the patient by finding an alternate caregiver if needed.
CORRECT! 🙂
[36:10] The medical profession is built on patient and community trust. Any medical provider’s actions that weaken that trust are generally professional misconduct, morally inappropriate, and illegal.
Wrong 😕
[36:10] The medical profession is built on patient and community trust. Any medical provider’s actions that weaken that trust are generally professional misconduct, morally inappropriate, and illegal.
36. Clinical Vignettes
1. Ms. Ruby Franklin is a 45-year-old teacher who comes to your clinic with complaints of chronic back pain. She has been experiencing the pain for several months, and it is becoming increasingly difficult to perform daily activities. She reports no previous history of back pain and has tried over-the-counter pain medication without relief. On physical examination, you find tenderness in the lower lumbar region and pain on extension. Your differential diagnosis includes lumbar strain, herniated disc, and spinal stenosis. What is the most appropriate course of action for the practitioner to take regarding Ms. Franklin's treatment plan?
2. Ms. Yasmin Williams, a 65-year-old retired teacher, comes to your clinic complaining of chest pain and shortness of breath. She has a past medical history of hypertension, hyperlipidemia, and type 2 diabetes. She reports experiencing these symptoms for the past two days, and you notice that she looks tired and pale. You conduct a thorough physical examination and order laboratory tests to determine the cause of her symptoms. The differential diagnosis includes acute coronary syndrome, pulmonary embolism, or exacerbation of heart failure. How should you proceed if Ms. Williams refuses hospitalization or further testing, citing her desire to avoid a costly and invasive workup that might not change her overall prognosis?
3. Mr. Nathaniel Harrison, a 65-year-old retired teacher, is admitted to the hospital with a diagnosis of metastatic lung cancer. His primary complaint is severe pain in his chest and difficulty breathing. The patient's daughter, who is his primary caregiver, reports that Mr. Harrison has been increasingly fatigued and has lost his appetite. The clinical team suspects that he may be experiencing other symptoms such as anxiety, depression, and spiritual distress. What is the ethical question that arises in this case?
4. Ms. Samantha Johnson is a 62-year-old retired nurse who presents to her primary care practitioner with a 2-month history of persistent cough and shortness of breath. She has a history of smoking and her vital signs are within normal limits. Her physical exam is unremarkable except for wheezing in both lung fields. The differential diagnosis includes chronic obstructive pulmonary disease, asthma, bronchitis, and lung cancer. What ethical issue arises if the practitioner fails to provide proper instructions and medical records when terminating the patient-practitioner relationship?
5. Ms. Diana Stone, a 45-year-old schoolteacher, presents to her primary care practitioner with complaints of difficulty sleeping, feeling irritable and having a lack of energy for the past few weeks. Upon further questioning, Ms. Stone reports that she has been going through a stressful divorce and has been experiencing a lot of anxiety and depression. Her primary care practitioner conducts a thorough physical examination and runs some laboratory tests to rule out any underlying medical conditions that may be contributing to her symptoms. The practitioner considers a clinical differential diagnosis of anxiety disorder, major depressive disorder, and adjustment disorder. What steps should the practitioner take to ensure Ms. Stone's autonomy in the decision-making process regarding her treatment plan?
Wrong 😕
Explanation: The most appropriate course of action for the practitioner is to provide Ms. Franklin with all available treatment options and allow her to make an informed decision regarding her care [36:2]. As autonomy is a fundamental aspect of the patient-practitioner relationship, the practitioner should empower Ms. Franklin to make informed medical decisions based on effective communication [36:2]. It is not appropriate to make the treatment decision without Ms. Franklin's input, as this would violate her autonomy and be considered paternalistic [36:2]. Similarly, providing Ms. Franklin with only one treatment option or refusing to treat her would also be considered paternalistic and would violate her autonomy [36:2]. The practitioner's ethical responsibility is to prioritize the patient's best interests and allow the patient to make informed decisions that maximize those interests [36:6].
CORRECT! 🙂
Explanation: The most appropriate course of action for the practitioner is to provide Ms. Franklin with all available treatment options and allow her to make an informed decision regarding her care [36:2]. As autonomy is a fundamental aspect of the patient-practitioner relationship, the practitioner should empower Ms. Franklin to make informed medical decisions based on effective communication [36:2]. It is not appropriate to make the treatment decision without Ms. Franklin's input, as this would violate her autonomy and be considered paternalistic [36:2]. Similarly, providing Ms. Franklin with only one treatment option or refusing to treat her would also be considered paternalistic and would violate her autonomy [36:2]. The practitioner's ethical responsibility is to prioritize the patient's best interests and allow the patient to make informed decisions that maximize those interests [36:6].
CORRECT! 🙂
Explanation: Ms. Williams has the right to make informed decisions regarding her healthcare [36:2]. Although hospitalization and further testing may be necessary, the patient's autonomy must be respected, and the healthcare provider should provide supportive care and symptom management in accordance with the patient's goals and values [36:1, 36:2]. Trying to persuade her to undergo further testing and hospitalization is not respectful of her autonomy [36:2]. Overriding her refusal and ordering emergency hospitalization is not appropriate unless it is necessary to prevent immediate harm [36:2, 36:6]. Discharging her with instructions for follow-up care and documenting her refusal of hospitalization and further testing is not sufficient to ensure the patient's well-being and could potentially result in medical malpractice if proper instructions and medical records are not transferred if the patient-practitioner relationship is terminated [36:4, 36:9].
Wrong 😕
Explanation: Ms. Williams has the right to make informed decisions regarding her healthcare [36:2]. Although hospitalization and further testing may be necessary, the patient's autonomy must be respected, and the healthcare provider should provide supportive care and symptom management in accordance with the patient's goals and values [36:1, 36:2]. Trying to persuade her to undergo further testing and hospitalization is not respectful of her autonomy [36:2]. Overriding her refusal and ordering emergency hospitalization is not appropriate unless it is necessary to prevent immediate harm [36:2, 36:6]. Discharging her with instructions for follow-up care and documenting her refusal of hospitalization and further testing is not sufficient to ensure the patient's well-being and could potentially result in medical malpractice if proper instructions and medical records are not transferred if the patient-practitioner relationship is terminated [36:4, 36:9].
CORRECT! 🙂
Explanation: Providing Ms. Jones with detailed information about her diagnosis and treatment options is essential to ensuring her autonomy in decision-making [36:2]. Dr. Ferguson should take the time to explain Ms. Jones' diagnosis and treatment options in a way that is easy for her to understand, and help her make an informed decision [36:4]. Withholding information or rushing into treatment without providing adequate information undermines the patient's autonomy and may lead to noncompliance or regret [36:5]. Referring Ms. Jones to another practitioner without discussing her diagnosis or treatment options would also be a form of patient abandonment [36:7, 36:9]. Therefore, the most appropriate approach is allowing for open communication and informed decision-making while respecting the patient's autonomy.
Wrong 😕
Explanation: Providing Ms. Jones with detailed information about her diagnosis and treatment options is essential to ensuring her autonomy in decision-making [36:2]. Dr. Ferguson should take the time to explain Ms. Jones' diagnosis and treatment options in a way that is easy for her to understand, and help her make an informed decision [36:4]. Withholding information or rushing into treatment without providing adequate information undermines the patient's autonomy and may lead to noncompliance or regret [36:5]. Referring Ms. Jones to another practitioner without discussing her diagnosis or treatment options would also be a form of patient abandonment [36:7, 36:9]. Therefore, the most appropriate approach is allowing for open communication and informed decision-making while respecting the patient's autonomy.
CORRECT! 🙂
Explanation: According to [36:7], patient abandonment is a form of medical malpractice and can result in legal consequences. If a practitioner terminates the patient-practitioner relationship, it must be done with proper time for the patient to find an alternative practitioner, and all medical records, notes, and information necessary for proper medical care must be transferred to the new practitioner [36:9]. Failure to provide proper instructions and medical records when terminating the patient-practitioner relationship would result in patient abandonment and is considered a form of medical malpractice. Nonmaleficence refers to the principle of doing no harm [36:6], autonomy refers to the patient's right to make informed medical decisions based on effective communication with the practitioner [36:2], and beneficence refers to the principle of doing good and maximizing the patient's best interests [36:6]. Although these ethical principles are important in the patient-practitioner relationship, they are not directly related to the ethical issue in the clinical vignette.
Wrong 😕
Explanation: According to [36:7], patient abandonment is a form of medical malpractice and can result in legal consequences. If a practitioner terminates the patient-practitioner relationship, it must be done with proper time for the patient to find an alternative practitioner, and all medical records, notes, and information necessary for proper medical care must be transferred to the new practitioner [36:9]. Failure to provide proper instructions and medical records when terminating the patient-practitioner relationship would result in patient abandonment and is considered a form of medical malpractice. Nonmaleficence refers to the principle of doing no harm [36:6], autonomy refers to the patient's right to make informed medical decisions based on effective communication with the practitioner [36:2], and beneficence refers to the principle of doing good and maximizing the patient's best interests [36:6]. Although these ethical principles are important in the patient-practitioner relationship, they are not directly related to the ethical issue in the clinical vignette.
Wrong 😕
Explanation: The correct answer is D as it aligns with the ethical principle of patient autonomy [36:2]. Patient autonomy refers to the patient's right to make informed decisions about their medical care based on their own goals, values, and priorities [36:1]. In order to empower Ms. Stone to make an informed decision, the practitioner must engage in effective communication with reflective understanding [36:4] and provide her with all available treatment options, potential risks and benefits, and consider her values and goals [36:2]. It is important to prioritize Ms. Stone's best interests while respecting her autonomy, and this can only be achieved through shared decision-making [36:1]. The other options violate the ethical principle of patient autonomy and do not prioritize Ms. Stone's best interests.
CORRECT! 🙂
Explanation: The correct answer is D as it aligns with the ethical principle of patient autonomy [36:2]. Patient autonomy refers to the patient's right to make informed decisions about their medical care based on their own goals, values, and priorities [36:1]. In order to empower Ms. Stone to make an informed decision, the practitioner must engage in effective communication with reflective understanding [36:4] and provide her with all available treatment options, potential risks and benefits, and consider her values and goals [36:2]. It is important to prioritize Ms. Stone's best interests while respecting her autonomy, and this can only be achieved through shared decision-making [36:1]. The other options violate the ethical principle of patient autonomy and do not prioritize Ms. Stone's best interests.
**
36. Reflection Vignettes
1. Dr. Maria Rodriguez is a 50-year-old family practitioner who has been seeing a patient, Mr. Howard Green, for several years. Despite providing treatment to Mr. Green for various health concerns, Dr. Rodriguez has grown to dislike the patient due to his constant complaining and lack of compliance with treatment plans. Dr. Rodriguez would like to terminate the patient-practitioner relationship, but Mr. Green refuses to find another practitioner and insists on continuing to see Dr. Rodriguez. If a medical practitioner no longer wants to provide care to a patient, they should approach the situation with care and sensitivity. The practitioner should provide a clear and concise explanation for why they are terminating the relationship, while also offering to help the patient find another practitioner who may better suit their needs. It is important to ensure that the patient is not abandoned or left without medical care, and to provide appropriate referrals and transitional support. It is also important to comply with any legal or ethical requirements for terminating a patient-practitioner relationship, such as providing written notice or offering a certain amount of time for the patient to find a new practitioner.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Dr. Emily Wilson, a 45-year-old medical practitioner with years of experience in endocrinology, has been treating Mr. John Davis for diabetes for the past five years. Despite her best efforts to adjust his medications, Mr. Davis has not been honest with Dr. Wilson about his diet and lifestyle, and his blood sugar levels have been poorly controlled. He also frequently misses appointments and does not follow up on recommended testing. Dr. Wilson is frustrated with Mr. Davis's lack of compliance and feels that she is unable to provide effective care for him. In this situation, Dr. Wilson should first try to communicate with Mr. Davis and understand why he is not being honest or compliant. She can also try to educate him on the importance of honesty and compliance in his treatment. If this approach does not work, she can consider terminating the patient-practitioner relationship. However, Dr. Wilson should ensure that Mr. Davis receives appropriate medical care and help him find a new practitioner if needed. Additionally, she should document Mr. Davis's lack of honesty and compliance in the medical record for legal and ethical reasons.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
