ketplace,” said TMLT President and Chief Executive Officer Charles R. Ott Jr. Texas physicians interested in apply- ing for TMLT coverage can call the sales department at (800) 580-8658, ext. 8603. Current policyholders will receive detailed information about their rates before their policy renews. TMLT is the largest medical liability insurance provider in Texas. It serves more than 15,500 TMA members. TMA created and endorses TMLT.
According to the Texas Medical As- sociation’s white paper “Termination of the Physician-Patient Relationship,” prepared by the TMA Office of the Gen- eral Counsel, abandonment is usually defined as “the unilateral severance of the professional relationship without reasonable notice at a time when there is still the necessity of continuing medi- cal attention.”
Create guidelines for dismissing patients
Many physician practices experience difficult or noncompliant patients. But rather than waiting until you are “up to here” to take action, you can make the situation less stressful by working out guidelines for your practice ahead of time. Include your plan in your office policies and procedures. Consider the patient problems you commonly have to deal with, and de- cide what level of behavior will trigger action on your part. For example, a spe- cific number of missed appointments or displays of rude behavior will result in a phone call to the patient with a follow- up letter; a certain number of repeat of- fenses will trigger a face-to-face meeting and a signed agreement by the patient to alter his or her behavior; and additional offenses will trigger formal termination procedures (unless your contract with the patient’s insurance company does not allow this).
Bear in mind that some circumstanc- es, such as violent behavior by a patient, will warrant exceptions to this process. Include a plan for dealing with the ex- ceptions in your policies and procedures. Physicians need to be careful when dismissing patients from their care. The only legal requirement physicians must meet when terminating a relationship with a patient is that they avoid aban- donment, which may result in civil liabil- ity for the physician.
48 TEXAS MEDICINE November 2012
The white paper says abandonment involves physician failure to provide “an adequate medical attendant” and failure to give adequate notice. Additionally, it recommends physicians orally advise the patient, document notice of termination in the chart, send a letter to the patient with return receipt requested, and keep a copy of the letter and the receipt. To request the white paper, contact the TMA Knowledge Center by tele- phone at (800) 880-7955 or by email at
knowledge@texmed.org. TMA’s customizable Policies and Pro-
cedures: A Guide for Medical Practices contains sample policies for dealing with difficult patients and terminating a pa- tient. Order a copy by visiting http://bit .ly/Sy0JaE.
Crystal Conde is an associate editor of Texas Medicine. You can reach her by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at
crystal.conde@
texmed.org.
a patient he or she declines to see? Does a physician who examines a patient for the benefit of an insurance carrier have an obligation to tell the patient about a medical condition he or she discovers? The answers to such scenarios may be surprising to some physicians. It is important to know when a physician- patient relationship exists because it im- poses a duty on the physician to exercise appropriate professional judgment and care.1
Contract
A physician-patient relationship exists because of a contract, express or implied, that the doctor will treat the patient with proper professional skill.2
A physi-
cian need not have physical contact or deal directly with a patient to create the relationship.3 Although the relationship is contract- based, the contract need not be formal — it can be implied in fact, which means it “arises from the acts and conduct of the parties … that there was a mutual inten- tion to contract.”4
For example, a court
recently found there was a relationship based on conduct of the parties, even though the physician never saw the pa- tient nor directly influenced the patient’s care.5
The physician-patient relationship
BY ANDREA SCHWAB, JD, TMA ASSOCI- ATE GENERAL COUNSEL
At the heart
of medical care is the unique relation- ship between a physician and patient. In most cases, physicians know when they have a physician-patient relationship, but there are times when its existence is unclear.
Does a physician have a duty to an individual he or she has never seen or treated, but for whom he or she altered care by consulting with a colleague? Does an on-call physician have a duty to
In that case, an individual con- sented to a technician performing laser hair removal “under the supervision and control” of the physician. The physician signed and dated the technician’s notes, having never seen the patient.6 A physician may also agree to a phy- sician-patient relationship pursuant to a formal contract, and the patient need not be a party. The important fact in de- termining whether the relationship is a consensual one is not who contracted for the service but whether it was with the express or implied consent of the patient, or for his or her benefit.7 For example, a physician and hospi- tal may agree to a physician-patient re- lationship that leaves the physician no discretion to decline treatment.8
Like-
wise, the relationship can arise under a patient’s health care plan if the physician is the designated doctor.9
In one such case, a court found there was a physician-patient relationship in part because both the physician and the
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