Managing challenging interactions with patients

Ms Shannon Doogue, Case Manager, Medical Protection, discusses some ways to manage difficult doctor-patient relationships

Due to issues related to the Covid-19 pandemic, there has been a striking increase in GPs requesting advice on dealing with difficult patients and on how to remove a patient (or families) from their lists.

GPs are entitled to end their professional relationship with a patient, but removing any patient from the practice list can be emotive and result in criticism. It is always worth reviewing and adhering to the professional and ethical standards set out by the Medical Council in its Guide to Professional Conduct and Ethics for Registered Medical Professionals when considering removing a patient.

When a doctor feels unable to continue to care for a patient, either as an individual practitioner or as part of a team, they are advised by the Medical Council to: “…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 that 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 their 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 and became increasingly annoyed and anxious. By the time he got to speak with the receptionist, patient A had called eight times. He launched into an argument and asked to speak to Dr C. The receptionist Ms B remained calm and apologised to patient A for the delay. She confirmed first that he did not need emergency care, then explained that Dr C was consulting with another patient and 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. Dr C had never experienced what appeared, from the retelling of the interaction, to be aggressive and abusive behaviour from the patient before.

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 the many 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. 

You must be satisfied that your reasoning for wanting to terminate the relationship is fair and does not discriminate against the patient

Learning points

This situation highlights the many pitfalls that can occur when there is an absence of 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. GPs should always consider whether there are reasonable grounds for removing the patient and decisions should not be made in haste.

It is also important for doctors to consider whether the patient’s behaviour 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, in need of care, or if the health of the patient may be harmed if their care was interrupted.

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 or team members feel or are unsafe, it would 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 to safety.

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), addresses the issue of ending a professional relationship with a patient fairly. Although the GMC has no jurisdiction in the Republic of Ireland, its guidance is sound and practical, and GPs might consider incorporating it when navigating such matters. Its guidance below offers a clearer step by step process when considering ending a doctor-patient relationship.

Before ending a professional relationship with a patient, clinicians should:

• Warn that you are contemplating ending the professional relationship.

• Consider what can be done to restore the relationship.

• Explore alternatives to ending the professional relationship.

• Discuss the matter with an experienced colleague, your employer, or contracting body.

You must be satisfied that your reasoning for wanting to terminate the relationship is fair and does not discriminate against the patient.

If the doctor-patient relationship cannot be salvaged, it is advisable to:

• Inform the patient of your decision to end the professional relationship, and your reasoning and rationale for doing so. Ideally, the patient should be told in writing.

• Follow the Irish Medical Council guidance and regulations.

• Document your decision to end the professional relationship – any information recorded in the patient’s medical records must be factual and objective, and should not include anything that could unfairly prejudice the patient’s future treatment.

• Make alternative arrangements promptly to ensure the patient’s continuity of care is not negatively impacted. This includes a swift transfer of records.

• Be prepared to justify your decision.

Summary

In summary, before practitioners consider whether ending 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, ensure 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, the reason why, and transfer their medical records without delay once they have consented to this.

To help reduce the scope for criticism, 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 patients’ medical records. This will demonstrate that they have carefully considered this situation, reviewed the relevant guidance and have come to an informed decision.

These situations can be a very stressful and emotional experience to deal with. Above all, try to remain professional and rational, and continue to provide your patients with the best care possible – even when it is tough.

References available on request