Affective Neutrality and Terminating the Physician-Patient Relationship
As physicians, our job is to care for the patients who seek our services. We are ethically obligated to provide the best care possible to each of our patients. Usually, providing care for a patient is uncomplicated, requiring compassion, empathy and the knowledge acquired in our training and practice. At other times, providing care is trying, difficult and exhausting. In either circumstance, caring for patients is what makes a career in medicine uniquely satisfying and grants us uncommon privileges.
The standard expectation is that we provide care for as long as a patient requests it. There are, however, circumstances when a physician should terminate his or her relationship with a patient. Care should be terminated when that is the best interest of the patient, the physician, or the physician’s staff. These circumstances are rare and must be carefully considered given the harm that termination may cause. Probably because of how infrequent it is that any one physician terminates care with a patient, and the often-upsetting nature of the experience, very little has been published on the subject.
Beyond situations in which a patient is threatening or abusive to the physician or their staff, there is little guidance on when it is appropriate to terminate a relationship and how it is best done. Threatening and abusive behavior are the reasons cited as the most common causes for dismissals. (Two good references here and here.) Without exception, guidelines emphasize the need to avoid patient abandonment. The AMA Code of Medical Ethics recommends the following when physicians terminate the physician-patient relationship:
Notify the patient (or authorized decision maker) long enough in advance to permit the patient to secure another physician.
Facilitate transfer of care when appropriate.
Beyond the understanding that physicians may terminate a relationship if the patient in threatening and that the physician may not abandon the patient, there is complexity. Forty to fifty percent of patient dismissals occur for reasons other than abusive behavior. (Same two references as above). These reasons include inappropriate demands on the physician’s time, non-adherence, deception or crimes. How do we decide when it is reasonable and appropriate to take the drastic step of “firing” a patient?
The reason underlying all appropriate terminations is a physician losing the capacity to maintain affective neutrality. Affective neutrality is “the expectation that the physician strive for and maintain objectivity in relating to patients.” When we agree that a patient who is threatening or abusive should be terminated from a practice, we do so not just because we are concerned about the safety of the physician but because we recognize that it is impossible for a physician to deliver excellent care to a threatening patient. If a physician has become too attached to a patient, has become a close friend or colleague, and thus is unable to make disinterested decisions, termination is reasonable. This is what underpins our prohibition of caring for family members.
Using “loss of affective neutrality” as a reason to end a relationship can be problematic. This loss is judged by the physician alone and is highly subjective. The decision model is paternalistic; it accepts that physicians alone make the decision that continuing a relationship outweighs the harm of ending it or that a patient would receive better care from another physician. It is also a decision prone to bias. One can easily imagine a physician whose ability to maintain neutrality is more robust with one group of patients compared to another. We would expect that patients from groups under-represented in medicine are those most at risk termination.
Terminating a physician/patient relationship is harmful to the patient. Even if orderly care transition is assured, patients generally view their termination as unjustified, see the doctor as the one at fault, and move on feeling threatened, distressed and stigmatized by the event. The physician/patient relationship is one that we are acculturated to consider important. We are taught that physicians are caring professionals who look after our best interests. When the relationship is terminated, patients may feel like the profession abandoned them or believe, wrongly, that they do not deserve to be cared for.
We accept that a physician must be able to terminate the care of a patient they feel they are failing. We also accept that the decision to terminate the physician/patient relationship is subjective, prone to bias, and potentially harmful to the patient. Given this how can we make the termination possible while fully protecting the patient?
A recommendation might be that the physician first identifies why they have lost affective neutrality in dealing with a patient. Do they feel threatened, undermined, or are they frustrated that they are no longer making progress with the patient – diabetes control, smoking cessation, alcohol use.
In most cases, the second step should be conversation with the patient. This should begin with the physician acknowledging that he or she feels the relationship is unproductive without placing “blame” on the patient. The patient should be asked how they view the situation? In our experience, this exploration often reveals important issues that are undermining a productive relationship. It sometimes yields better understanding and communication going forward.
If this exploration does not enable progress, does the patient agree that the relationship is no longer productive? Are there reasons that they feel changing to another provider might be harmful? Patients should not be able to veto termination but their insight might be helpful in determining a successful referral.
If the physician decides that termination remains appropriate, every effort should be made to ensure that severing the relationship does not negatively affect the patient or their care. The patient should be given time to find another physician (and assisted in this task when necessary). Records should be provided and consultation with those assuming care should be offered. We advocate a “warm handoff.”
If a physician finds that they are frequently ending relationships with patients, efforts should be made to identify the reason. Is bias interfering with their relationships? Are they particularly bad at dealing with some forms of conflict? Implicit bias training or developing a process to include others (colleagues, practice managers, conflict resolution experts) in the decision might be helpful.
The physician/patient relationship is special one. One ideally based on physician empathy and beneficence, mutual respect and trust. There are times, however, when this relationship must be ended either for the patient’s interest, the physician’s interests or both. Open and honest consideration of how this is best accomplished should be a topic of discussion among physicians broadly and between the physicians and patients.
The Clinical Excellence Podcast hosts a discussion of this topic with the authors. Download the episode where you get your podcasts or here for Apple Podcasts.
Scott Stern, MD is a Professor of Medicine at the University of Chicago where he practices general internal medicine.
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