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EXPECTATION OF CONTINUED TREATMENT

There is a presumption that treating a patient creates an ongoing physician-patient relationship. This presumption derives from the traditional ongoing relationship between physicians and their patients. It is questionable how effectively it describes modern innovations such as ambulatory care centers in shopping malls and contract emergency room physicians. The extent of the physician's continuing responsibility to the patient is predicated on whether the patient has a reasonable expectation of continued treatment, the nature of the patient's illness, and whether the physician explicitly terminates the relationship.

There are four traditional models of physician practice: the family practice model, the treating specialist model, the consultant model, and the company doctor model. These traditional models have recently been joined by the ambulatory care center and the HMO models. Each of these models has a slightly different approach to the problem of the continuing duty to treat. This chapter will discuss the family practice model as the archetypical physician-patient relationship. The other models are discussed in other chapters.

The family doctor is the idealized physician-patient relationship beloved of nostalgia buffs and television script writers. In this romantic notion of medical practice, these physicians are intimately acquainted with all the details of their patients' lives, payment is never an issue, and the patients have unlimited resources to comply with the physician's recommended treatment. Life was never this way. The central problem for family physicians or general practitioners is to reach an accommodation between their style of practice and patients' expectations. This accommodation helps prevent legal misunderstandings, but its most important goal is preserving trust and mutual respect between physicians and their patients. How this accommodation is reached depends on the type of practice each physician is engaged in.

The law requires a family physician to provide treatment to a patient until that patient can be transferred to another physician safely or can be released from care. The physician is not required to provide that treatment personally, but responsibility for after-hours care and emergency care is always a vexing issue. This is easier to manage in urban settings because of the availability of alternative medical care. Urban physicians usually have arrangements with other physicians to share calls, reducing the burden of 24-hour responsibility for patient care. The availability of emergency room facilities can relieve the burden of after-hours care, although these facilities are more important for patients who may need more extensive care than is available in the office. The problem of urban practitioners is educating patients about the use of these alternative sources of care.

The main problem with small town practice is the lack of backup coverage, either through fellow practitioners or easily accessible emergency room facilities. Physicians in this situation will face the "super doc" dilemma: the "If I don't treat them, nobody will!" mind-set. While there is great ego gratification in being indispensable, this leads to burnout and the compromising of professional standards. Physicians must take personal time for relaxation and education and arrange for backup medical care for those times.

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