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Patient-Initiated Terminations

In the simplest scenario, the patient voluntarily terminates the physician-patient relationship and seeks care from another physician. Unfortunately, patients sometimes stop coming before they are fully recovered from the acute condition that brought them to the physician. When this happens, the physician must make some effort to determine whether the patient is knowingly forgoing further care, has found another physician, or is staying away out of ignorance or a misunderstanding of the physician's instructions. As discussed later under "documentation," the process of investigating the patient's disappearance also generates the necessary record that the physician has discharged the duty to the patient.

An adult patient has the right to refuse to follow the physician's advice. If this person understands the need for further treatment and the consequences of not having that treatment, the physician has no legal liability for the patient's subsequent course. (The physician's duty is different for a minor patient.) The problem arises in establishing what the patient was told. A jury will presume that a severely injured patient would not have refused to follow the physician's instructions if he or she had understood the consequences of the refusal. An example of this problem arose when a woman died of cervical cancer and her family sued the physician for failure to diagnose.[25] The physician argued that she had refused a Pap smear, and this prevented him from making a proper diagnosis. The physician lost. The jury did not believe that he had properly informed her of the value of the test. His credibility was undermined because she had dutifully returned for gynecological checkups, including pelvic examinations. It was hard to believe that she would go to this much trouble and refuse a minor diagnostic test.

Problems also arise if the patient has misunderstood either the physician's directions as to the need for further care or the seriousness of forgoing further care. In this case the patient is not intentionally accepting the risk of injury. The physician may be liable if it can be established that the patient was not properly informed about the need for further treatment. There are steps the physician may take to ensure that the patient receives the proper information, but nothing can ensure that the patient understands this information. Since the goal of the physician is to prevent patient injuries whenever possible, he or she should make some effort to follow up with patients who do not return for needed visits.

Patients sometimes discharge their physicians explicitly. They may fire the physician over a disagreement or courteously inform the physician that they are seeking care elsewhere. In either case, the physician should endeavor to identify the subsequent treating physician and document the patient's decision to seek care elsewhere. If the patient has a new physician, the patient should be asked to write down the name of the new physician so that records may be forwarded. If the patient has not made arrangements for care, the physician should reiterate the need for care and offer to help the patient find a new physician. These efforts will help ensure that the patient receives proper care. If, despite the physician's efforts, the patient does not follow through in seeking proper care, there will be evidence that the original physician made a good-faith effort to help the patient.

Many medical insurance schemes use financial incentives to coerce patients into abandoning their usual physicians. The purpose is to shift patients to the care of physicians who have agreed contractually with the insurance company to accept reduced fees, modify their way of practice, or both. The effect is that the patient is forced to discontinue an established medical relationship and seek care from a new physician who is unfamiliar with the patient's condition. This poses a legal risk to physicians who subsequently treat these patients. Patients who are forced to abandon a long-standing relationship with a physician may be very demanding of a physician they see under duress. This increases the probability that misunderstandings and bad results will escalate to litigation. It also puts the physician at a technical disadvantage. He or she is expected to pick up the patient's care exactly where the previous physician left off, without the benefit of the previous physician's knowledge of the patient.

The physician who accepts a new patient who has sought care voluntarily is not expected to have all the knowledge of the patient's condition that the previous physician possessed. A physician who participates in a coercive effort to force patients to enter his or her practice cannot complain of being handicapped in any treatment of the patient by a lack of prior information. This is a natural consequence of the physician's actions, and he or she will be legally responsible if it causes the patient harm.

[25]Truman v. Thomas, 27 Cal 3d 285, 611 P2d 902, 165 Cal Rptr 308 (1980).

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