APA ☠ Principles of Medical Ethics Applicable to Psychiatry ℞ 2020-2021 APA ☠
Serving the Healthcare Needs of Louisiana and Mississippi
✟ sisters ✟ pray for beneficence ✟ non-maleficence to find Mark Zielinski MD. Kathleen Crapanzano MD, Lee Tynes MD, ☠ after censure ☠
Our Lady of the Lake Physician Group Center for Psychiatric Residency Services
5131 O'Donovan Dr. | Suite 300 | Baton Rouge, LA 225 374-0400
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Principles of Medical Ethics With Annotations Applicable to Psychiatry (2020-2021)
The American Psychiatric Association (APA) Ethics Committee
"The psychiatrist may want to review the new ethics opinions related to COVID-19 address telemedicine. Arbitrary decisions to deny mental health treatment based on information obtained through dubious means, which not be correct, stigmatizes and discriminates against psychiatric patients, penalizes patients for behaviors resulting from mental illness .. in direct contravention of Principles which enjoin physician / psychiatrist to "...support medical care for all people."
“A physician shall provide competent medical care with compassion and respect for human dignity and rights. Continuity of care must be assured. Abandonment is unethical and a cause of action under the law. Physician-initiated termination is a serious event." (APA) Ethics Committee
https://www.instagram.com/apapsychiatric/
Mark Zielinski, MD
LSU OLOL Physician Group | Dept. of Psy Svcs.
Residency & Assoc. Dir. Outpatient Svcs
Angela Gourney, Cinic Dir Op
Tina S. Holland, PhD
Pres Franciscan U
K. Scott Wester
President CEO Franciscan Missionaries
Our Lady Health System
✟
Coletta Barrett
civilrights@ololrmc.com
✟
Leslie Yander
FMOLHS
Leslie.Yander@FMOLHS.org
✟
Corporate Off., Materials Management
Franciscan Missionaries of Our Lady Health System
☠
DOJ LA (MFDU)
Chris Morgan (Agent) ☠
🐪
www.ag.state.la.us
Karen Glassman
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OIG Inspector General
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Brett Mason
2020-2021 @APAPsychiatric ☠ Principles of Medical Ethics Applicable to Psychiatry ℞ sisters ✟ pray for #beneficence #nonmaleficence to find Mark Zielinski MD. Kathleen Crapanzano MD, Lee Tynes MD, ☠ after censure ☠@ololhealth @FranciscanU
— mrjyn (@mrjyn) 29 giugno 2021
https://t.co/M6mjzcVNrM pic.twitter.com/7HrpGGgM3Y
2. The psychiatrist should contact her malpractice carrier to ascertain if there are any other specific legal considerations pertaining to state law in the relevant jurisdictions.
Recent Opinions of the APA Ethics Committee on The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry (2020-2021)
The psychiatrist may want to review the new ethics opinions related to COVID-19 since they also address telemedicine and personal risk issues.(Section 6) ( APA Recent Ethics Opinions 2020-2021)
In addition, arbitrary decisions to exclude a person seeking mental health treatment based on information obtained through dubious means, which may or may not be correct, further stigmatizes and discriminates against psychiatric patients, penalizes such patients for behaviors that could be the result of mental illness and significantly decreases access to care.
This is in direct contravention of Section 9 of the Principles which enjoins physicians/psychiatrists to "...support access to medical care for all people." Likewise, Section 1 states: “A physician shall be dedicated to providing competent medical care with compassion and respect for human dignity and rights”.
(Sections 1, 2 and 9) (2020 fidelity, non-maleficence, and proper distribution of scarce resources (fairness).
Review of the American College of Physicians Ethics Manual, Sixth Edition Ezekiel J. Emanuel
Under rare circumstances, the physician may elect to discontinue the professional relationship, provided that adequate care is available elsewhere and the patient's health is not jeopardized in the process (14, 15).
The physician should notify the patient in writing and obtain patient approval to transfer the medical records to another physician and comply with applicable laws.
Continuity of care must be assured.
Abandonment is unethical and a cause of action under the law.
Physician-initiated termination is a serious event, especially if the patient is acutely ill, and should be undertaken only after genuine attempts to understand and resolve differences.
The physician's responsibility is to serve the best interests of the patient.
A patient is free to change physicians at any time and is entitled to the information contained in the medical records.
Re: Tynes crapanzano failure to report
It is unethical for a physician to disparage the professional competence, knowledge, qualifications, or services of another physician to a patient or a third party or to state or imply that a patient has been poorly managed or mistreated by a colleague without substantial evidence.
This does not mean that a physician cannot disagree with a plan of management or recommendations made by another physician.
A physician therefore has a duty to patients, the public, and the profession to report to the appropriate authority any well-formed suspicions of fraud, professional misconduct, incompetence, or abandonment of patients by another physician.
14.
Farber N, Snyder L.
The Difficult Patient: Should You End the Relationship? Ethics Case Study.
The American College of Physicians Ethics Case Studies Series.
American Medical Association.
AMA Code of Medical Ethics.
Communication patterns of primary care physicians.
JAMA.
Department of Justice U.S. Attorney’s Office Middle District of Louisiana Acting Assistant Attorney General Nicholas L.
McQuaid of the Justice Department’s Criminal Division; Acting U.S. Attorney Ellison C.
Travis of the Middle District of Louisiana; Special Agent in Charge Miranda Bennett of the U.S. Department of Health and Human Services Office of Inspector General’s (HHS-OIG) Dallas Field Office; and Special Agent in Charge Bryan A.
Vorndran of the FBI’s New Orleans Field Office made the announcement.
HHS-OIG and the FBI investigated the case.
Assistant Chief Dustin M.
Davis and Trial Attorney Justin M.
Woodard of the Criminal Division’s Fraud Section and Assistant U.S. Attorney Elizabeth E.
White of the U.S. Attorney’s Office for the Middle District of Louisiana prosecuted the case.
The Fraud Section leads the Medicare Fraud Strike Force.
Medicare Fraud Strike Force, which maintains 15 strike forces operating in 24 districts, has charged more than 4,200 defendants who have collectively billed the Medicare program for nearly $19 billion.
In addition, the HHS Centers for Medicare & Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.
U.S. Attorney Fremin stated, “Our office is closely monitoring the situation surrounding the Coronavirus and, in the interest of the health and safety of our staff, has modified operations to abide by the guidance of the President, the Department of Justice, the Centers for Disease Control, and recent District Court orders.
My commitment to the Middle District is to remain vigilant to the public safety needs of our citizens, while balancing the health and safety concerns we all share.
The American Psychiatric Association (APA) is committed to ensuring accessibility of its website to people with disabilities.
If you have trouble accessing any of APA's web resources, please contact us at 202-559-3900 or apa@psych.org for assistance.
Louisiana Psychiatric Medical Association Cathy Thompson, Executive Director lpmastaff@lpma.net
Hammond, LA 70401 Phone: (225) 761-3718 Fax: (225) 761-3719 Ethics and COVID-19 APA's Ethics Committee is taking questions and providing answers to ethical issues members are facing during the COVID-19 pandemic.
Read the committee's answer to some questions below: COVID-19 Related Opinions of the APA Ethics Committee If you have an ethical dilemma and need advice from APA's Ethics Committee, submit your questions to apaethics@psych.org. The committee will respond to your directly.
APA Ethics Resources and Standards The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, 2013 Edition APA adheres to the American Medical Association's Principles of Medical Ethics.
APA interprets these general guidelines in its annotations and published opinions.
The annotations are not absolutes; instead, they are intended to put ethical guidance in the context of psychiatry.
The annotations are revised from time to time to make them applicable to current practices and problems.
Download Ethical Complaints When a person with personal knowledge believes an APA member may have violated these ethical principles, they may file a complaint with the APA District Branch to which the member belongs.
View contact information for District Branches.
Complaints are handled in accordance with APA's procedural code by the District Branch's ethics committee.
Appeals from district branch decisions are made to the APA Ethics Committee.
APA Principles and Procedures for Handling Complaints of Unethical Conduct APA Commentary on Ethics in Practice The Commentary is based on the existing Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry and is meant to provide practical guidance for managing ethical dilemmas that come up in day-to-day practice.
The commentary is cross-referenced to the Annotations so that there is an explicit link between each subject and the existing ethics code.
Download The Opinions of the Ethics Committee on the Principles of Medical Ethics The Opinions of the Ethics Committee on The Principles of Medical Ethics includes ethics questions raised by APA members and opinions prepared by APA's Ethics Committee.
The opinions reflect the perspectives of the particular time in which each was written and do not represent APA policy.
The opinions are offered to assist APA's members and district branches in understanding the ethical principles.
APA members who have a question on which they would like an opinion from APA's Ethics Committee on an ethical problem they are trying to solve may contact apaethics@psych.org. Please include your member identification number in your email.
Table 1.
Principles That Guide the ACP Ethics Manual Recommendations In addition, considerations of justice must inform the physician's role as citizen and clinical decisions about resource allocation.
The principle of distributive justice requires that we seek to equitably distribute the life-enhancing opportunities afforded by health care.
How to accomplish this distribution is the focus of intense debate.
More than ever, concerns about justice challenge the traditional role of physician as patient advocate.
The environment for the delivery of health care continues to change.
Sites of care are shifting, with more care provided in ambulatory settings while the intensity of inpatient care increases.
The U.S. health care system does not serve all of its citizens well, and major reform has been needed.
Health care financing is a serious concern, and society's values will be tested in decisions about resource allocation.
Ethical issues attract widespread public attention and debate.
Through legislation, administrative action, or judicial decision, government is increasingly involved in medical ethics.
The convergence of various forces—scientific advances, patient and public education, the Internet, the civil rights and consumer movements, the effects of law and economics on medicine, and the heterogeneity of our society—demands that physicians clearly articulate the ethical principles that guide their behavior in clinical care, research, and teaching, or as citizens or collectively as members of the profession.
It is crucial that a responsible physician perspective be heard as societal decisions are made.
From genetic testing before conception to dilemmas at the end of life, physicians, patients, and their families are called upon to make difficult decisions.
The 1970s saw the development of bioethics as a field.
Important issues then (and now) include informed consent, access to health care, genetic screening and engineering, and forgoing life-sustaining treatment.
These and other issues—physician-assisted suicide, technological changes, and the physician as entrepreneur—challenge us to periodically reconsider such topics as the patient–physician relationship, relationships with family caregivers (7), decisions to limit treatment, conflict of interest, physician–industry relations, changing communication modalities, and confidentiality.
This Manual was written for our colleagues in medicine.
The College believes that the Manual provides the best approach to the challenges addressed in it.
We hope it stimulates reasoned debate and serves as a reference for persons who seek the College's position on ethical issues.
Debates about medical ethics may also stimulate critical evaluation and discussion of law and public policy on the difficult ethical issues facing patients, physicians, and society.
Professionalism Medicine is not a trade to be learned, but a profession to be entered (1).
A profession is characterized by a specialized body of knowledge that its members must teach and expand, by a code of ethics and a duty of service that put patient care above self-interest, and by the privilege of self-regulation granted by society (8).
Physicians must individually and collectively fulfill the duties of the profession.
While outside influences on medicine and the patient–physician relationship are many, the ethical foundations of the profession must remain in sharp focus (9).
The definition of medical profession is noted in Box 2.
Box 2.
Definition of medical profession as used in the Manual Download figure Download PowerPoint The Physician and the Patient The patient–physician relationship entails special obligations for the physician to serve the patient's interest because of the specialized knowledge that physicians possess, the confidential nature of the relationship, and the imbalance of power between patient and physician.
Physicians publicly profess that they will use their skills for the benefit of patients, not their own benefit (10).
Physicians must uphold this declaration, as should their professional associations as communities of physicians that put patient welfare first (10).
The physician's primary commitment must always be to the patient's welfare and best interests, whether in preventing or treating illness or helping patients to cope with illness, disability, and death.
The physician must respect the dignity of all persons and respect their uniqueness.
The interests of the patient should always be promoted regardless of financial arrangements; the health care setting; or patient characteristics, such as decision-making capacity, behavior, or social status.
Although the physician should be fairly compensated for services rendered, a sense of duty to the patient should take precedence over concern about compensation.
Initiating and Discontinuing the Patient–Physician Relationship At the beginning of and throughout the patient–physician relationship, the physician must work toward an understanding of the patient's health problems, concerns, goals, and expectations.
After patient and physician agree on the problem and the goals of therapy, the physician presents one or more courses of action.
The patient may authorize the physician to initiate a course of action; the physician can then accept that responsibility.
The relationship has mutual obligations.
The physician must be professionally competent, act responsibly, seek consultation when necessary, and treat the patient with compassion and respect, and the patient should participate responsibly in the care, including giving informed consent or refusal to care as the case might be.
Effective communication is critical to a strong patient–physician relationship.
The physician has a duty to promote patient understanding and should be aware of barriers, including health literacy issues for the patient.
Communication through e-mail or other electronic means can supplement face-to-face encounters; however, it must be done under appropriate guidelines (11).
“Issuance of a prescription or other forms of treatment, based only on an online questionnaire or phone-based consultation, does not constitute an acceptable standard of care” (12).
Exceptions to this may include on-call situations in which the patient has an established relationship with another clinician in the practice and certain urgent public health situations, such as the diagnosis and treatment of communicable infectious diseases.
An example is the Centers for Disease Control and Prevention–endorsed practice of expedited partner therapy for certain sexually transmitted infections.
However, aspects of a patient–physician relationship, such as the physician's responsibilities to the patient, attach even in the absence of interpersonal contact between the physician and patient (12).
Care and respect should guide the performance of the physical examination.
The location and degree of privacy should be appropriate for the examination being performed, with chaperone services as an option.
An appropriate setting and sufficient time should be allocated to encourage exploration of aspects of the patient's life pertinent to health, including habits, relationships, sexuality, vocation, culture, religion, and spirituality.
By history, tradition, and professional oath, physicians have a moral obligation to provide care for ill persons.
Although this obligation is collective, each individual physician is obliged to do his or her fair share to ensure that all ill persons receive appropriate treatment (13).
A physician may not discriminate against a class or category of patients.
An individual patient–physician relationship is formed on the basis of mutual agreement.
In the absence of a preexisting relationship, the physician is not ethically obliged to provide care to an individual person unless no other physician is available, as is the case in some isolated communities, or when emergency treatment is required.
Under these circumstances, the physician is morally bound to provide care and, if necessary, to arrange for proper follow-up.
Physicians may also be bound by contract to provide care to beneficiaries of health plans in which they participate.
Physicians and patients may have different concepts of or cultural beliefs about the meaning and resolution of medical problems.
The care of the patient and satisfaction of both parties are best served if physician and patient discuss their expectations and concerns.
Although the physician must address the patient's concerns, he or she is not required to violate fundamental personal values, standards of medical care or ethical practice, or the law.
When the patient's beliefs—religious, cultural, or otherwise—run counter to medical recommendations, the physician is obliged to try to understand clearly the beliefs and the viewpoints of the patient.
If the physician cannot carry out the patient's wishes after seriously attempting to resolve differences, the physician should discuss with the patient his or her option to seek care from another physician.
Under rare circumstances, the physician may elect to discontinue the professional relationship, provided that adequate care is available elsewhere and the patient's health is not jeopardized in the process (14, 15).
The physician should notify the patient in writing and obtain patient approval to transfer the medical records to another physician and comply with applicable laws.
Continuity of care must be assured.
Abandonment is unethical and a cause of action under the law.
Physician-initiated termination is a serious event, especially if the patient is acutely ill, and should be undertaken only after genuine attempts to understand and resolve differences.
The physician's responsibility is to serve the best interests of the patient.
A patient is free to change physicians at any time and is entitled to the information contained in the medical records.
Third-Party Evaluations Performing a limited assessment of an individual on behalf of a third party, for example, as an industry-employed physician or an independent medical examiner, raises distinct ethical issues regarding the patient–physician relationship.
The physician should disclose to the patient that an examination is being undertaken on behalf of a third party that therefore raises inherent conflicts of interest; ensure that the patient is aware that traditional aspects of the patient–physician relationship, including confidentiality, might not apply; obtain the examinee's consent to the examination and to the disclosure of the results to the third party; exercise appropriate independent medical judgment, free from the influence of the third party; and inform the examinee of the examination results and encourage her or him to see another physician if those results suggest the need for follow-up care (16, 17).
Confidentiality Confidentiality is a fundamental tenet of medical care.
It is increasingly difficult to maintain in this era of electronic health records and electronic data processing, e-mail, faxing of patient information, third-party payment for medical services, and sharing of patient care among numerous health professionals and institutions.
Physicians must follow appropriate security protocols for storage and transfer of patient information to maintain confidentiality, adhering to best practices for electronic communication and use of decision-making tools.
Confidentiality is a matter of respecting the privacy of patients, encouraging them to seek medical care and discuss their problems candidly, and preventing discrimination on the basis of their medical conditions.
The physician should not release a patient's personal medical information (often termed a “privileged communication”) without that patient's consent.
However, confidentiality, like other ethical duties, is not absolute.
It may have to be overridden to protect individuals or the public or to disclose or report information when the law requires it.
The physician should make every effort to discuss the issues with the patient.
If breaching confidentiality is necessary, it should be done in a way that minimizes harm to the patient and heeds applicable federal and state law.
Physicians should be aware of the increased risk for invasion of patient privacy and should help ensure confidentiality.
They should be aware of state and federal law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy rule (18).
Within their own institutions, physicians should advocate policies and procedures to secure the confidentiality of patient records.
To uphold professionalism and protect patient privacy, clinicians should limit discussion of patients and patient care issues to professional encounters.
Discussion of patients by professional staff in public places, such as elevators or cafeterias, violates confidentiality and is unethical.
Outside of an educational setting, discussion of patients with or near persons who are not involved in the care of those patients impairs the public's trust and confidence in the medical profession.
Physicians of patients who are well-known to the public should remember that they are not free to discuss or disclose information about any patient's health without the explicit consent of the patient.
In the care of the adolescent patient, family support is important.
However, this support must be balanced with confidentiality and respect for the adolescent's autonomy in health care decisions and in relationships with clinicians (19).
Physicians should be knowledgeable about state laws governing the right of adolescent patients to confidentiality and the adolescent's legal right to consent to treatment.
Occasionally, a physician receives information from a patient's friends or relatives and is asked to withhold the source of that information from the patient (20).
The physician is not obliged to keep such secrets from the patient.
The informant should be urged to address the patient directly and to encourage the patient to discuss the information with the physician.
The physician should use sensitivity and judgment in deciding whether to use the information and whether to reveal its source to the patient.
The physician should always act in the best interests of the patient.
The Medical Record Physician entries in the medical record, paper and electronic, should contain accurate and complete information about all communications, including those done in-person and by telephone, letter, or electronic means.
Ethically and legally, patients have the right to know what is in their medical records.
Legally, the actual chart is the property of the physician or institution, although the information in the chart is the property of the patient.
Most states have laws that guarantee the patient personal access to the medical record, as does the federal HIPAA privacy rule.
The physician must release information to the patient or to a third party at the request of the patient.
Information may not be withheld, including because of nonpayment of medical bills.
Physicians should retain the original of the medical record and respond to a patient's request with copies or summaries as appropriate unless the original record is required.
To protect confidentiality, protected health information should be released only with the written permission of the patient or the patient's legally authorized representative, or as required by law.
If a physician leaves a group practice or dies, patients must be notified and records forwarded according to patient instructions.
Disclosure To make health care decisions and work in partnership with the physician, the patient must be well-informed.
Effective patient–physician communication can dispel uncertainty and fear and enhance healing and patient satisfaction.
Information should be disclosed to patients and, when ap Understanding and Addressing Disparities and Discrimination in Education and in the Physician Workforce Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards How to cite this paper:Serchen J, Doherty R, Hewett-Abbott G, Atiq O, Hilden D; Health and Public Policy Committee of the American College of Physicians.
Understanding and Addressing Disparities and Discrimination In Education and in the Physician Workforce: A Position Paper of the American College of Physicians.
Philadelphia: American College of Physicians; 2021.
(Available from American College of Physicians, 190 N Independence Mall West, Philadelphia, PA 19106.) Copyright © 2021 American College of Physicians All rights reserved.
Individuals may photocopy all or parts of Position Papers for educational, not-for-profit uses.
These papers may not be reproduced for commercial, for-profit use in any form, by any means (electronic, mechanical, xerographic, or other) or held in any information storage or retrieval system without the written permission of the publisher.For questions about the content of this Position Paper, please contact ACP, Division of Governmental Affairs and Public Policy, Suite 700, 25 Massachusetts Avenue NW, Washington, DC 20001-7401; telephone 202-261-4500.
To order copies of this Position Paper, contact ACP Customer Service at 800-523-1546, extension 2600 Franciscan Missionaries of Our Lady Health System, covered entity affiliates, Our Lady of the Lake, Franciscan Missionaries of Our Lady University (FranU) and their subsidiaries comply with Federal civil rights laws discriminate ... FMOL and covered entity affiliates exclude Coletta Barrett olol RMC civilrights@ololrmc.com 765-3295 Leslie Yander FMOLHS Health Plan Essen Lane Leslie.Yander@FMOLHS.org (225) 765-6827 St.
Dom Jackson Hospital K.
Jerry Farr, Chair, Grievance icare@stdom.com 601-200-5123 phone Ivo Lukitsch, MD Consulting Staff/Faculty, Department of Nephrology, Ochsner Medical Center is a member of the following medical societies: American Society of Transplantation Eleanor Lederer, MD, FASN is a member of the following medical societies American Association for the Advancement of Science American Federation for Medical Research National Kidney Foundation Chief Editor Vecihi Batuman, MD, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Interim Chair, Deming Department of Medicine, Tulane University School of Medicine Vecihi Batuman, MD, FASN following medical societies: American College of Physicians American Society of Hypertension American Society of Nephrology International Society of Nephrology Southern Society for Clinical Investigation Office for Civil Rights hhs 1-800-368-1019 Section 1909(b)(2) of the Act requires State law to contain provisions effective in rewarding qui tam actions for false and fraudulent claims as sections 3730 through 3732 Federal False Claims Act.
FFC Act, Patient Protection Affordable Care Act, in action or claim were publicly disclosed (i) in a Federal criminal, civil, or administrative hearing, Government or its agent is a party; (ii) congressional, Gov Accountability, Federal report, hearing, audit, investigation; (iii) news media, unless brought by Attorney General See 31 U.S.C. § 3730(e)(4)(A).
OFFICE OF THE LOUISIANA ATTORNEY GENERAL Baton Rouge, LA 70802 (225) 326-6705 Louisiana Department of Justice Medicaid Fraud Unit Louisiana MFCU combat incorrect reporting of diagnoses or procedures to maximize payments; billing for services, medical supplies or equipment not furnished; misrepresentation of the dates and descriptions of services furnished, the identity of the recipient or the individual furnishing services; and billing for noncovered or nonchargeable services as covered items.
discriminate against a beneficiary (e.g., prevent them from signing up for a plan based on their age, health status, race or income), entice beneficiaries to enroll in a more costly plan than they require, or erroneously - and vigorously prosecute criminals who prey (225) 326-6210 Karen Glassman 202-708-9777 Susan Gillin 202-205-9426 Daniel R.
Levinson Inspector General Government payers, however, have stricter policies.
Government payers, however, have stricter policies.
Involuntary disenroll of a patient in a government health coverage plan can be strictly regulated by the state.
High-level governmental review and approval of the documentation surrounding the dissolution of the patient-physician relationship may be required before the patient can be involuntarily disenrolled.
When you have a relationship with a Medicare or Medicaid enrollee that you think needs to be terminated, carefully review your provider manual and state regulations.
Our state generally requires demonstration of significant wrap-around services (such as anger management counseling or social worker intervention) or transfer to another provider within our system (a “second chance”) before the patient can be transferred to another system or involuntarily disenrolled.
RISK MANAGEMENT Physicians’ offices are subject to state and federal civil rights laws.
The AMA says a physician may not decline to accept patients because of “sex, color, creed, race, religion, disability, ethnic origin, national origin, sexual orientation, age or any other basis that would constitute invidious discrimination.” Lawsuits that allege discrimination or violations of the Americans With Disabilities Act are increasing.
If you are considering ending your relationship with a patient who is in a protected class or disabled, you may want to consult an attorney to assess your liability risk.
Having a plan helps Jump to section + Terminating a patient-physician relationship is never fun.
But in our experience, the termination process is much easier if we follow a standardized approach for all of our challenging relationships.
Date:Originally Posted May 5, 2020; Updated May 29, 2020 Re:COVID-19 Related Opinions of the APA Ethics Committee That being said, as during the current COVID-19 pandemic, actual conditions and protections may deviate from the ideal during times of public health emergencies.
These are very difficult issues being faced at a very difficult time for humanity.
When determining the appropriate resolution of professional ethical dilemmas, it is important to maintain humility – while psychiatrists can and should think through how to balance competing responsibilities in any individual case, they also must recognize that often the answer is not clear and it will always depend on the circumstances of each individual case.
Psychiatrists should be aware of the both the risks of service and of recusal from service in light of medicine’s responsibilities to the public good as a healing profession.
Many family physicians chose the specialty of family medicine because of the value placed on the therapeutic relationship between the patient and the physician.
When that relationship is significantly or repeatedly challenged, family physicians feel it deeply, and it’s not always clear how best to address the problem.
We have found that, when emotions are high, having a standardized process for dealing with these challenges makes it easier to take appropriate action.
Our process provides patients with plenty of opportunities to reconsider their behavior and re-engage in the relationship, when appropriate, and it provides the physician and staff the assurance that comes with following a reasoned, consistent approach when difficult circumstances arise.
If it becomes necessary to terminate the relationship, our approach describes how to do it without running afoul of payers’ guidelines.
While our system is not perfect, it has significantly improved our ability to set expectations and draw boundaries in an environment where some payers have very narrowly defined the circumstances under which termination is acceptable.
The flow charts in this article are based on ones we have used with success in our health system.
You can download them below and adapt them for use in your practice.
Working it out Jump to section + An appropriate response depends on the type of events that have strained the relationship, and these can vary widely, from behaviors that annoy you, such as multiple missed appointments, to those that make you angry, such as unpaid bills, to those that cause you or your staff to feel threatened.
The least severe incidents can usually be addressed by discussing them with the patient or through a discussion between the patient and the office manager or administrator.
The most severe incidents may call for immediate termination.
In our group, the medical director reviews significant incidents and has the authority to adapt the response if the situation or the rules of the patient’s insurer call for it.
The first step to take when evaluating a potentially broken relationship with a patient may be a step backwards.
Unless the patient’s misconduct is severe, it is often productive to step back and consider whether you have done everything you reasonably can to salvage the relationship.
Investing this extra effort has transformed some of our most challenging relationships into ones where the patients are engaged and invested partners in their health care and appreciative of the work of our staff and physicians.
Patients sometimes escalate their behavior when they feel they aren’t getting the services they expect or when they feel their needs aren’t being addressed.
Taking time to sit down with the patient with the goal of better understanding the underlying expectations or needs that are driving his or her behavior can be valuable.
Some patients have unreasonable expectations, but for others, understanding the point they’re trying to make can go a long way in repairing the relationship.
Patients may be frustrated by the way we deliver care in our office or by other parts of the health care system (other providers, other hospitals or third-party payers).
Learning about the root cause of their dissatisfaction can help us improve the delivery of care to all our patients.
Of course angry patients can make offensive remarks about you and your staff.
The quickest response is often a defensive one.
Since listening is very difficult to do when you are being accosted, deferring the patient to another member of your staff who is less invested in the relationship or the process of care can be quite helpful.
You can do this with a simple statement such as, “I understand you are upset.
To make sure we address your concerns to the best of our ability, let me get the office manager to assist you.” Distancing yourself from the situation in this way can keep you from saying things you’ll wish you hadn’t and might provide you with valuable perspective.
If you don’t have this opportunity, or if your office staff have exhausted their efforts to communicate with the patient, you may be able to refer the patient to another resource.
Most health plans have member service representatives to which you can refer a challenging patient.
Patient adherence, or lack thereof, can be as big a problem as disruptive behavior in the office.
If a patient isn’t complying with your treatment recommendations, be sure to document that fact in the patient’s record, as well as your efforts to inform the patient about the potential consequences of noncompliance – both in terms of his or her health and your ability to continue as his or her physician.
Sometimes, no matter what you do, there is no hope of resurrecting the relationship.
In this case, your chances of successfully ending the relationship are greatest if you have communicated clearly with the patient about the process, what to expect and the consequences of continued problems.
Direct statements such as, “If you do this again, we will no longer care for you, and you will have to go to another practice,” can be quite eye-opening for some patients.
Ultimately, if you’ve followed an approach like the one depicted on the following pages, the patient should not be surprised when you terminate the relationship.
MANAGING DIFFICULT PHYSICIAN-PATIENT RELATIONSHIPS Download in PDF format
The flowcharts below depict a three-tiered approach similar to the process used in our health system.
For this approach to be effective, you must categorize the types of problems you encounter in your practice into three tiers.
For example, in our system, tier 1 behaviors include a patient missing five appointments in six months or a patient using abusive language while talking with a staff member.
Tier 2 behaviors include a continuation of issues identified in tier 1, or any actions that staff perceived as threatening.
Tier 3 behaviors include a continuation of issues identified in tier 2, or any violent or potentially illegal actions.
The typical termination procedure involves consulting with the patient’s insurer about your plans, then sending a letter to the patient by certified mail, with a return receipt requested.
The letter should explain that the relationship has been terminated and that you will continue to direct the patient’s care for emergent issues until a specific date approximately 30 days from the notification letter (see the sample letter).
Don’t forget to keep your office staff, and particularly your scheduler, in the loop.
Unless otherwise specified by the patient’s health plan, the primary care physician generally doesn’t have further obligations to assist the patient in finding another physician.
Assisting the patient in transferring medical records to another physician is important, however.
It signals your interest in facilitating continuity of care.
Because of privacy requirements, you should not contact the patient’s future physician about the dissolution (no matter how tempting it may be) unless that provider is a business associate of yours.
In some instances, the patient may not pick up the certified letter.
In that situation, if he or she contacts you after 30 days and tries to schedule another appointment or even shows up at your clinic, you must show him or her a copy of the letter and pleasantly but firmly reiterate that you will no longer care for the patient because of his or her behavior.
SAMPLE TERMINATION LETTER
When you decide to end your relationship with a patient, inform him or her in writing and send the letter by certified mail, with a return receipt requested.
If it’s possible to describe the reason for the termination in a brief, clear, objective way, do so in the letter.
If not, you might be better off not providing a reason.
The patient ought to be aware of the reason as a result of earlier discussions and correspondence.
Some malpractice insurance carriers offer sample termination letters, or you can adapt the following sample.
Dear [patient name],
As you know, a good relationship between a physician and his or her patient is essential for quality medical care.
There are times when this relationship is no longer effective and the physician finds it necessary to ask the patient to select another physician.
This letter is to inform you that I am no longer willing to be your primary care physician.
The reason for this decision is [describe reason briefly, or omit this sentence].
Our office will continue to direct your care for any emergencies that arise over the next 30 days.
It is imperative that you select another physician and arrange with our office for your records to be sent to your new physician before [date].
Your insurance plan or the local medical society [insert contact information] will be able to assist you in choosing a new physician.
Sincerely, [Physician’s name]
+ Third-party payers typically have their own policies and procedures about terminating a patient-physician relationship.
These may affect your response.
Obtaining copies of the policies in at the first sign of trouble can be useful.
In our state, most of the commercial policies require notification of the insurance company and then a 30-day notice to the patient.
There are no simple answers and psychiatrists are encouraged to seek consultation with colleagues and ethics resources to navigate these challenging times.
Please see response to Question 4 regarding practice outside of your normal area of expertise It is ethical for the psychiatrist to terminate treatment under these circumstances if she does not feel she can safely care for the patient due to a variety of factors, including geographic distance, the severity of the patient’s symptoms, and the psychiatrist’s own circumstances.
As long as she has provided the patient with ample notice and appropriate referrals or other opportunities for the patient to transition her/his care, she has fulfilled her ethical responsibilities to the patient relating to the principles of non-abandonment and the ethical obligation to provide opportunities for transfer of care.
Recent Opinions of the APA Ethics Committee on The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry (2020-2021)
Beneficence and non-maleficence: Psychiatrists have ethical obligations to strive to benefit their patients and in enforcing Section 1557, as stated above, OCR will comply with the Religious Freedom Restoration Act, 42 U.S.C. § 2000bb et seq., and all other legal requirements.
Additionally, OCR will comply with all applicable court orders that have been issued in litigation involving the Section 1557 regulations