Occasionally, it is appropriate to terminate doctor-patient relationship, and it may be a measure to the best interest of the patient.  It is necessary to consider all alternative management and patient safety before such approaches may be taken.  It is useful to discuss with another senior clinician prior to such decisions. It is inappropriate to terminate doctor-patient relationship when the patient is under immediate danger. Such drastic actions are indeed extremely rare over 2 decades of private practice by the author.

The doctor exercises art in collection of factual information, patient attitude, clinician’s own psychology, possible and alternative approaches in management, and positive/negative consequences to each and every stakeholder.

The communication is a professional one carrying sincerity, respect, empathy and honesty. Often the environment and previous encounters set the stage leading to termination.  There is no need for a professional to express anger, frustration or fear during the termination. Sometimes it is not preference of the doctor or patient, skill or competence of the doctor, or even personal relationship between doctor and patient, but the choice of optimal environment for care of the situation, which leads to the termination. Increasing the professional fee is definitely a self-defeating way to terminate doctor-patient relationship.

The client is courteously, professionally and explicitly informed about the termination, most preferably by the doctor himself.  In fact, it is not easy for support colleagues such as nurses to explain such difficult communication to a client most likely being upset by the message.  Often miscommunication occurs and further misunderstanding arises out of relayed messages.

The patient is given information about medical conditions, immediate need if any, reason for termination of relationship, extent of termination (an individual clinician, a team or bigger scale), and if appropriate whether the doctor-patient relationship may be reestablished.  It is usually appropriate to give a copy of medical report and/or medical notes and/or investigation results, to facilitate future care by another doctor.

Usually, and especially there is need for subsequent related care, a referral note to another clinician is a fair and appropriate outlet to the client. For practical reasons, often the referral destination is another sector (public/private).

It is vitally important to record in medical documents the rationale and logistics about the termination.

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In a hypothetical situation, a doctor terminates relationship with a client.  Readers may concentrate on the process of termination.  Whether it is the best to do the same in a similar situation, is not the main theme of this page.

“Ms Chan, you have been shopping around many doctors including myself and done many investigations.  Last year I recommended you to take up Treatment A, B or C, or at least observe diligently.  But neither did you arrange any care by me or another clinician, nor take care of yourself.  I feel that it is time to give you an honest and very firm message, so that you think carefully about your health and may decide in your best interest.   I hope to let you understand that there is at least a very honest doctor who tells you the truth without consideration to personal benefit or patient volume.

There is no immediate danger over the next 3 months, but you must take good care of yourself.  As from today onwards, I am no longer your doctor.  I have photocopied my medical notes and nurses will give you a copy.  I have also written a referral letter for you to consult the specialty clinic of XYZ Hospital.  Please understand that I am not able to influence schedules of appointment and you have to book appointments yourself.  I would encourage you to book an appointment there for an impartial opinion, the earlier the better.

I feel sorry that I have to make this arrangement for you, and I understand that it would make you feel nervous. In future, if you still want me to take care of you, you may still book an appointment as an entirely new patient.  But please understand that I would ask you to make decisions instead of dragging on.  It is a waste of your valuable time to see me without arrangements to help with your problems, and I feel sorry that I may even stress you.

Is there any question?

Rose (name of nurse), please escort Ms Chan back to the reception, and give her documents which I prepared to her.  I would not charge her this time.  There is no need to book any follow-up for Ms Chan.”

(In the whole process, the doctor wears his smile, keeps his volume of voice down but audible, his tone firm and professional, communicates clearly and maintains in-control body language.)