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Ethics in Practice   |    
Ethics in PracticeTerminating the Physician-Patient Relationship
James D. Capozzi, MD1; Rosamond Rhodes, PhD2; George Gantsoudes, MD2
1 Mount Sinai Medical Center, Manhattan Orthopedic and Sports Medicine Group, 1065 Park Avenue, New York, NY 10128. E-mail address: capoz5@aol.com
2 Departments of Bioethics Education (R.R.) and Orthopaedics (G.G.), Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jan 01;90(1):208-210. doi: 10.2106/JBJS.G.01176
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

A.G. is a thirty-six-year-old reading teacher who presented to an orthopaedic surgeon with patellofemoral pain. After an appropriate evaluation, the physician suggested a course of physical therapy and anti-inflammatory medication. The patient asked for and received time off from her work, stating that her job required her to climb stairs. At multiple follow-up visits, A.G. was found to be poorly compliant with physical therapy and home-exercise programs. Her only interest appeared to be in securing the doctor's letter of support for an extended medical leave. At each visit, she demanded that the physician write a letter stating that she was unable to work as a reading teacher due to knee pain. At one point, she became belligerent with the medical office staff when the letter was not prepared.

When her physician tried to elicit information about whether there were any unaddressed obstacles to rehabilitation treatment, A.G. did not answer the questions. Instead, she explained that her job required her to climb stairs and that she was unable to return to work because of the continued knee pain. The physician explained that, on the basis of his examination and assessment, he expected that her pain would improve if she complied with the treatment plan.

After multiple visits, the orthopaedic surgeon counseled the patient that he did not see that his attempts to help her were providing any benefit and that perhaps it would be best for her to seek help from another physician. A.G. replied that she did not want to start going to another doctor. She stated emphatically that he was her doctor, that she was paying him, and that she wanted a letter saying that she should be granted an extended medical leave from work because of her inability to climb stairs. After this encounter, the surgeon thought it best to terminate the professional relationship.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    James D. Capozzi, M.D.
    Posted on January 20, 2008
    Dr. Capozzi et al. respond to Dr. Lack.
    Mount Sinai Medical Center, New York, NY

    We thank Dr. Lack for her insights from a psychologist's point of view. There most likely was, in this case and in many others like it, a hidden agenda. I am sure a consultation with a psychologist would have been most helpful. I know of a work related injury treatment center that routinely has all of its patients see a psychologist because they, too, have found that in many instances, patients who delay returning to work do so not because of injury related issues but, rather, becuase of other issues such as job dissatisfaction, employer conflicts, or personal issues at home.

    Dorothea Z. Lack, Ph.D.
    Posted on January 03, 2008
    A Psychologist Responds
    Independent Practice. Affiliate staff, California Pacific Medical Center, San Francisco, CA

    To The Editor:

    Drs. Capozzi, Rhodes and Gantsoudes describe one of the difficulties that often arise in clinical practice. The patient has what is often called in psychology "a hidden agenda." The doctor and the patient have different goals for the treatment. The doctor is devoted to treating the physical problem, the patient is focused on trying to avoid her work situation for one reason or another. This is a dilemma in which a psychologist could really help.

    If the doctor were able to refer the patient for an interview or two, the probability of a positive treatment outcome would be enhanced by making the hidden agenda transparent, and helping the patient to make whatever adjustments were necessary to cope with the work situation.

    Recent studies have identified a variety of psychological factors that correlate with outcome in TKA and THA(1-4). Pretreatment interventions have been identified as useful for patients who are anxious, depressed and in pain. If this patient had been interviewed pre-treatment, her vocational difficulty might have been identified. As it is, a postreatment referral might just be the answer, and help the patient to avoid losing her doctor, and to have a more positive outcome.

    The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of her immediate family, is affiliated or associated.

    References:

    1. Smith, B.W., Zautra, A.J., The role of purpose in life in recovery From knee surgery. Int. J. Behav Med. 2004; 11(4):197-202

    2. Faller, H., Kirschner, S. & Konig, A. Psychological distress predicts functional outcomes at three and twelve months after total knee arhtroplasty. General hospital psychiatry. 2003;25(5): 372-373.

    3. Lingard, E.A., Riddle, D.L., Impact of Psychological Distress On Pain and Function Following Knee Arthroplasty, J Bone Joint Surg Am. 2007;89:1161-9.

    4. Salmon, P., & Hall, G.M., Postoperative fatigue is a component of the emotional response to surgery: Results of a multivariate analysis. Journal of psychosomatic research. 2001;50(6):325-335.

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