In a previous article, we discussed the professional responsibilities that endure even when dealing with a difficult patient1. The patient discussed in that article had failed to adhere to his prescribed treatment regimen and nearly died by overdosing on self- administered narcotics while he was hospitalized. Both that case and this current case scenario illustrate the problems that arise when patients repeatedly behave in ways that are detrimental to their own health care.
It is widely accepted that the primary responsibility of a physician is to promote the good of the patient2. In other words, doctors are professionally bound to provide medical care to their patients to the best of their abilities regardless of the appealing, unappealing, or even repugnant characteristics of those patients. It is well recognized that the foundation of our vocation as caregivers places us in a position that is unique in comparison with that of all other professions. Society expects physicians to be responsive to the medical needs of patients, and individual patients are entitled to trust that the physicians who are involved in their care will live up to these freely undertaken and publicly affirmed commitments.
Likewise, it seems fair to say that patients should also do their part in promoting the health and healing of their bodies. It is also fair to say that there are limits to a physician's obligation to provide care. But, where is that limit and what justifies severing a relationship with a patient? In that light, two specific questions are raised by the behavior of patients like A.G. The first question is, "When does the failure of a patient to do what he or she should do release a physician from professional responsibility?" In other words, does a physician have ongoing duties even when a patient drops the ball? The second question relates to the scope of what the patient expects of the physician. "What are the physician's professional limitations with regard to promoting the good of the patient?"
Our answer to the first question is largely that the irresponsible or unhealthy behavior of a patient does not release a physician from his or her responsibility to that patient. Even though each of us should endeavor to be a good steward of the body, a patient's failure to do so is quite common. A patient may not fully understand the physician's instructions or may not fully appreciate the importance of following instructions or the consequences of not adhering to the treatment plan. The judgment of a patient may be impaired by depression, fear, denial, repression, or distorting biases. Similarly, patients may lack the means to adhere to, or may be overwhelmed by, the burdensomeness of what has to be done. Or, patients may have other goals (job, family, or personal commitments) that are more important than their own health or continued function. When under medical care, even doctors fail to complete the courses of antibiotics or other therapies that are prescribed for them.
Nevertheless, when a patient has ongoing medical needs, a physician has an ongoing duty to provide medical care. Patients' responsibilities are a duty to themselves. When they fail in their responsibilities, they let themselves down. Physicians have a professional duty to their patients and to society, and they must also uphold the trustworthiness of the profession. When a physician fails to fulfill a duty to a patient with medical needs, that patient is left without the care that the profession is committed to providing, thus jeopardizing the profession's standing in society.
Our answer to the second question (the extent of the physician's duty to promote the good of the patient) is, "It depends." Although defining the boundaries of medicine can be difficult, we generally see the scope of medicine in terms of the utilization of the special knowledge, skill, and expertise reserved for the profession. When the good of the patient can be promoted by employing the special tools of medicine, professional responsibility is involved. In contrast, when the interest of an individual would be advanced with financial information, cooking advice, or a beauty tip, because those interventions do not involve the special medical knowledge, skill, or expertise entrusted to the medical profession, those services do not fall under the professional obligation of the physician. Even if those services would benefit and promote the good of the individual, they are not within the domain of the medical profession.
In this case, deciding whether or not to provide a letter to A.G.'s employer depends on a determination of whether there are any valid medical reasons that would prevent A.G. from returning to work. The orthopaedic surgeon was engaged in making a sincere effort to assess her condition, offer interventions that could alleviate her pain, and determine whether there were any barriers to A.G.'s treatment. The surgeon was careful to avoid falling into the natural trap of blaming the patient and tried to take her complaints seriously3.
At the follow-up visits, the surgeon reviewed A.G.'s medical diagnosis to determine whether some physical cause for the continued pain might have been overlooked. He also performed a thorough physical examination and a careful analysis of whether further tests might be in order. The orthopaedic surgeon also tried to discover barriers that might have impeded A.G.'s access to rehabilitation by asking her to explain why she had not done her exercises or made appointments for her prescribed physical therapy. He even tried to be sensitive to the possibility that A.G. might not have been aware of what impeded her progress, and he was alert to the possibility that her vague answers that expressed bewilderment or lack of insight might be an indication of the need for psychological support and an appropriate referral. Yet, A.G. was repeatedly noncompliant with the recommendations of her physician and showed no evidence that her knee condition would preclude her from performing her job duties. All of her responses suggested that A.G. was malingering and that, barring her compliance with a therapy program, there was no further need for additional medical intervention. Once the physician concluded that he had little more to offer this patient, irrespective of the persistent demands for a work letter, continued visits would have been inappropriate, futile, and costly.
The issue of the work letter still remains. Sometimes legitimate reasons prevent individuals from fulfilling their commitments. When the reason is a disabling medical condition, the person is often excused. To help sort out legitimate medical excuses from frivolous ones, our society typically accepts the word of a doctor as being an honest report, and a doctor's letter is considered to be an authoritative verdict. Workers' Compensation boards, airlines, gym facilities, and employers accept the testimony offered in a doctor's letter, and that testimony allows patients to avoid the penalties that they otherwise would have to endure. This system benefits many, but it only works to the extent that doctors' reports can be trusted. So it is important that physicians uphold their commitment to honest reporting for the sake of preserving the trustworthiness of those reports.
Although A.G. sees the benefits that a letter from her doctor would provide, the orthopaedic surgeon can only write an honest report. Providing for a patient's extended vacation from work does not involve the use of medical knowledge or skills; therefore, providing that benefit is not a medical obligation. Furthermore, because providing a dishonest report would tend to undermine society's trust in medical reports (and violate conventional moral and legal standards), the orthopaedic surgeon must resist the pressure from the patient to do so.
The physician should always make reasonable attempts to resolve any patient dispute. Obviously, if a patient is violent or makes serious threats toward a physician or staff member, the appropriate authorities should be notified and the relationship should be terminated immediately. Because the orthopaedic surgeon saw that he had little to offer to A.G. in the current relationship, the physician suggested that A.G. find another doctor. When a physician begins to see that terminating a physician-patient relationship may be inevitable, it is prudent to document each step that is taken to respond to the patient's complaints or to resolve the problematic situation. This will serve to demonstrate the desire to repair the relationship and will protect the physician against any legal charges of abandonment4.
Once the decision to end the relationship is made, the physician should talk to the patient and explain the reasons for the termination in a professional and reserved manner. For self-protection, the patient should also be notified in writing, preferably in a way that provides a signed receipt of delivery. The letter should explicitly give notice of the termination, provide an explanation for the termination, include recommendations with regard to other physicians, state that treatment will continue to be provided until a transfer of care can be put in place, and state that the patient's records will be transferred to the new physician on receipt of written authorization from the patient5.