A 17-year-old male came to the inpatient ward after an overdose of trazadone that he was taking for depression. He had had a fight with his girlfriend and decided to take several tablets. He became very sleepy and regretted taking them, so he confided in his mother. She took him to the local emergency room, where his urine drug test was negative for other substances. The local hospital did not have psychiatric beds available and the emergency room physician tried to contact his psychiatrist. The office answering machine did not have any contact information. Another town’s hospital where the psychiatrist also practiced also did not have any after hours contact information for the psychiatrist. That hospital also did not have any psychiatric beds available at that time. The emergency room physician contacted the regional children’s hospital who accepted the patient to the inpatient medical pediatric floor. The past medical history revealed that the patient had another similar suicide attempt 6 months previously and was begun on the trazadone.
The pertinent physical exam showed a sleepy male who was arousable but not very communicative. BP was 66/46 and his heart rate was 64. The rest of his examination was normal. He denied acute suicidal ideation and showed remorse for taking the medication. The diagnosis of a suicide attempt versus gesture was made. A child psychiatrist evaluated the patient and felt that he was not acutely suicidal and could be followed by his outpatient psychiatrist. The pediatric resident contacted his local psychiatrist to arrange followup care. The resident was told that although there were no problems with the patient-doctor relationship the psychiatrist is refusing ongoing care of the patient because he didn’t want to see the patient again. The resident and the child psychiatrist arranged for outpatient followup and made an emergency/safety plan for the family, and the family agreed to continue his care at the children’s hospital.
The American Academy of Pediatrics states “[p]rofessionalism has been a central and defining feature in medicine….Pediatricians have a special status in society as priviledged and trusted advocates for the well-being of children. Pediatricians have a responsibility to use their knowledge, skills, and influence to advocate for children and their interests in all domains of society, not just in health care.” The American Board of Pediatrics has endorsed eight components of professionalism for teaching and evaluation of resident physicians. These are: honesty and integrity, reliability and responsibility, respect for others, compassion/empathy, self-improvement, self-awareness/knowledge of limits, communication and collaboration, and altruism and advocacy.
There are professional standards for any health care professional – basically agreement by both the provider and patient/family to enter into a therapeutic relationship with the provider providing services within the scope of his/her practice and the patient/family agreeing to work in good faith with the provider including payment for services. The relationship can be terminated by either party. Families will often terminate the relationship without a formal process – they just don’t come back. But a health care provider wishing to terminate a relationship should have a formalized process with the patient/family notified in person if available and also in writing usually by registered mail. Notification should include the reasons for needing continued treatment by a qualified provider, reasons why this specific provider cannot continue treatment, reasonable efforts to refer the patient to another provider (specific options/recommendations) and a specific termination date that allows enough time to reasonably expect that a successful transition will occur. Notice of the need to consent to transferring medical records to another provider is often added to remind patients/families that this is a separate consent. Some providers also add recommendations for emergency care after the termination date, in case the patient/family has not successfully transitioned. There may be specific state regulations that a provider must also follow. According to the Iowa Board of Medical Examiners for instance – “A physician may choose which patients to serve. If your physician no longer wants to provide care for you, he or she should provide you with written notice 30 days before terminating your care. Your physician should ensure that emergency medical care is available to you during the 30-day period following the written notice. This does not mean that he or she must provide the care himself or herself.”
While this may seem straightforward that a provider has a duty to care for patients/family, there are many nuisances which ultimately depend on the relationship. As an example, was the relationship a time-limited relationship such as a specialist being asked their opinion about a specific problem? The service was provided, the opinion given and usually if there are no ongoing issues, the relationship is then terminated. It could be re-constituted, if the problem recurs in the future but this is a different relationship. Another reason to terminate a relationship is that the problem that initiated the relationship has resolved. For example, a patient with resolved Henoch-Schonlein purpura was treated by a nephrologist, but as there is no ongoing renal disease the patient maybe “discharged” back to care of her primary care provider. In an ongoing relationship, if a problem is revealed by the patient/family or detected by the healthcare provider that is outside the scope of practice of the healthcare provider, the provider also does not have to provide care for that problem. Usually the provider will assist the patient/family in seeking appropriate care though. For example, a pediatric cardiologist is seeing an adolescent female who discloses a gynecological problem.
Information about the relationship may be kept confidential to outside entities because of HIPAA or other reasons, such that it may appear that there is an ongoing relationship when in fact there may not be. This could be one reason for the psychiatrist’s actions in the above case. Some practices have very specific agreements under which they will treat patients/families and if the patient violates the agreement then they could be terminated. Some practices within their agreement with patients may not provide emergency care. If a patient is in acute medical crisis, care needs to be given to the patient but the provider themselves does not have to provide the service him/herself. For example, a patient becomes violent and is a danger to himself and others. The provider does not have to provide care to the patient, but by calling safety officers, police officers and/or other emergency personnel, the provider has begun to provide emergency care and is meeting the duty to care for the patient. Basically, if a provider had a clear relationship with a patient/family (particularly a continuous one over time) and the patient had a medical crisis that was within the scope of practice of the provider, and then the provider refused to continue services without a clear therapeutic cause and/or appropriately diligent effort to assist in finding appropriate alternative care options, then the provider may be negligent.
The American Academy of Pediatrics states that “[a] pediatrician has broad authority to enter into or decline a medical relationship with a family except in emergency situations. Once a relationship is established, however, the pediatrician should assume responsibility for the medical care of the child and also recognize when the child needs to be referred to a pediatric medical subspecialist, pediatric surgical specialist, or other physician or qualified clinician for diagnosis or treatment of a condition or symptoms complex outside of the physician’s scope of practice.”
Questions for Further Discussion
1. How do you personally define professionalism?
2. If you were the physicians in this case, how would you have handled the case above?
3. If you believe a healthcare provider has been medically negligent and/or liable, what local, state or national organizations could/should you report the provider to?
- Specialty: Emergency Medicine | General Pediatrics | Pharmacology / Toxicology | Psychiatry and Psychology
- Age: Teenager
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Van Sustern L. Psychiatric Abandonment: Pitfalls and Prevention. Psychiatric Times. 2001;18.
American Academy of Pediatrics Technical Report. Professionalism in Pediatrics. Pediatrics. 2007:120;e1123-1133. Available from the Internet at: www.pediatrics.org/cgi/doi/10.1542/peds.2007-2230 (rev. October 2007, cited 9/23/09).
Iowa Board of Medical Examiners. Available from the Internet at http://medicalboard.iowa.gov/Questions.html (cited 9/23/09).
American Psychiatric Association The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. 2009.
http://www.psych.org/MainMenu/PsychiatricPractice/Ethics/ResourcesStandards.aspx (rev. 2009, cited 9/23/09).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital