Case and Commentary
Jan 2005

Saying Goodbye to Mr. Jones, Additional Information

Jennifer Reenan, MD
Virtual Mentor. 2005;7(1):18-22. doi: 10.1001/virtualmentor.2005.7.1.ccas4c-0501.


At times the relationship between patient and physician can be perceived as "difficult" by either the patient or the physician. Physicians might label a patient as difficult when they perceive him or her to be demanding or refusing to follow the agreed-upon treatment plan. Studies conducted in this area suggest that a difficult patient-physician relationship emerges from the conflicting expectations and misunderstood behaviors on the part of both patient and physician.

Putting concerns to patients in writing is not unusual when talking with the patient does not seem to be effective or when documentation is prudent. The written communication must be clear about what will occur next. Requesting that the patient come in for an appointment to discuss what seems to be a problem situation demonstrates courtesy and respect. Illness can make people feel vulnerable and unsure of the future. Rather than accelerating the difficulty, the physician can facilitate a discussion in which the problem is acknowledged, both patient and physician's perspectives are identified, the physician tries to understand his or her own reactions to the patient's behavior, and there is an attempt to negotiate grounds for continuing the relationship.

Nonetheless, knowing if and when to refer a patient is also important. When a physician terminates the relationship and patients do not fully understand why, they may feel that they are being punished or abandoned by their doctor. These feelings may create hesitancy for the patient to seek additional medical care.

Physicians who terminate a relationship with a patient, must give the patient sufficient time to find another physician. Patients, especially those with diagnosed conditions, have the right to expect "continuity of care." Without sufficient notice the patient's health can be put into severe jeopardy necessitating emergency treatment.

Although some state laws require 30 days notice, in other states "sufficiency of notice" is an open time frame that will vary from patient to patient and situation to situation. With patients for whom a transfer can be made relatively easily, "sufficient" may be the time it takes to transfer of records to the physician in the next office. In other situations, 30 days may be necessary. Prudence suggests giving the patient a reasonable period of time to accept the termination emotionally and secure a new physician. In those situations where the patient does not wish to accept alternative sources of health care, it is in the best interests of the patient and physician to have a clear date by which the physician will no longer accept responsibility for the patient.


Virtual Mentor. 2005;7(1):18-22.



The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.