Ending the treating relationship

As a health professional, your focus is on being there for your patients and providing the best healthcare possible to meet their needs. However, there’ll be times when the treating relationship isn’t effective or appropriate and you wish to end it. Guild Insurance regularly receives queries about how to do this professionally while keeping patient care a core focus.

Possible scenarios

  • There’ll be occasions where you realise that the treatment you’re able to provide, according to your skills and scope of practice, won’t suit the needs of a particular patient. This might be evident at the first consultation, or it might only become apparent after treatment has begun.
  • In other situations, it may not be you as the practitioner who has concerns about treatment, it may be the patient who’s expressed concerns. It’s possible to face a situation where the patient has expressed dissatisfaction, or a lack of confidence, with treatment. These situations may lead to the practitioner questioning whether it’ll be difficult to meet the expectations of that patient and whether it would be best for them to be treated elsewhere.
  • Unfortunately, there are occasions where a practitioner doesn’t want to provide treatment to a patient for safety reasons, not clinical ones. If a patient is making you, your colleagues or other patients feel uncomfortable or unsafe due to their behaviour, this is a very valid reason to end the treating relationship.

Considerations for ending the treating relationship

Be sure there’s a proper and fair reason

While health practitioners can end treating relationships, they also need to be sure they’re meeting their professional requirements regarding treating patients fairly and with respect. It’s therefore recommended that before ending a treating relationship, the practitioner is honest with themselves in considering their reasons why and be sure they’re treating all patients equally when making these decisions.

Consider all options

Before ceasing treatment, consider the various options for the patient, and have a plan for how you’ll discuss these options with them. Is there another practitioner at the practice who might be better positioned to treat them? Is there another practice you could recommend they attend instead?

If there are some behavioural challenges with the patient, maybe asking them to book appointments at particular times of the day when there are either more or less, depending on the circumstances, people present.

Maintain appropriate and professional communication

Be sure that the way you deal with what’s potentially a challenging situation is done so appropriately. Plan the conversation; being prepared will likely avoid awkward or inappropriate comments. Be respectful, keeping in mind this conversation could be confronting or upsetting for the patient.

Document the conversation

Keep a record of the conversations had, and the reasons given, for ending the treating relationship. This information should include any responses, both positive and negative, from the patient. Also include any suggestions or referrals given to the patient in terms of them seeking treatment elsewhere.

Maintain continuity of care

Practitioners have an obligation to help to facilitate continuity of care and one way this can be done is by offering to provide the records to the patient’s nominated practitioner with a handover.

The practitioner doesn’t have to refer them to another practitioner or practice; however, this is an option worth considering. The referral could also be to the patient’s GP.

Practitioners should also be mindful that it isn’t appropriate to cease a treating relationship if there are any urgent care needs.

Develop practice policies

Practice policies regarding patient behaviour are recommended to support the practice when dealing with challenging patients. These policies should document what’s expected of all patients in terms of how they interact with and treat staff. They should be made available to patients, possible by being posted in the waiting area, treatment areas and on the practice website.

Having this information documented and available will provide support when explaining to patients why they’re no longer welcome at the practice. It’ll also ensure all patients are treated fairly and equally.

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    Maintaining personal and practice safety in Chinese medicine

    All employers, business owners, contractors and employees have an obligation to create and maintain a safe working environment. And to do this, we all need to think about what makes our workplace unique in terms of the risks and the strategies needed to keep it safe.

    There are a few ways in which Chinese medicine and acupuncture practices can pose risks to the personal safety of practitioners, other people who work there and patients. One-on-one consultations mean that the practitioner is always alone with a patient. Small practices can lead to practitioners being the only worker present in a clinic. And the varied hours of clinics will often see practitioners working late at night.

    Below are some tips to help you create a safe workplace for everyone who comes into your practice.

    • When booking in a new patient who you know nothing about, consider booking them in during a busy time of the day when there are other staff around, rather than when the practitioner will be in the practice alone.
    • If you have a patient who, for any reason, raises some red flags in terms of the practitioner’s comfort levels, only allow them to book in when there are others in the practice.
    • If a practitioner is practicing in the evening and is the only person working at that time, consider locking the front door to the practice. If you do this, explain to patients inside what you’re doing and why. And consider your process for other patients who’ll be arriving. Will you let them know the door will be locked and that they’re to wait outside until you’re ready for them? Maybe you’ll only lock the door once the final patient for the day has arrived.
    • Installing a buzzer on the front door notifies you when it’s been opened, thereby allowing you to be sure when people are entering your practice.
    • Consider installing a reception area camera and post clear signage so anyone who enters understands they’re being filmed and will be identifiable. Don’t use cameras in treatment rooms.
    • Consider walking patients and colleagues to their cars when it’s late, however be sure to consider your own safety when doing this. Provide patients with advice on safe places to park.
    • Always lock your car doors as soon as you get in, and keep in mind criminals can approach from varying angles, so they may be in your blind spot.
    • If the practice is in the home of the practitioner, have processes in place to separate the living space from the practice to protect the privacy and safety of the practitioner and their family members, especially children. And be aware, family members may also breach a patient’s privacy or modesty, so ensure everyone in your household understands the rules.
    • Keep records of any uncomfortable, challenging or threatening behaviours from patients, and be sure to save anything that’s received via text or email. This information is to be recorded in the patient record. The details on what occurred can be brief, but must be professional, keeping in mind records can be seen by others.
    • Don’t contact patients via your personal email or mobile phone or provide these details to them. If you need to contact them while off-site, put your phone on “No Caller ID” so they don’t have access to your phone number. If you leave a voicemail message, ask the patient to call the clinic phone, not your mobile.
    • Have a practice policy that advises against practitioners connecting with patients on social media as these connections can contribute to the blurring of professional boundaries. And be sure to understand the privacy settings of any social media platforms used.
    • Discuss any challenging or awkward situations with your colleagues or other healthcare professionals, while maintaining patient confidentiality. This not only provides support when dealing with challenging situations, it can also provide additional tips for how to manage these situations.

    It’s important to remember that workplace safety laws apply to everyone in the business, including contractors, not just the business owner. A safe work environment is in everyone’s best interest so open communication about any concerns is the best way to protect all staff members.

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    Why has my Chinese medicine practitioner touched me there?

    Guild Insurance sees numerous allegations against Chinese medicine practitioners and acupuncturists where the patient claims the practitioner has behaved in a sexually inappropriate manner during treatment.

    These claims may involve allegations regarding the way the practitioner has touched them, or they may relate to what’s been said during the consultation. These are incredibly serious allegations that cause a great deal of stress for both the practitioner and the patient.

    Case example 1

    The patient alleged that during treatment the practitioner moved and undid items of the patient’s clothing without the patient’s consent, leaving the patient feeling exposed and uncomfortable.

    Case example 2

    The patient complained about what they perceived to be excessive and unnecessary physical contact during treatment that left them feeling uncomfortable. The patient stated they’d received this type of treatment before and had never been touched in this manner.

    How can these allegations be avoided?

    Be mindful of patient clothing

    If treatment would be easier with the patient’s clothes removed or adjusted, this should be clearly explained to the patient, while seeking their consent. Being even partially undressed can leave patients feeling exposed and vulnerable. Adhere to the following tips regarding patients and their clothing:

    • Consider making patients aware prior to their appointment that they may be asked to remove or adjust clothing, if they’re comfortable doing so. This allows the patient to consider what clothing might be most suitable and practical to wear.
    • Be sure you explain to patients why you would like them to remove or adjust their clothing, keeping in mind it may not be obvious to them.
    • Provide the patient with clean towels and/or gowns to keep the parts of their body not being treated covered. These must be of a sufficient size to adequately cover all patients.
    • If moving or adjusting the patient’s clothing once treatment has begun, seek the patient’s consent first, and ensure you offer to re-position the clothes afterwards.
    • Be very clear about what you want patients to remove and what they should leave on. Simply asking them to undress is likely to cause confusion and apprehension.
    • Give patients privacy when undressing and dressing by either having a screen for them to go behind, or by leaving the room.
    • Remember that patients can decline to consent to adjusting or removing clothes; don’t assume they’re ok with it.

    Gender is irrelevant

    It’s easy to think that allegations of inappropriate touching are predominately issues when treating patients of the opposite gender. However, this isn’t the case. Regardless of the patient’s or your gender, there’s always a possibility for the patient to feel uncomfortable. The way you explain treatment to patients and seek their informed consent should not differ based on the patient’s gender.

    Informed consent

    All health professionals would be aware of their professional obligation to ensure a patient has given their informed consent prior to assessment and treatment beginning. For a patient to be able to give informed consent, they need to have had the assessment and treatment explained to them in a manner they understand. This means avoiding clinical language which may be confusing while providing the risks and benefits to what you’re proposing and allowing time for the patient to ask questions.

    When treatment involves touching the patient, it’s important to clearly explain to patients where you’re proposing to touch them, and why. It may even require you to demonstrate on yourself exactly where you’re referring to. Remember that in some cases you won’t directly touch the patient where they feel pain or discomfort, so the treatment area may not be obvious to them. Keep in mind that even after treatment has commenced, patients can withdraw consent at any time if they don’t feel comfortable.

    Record keeping

    Record keeping is a professional requirement which serves several purposes. Detailed and accurate clinical notes allow for continuity of patient care. They also provide evidence of what took place during a consultation, and why.

    If a patient alleges they’ve been touched inappropriately, the practitioner’s clinical record will be examined for evidence of what treatment was provided and the clinical justification for this. The clinical record should also contain evidence of the patient consenting to the treatment. Without this information in the clinical record, it becomes very difficult for the practitioner to defend their actions.

    Don’t make assumptions

    As with any professional, practitioners can become overly familiar with what they know and do every day. However, they must remember that patients won’t have that level of familiarity when it comes to treatment. Regardless of how many times a practitioner has treated a patient, they should never make assumptions about what the patient will understand about treatment, be comfortable with and be willing to consent to. Treatment always needs to be explained to patients, even if they’ve received that treatment before.

    Consider the patient’s demeanour

    While it isn’t expected that a practitioner can be sure of what a patient is thinking and feeling just by their body language, we all have some ability to gauge when a person is feeling uncomfortable with a situation. If you have a patient who appears to not be comfortable with the treatment being suggested or carried out, stop what you’re doing and assess the situation. You may need to further explain the treatment so it’s better understood. You may need to reposition clothing or gowns so the patient is more adequately covered. Or you may need to remind the patient that they don’t have to consent to treatment being proposed and discuss other treatment options. It’s also worth informing patients that they can bring a support person, such as a friend or relative, into the treatment room with them if that would make them feel more comfortable.

    Talking while treating

    Being a personable and friendly health professional can be beneficial in terms of building relationships with patients, but it can also have its downside. While having non-treatment related chats with a patient during treatment is acceptable, there will be occasions when the chatting should cease so further information about treatment can be discussed. It’s far too easy to forget what has and hasn’t been explained, and consented to, when continually chatting during treatment.

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    You said what? Appropriate conversations in Chinese medicine

    Complaints of wrongdoing against Chinese medicine practitioners and acupuncturists aren’t always about the treatment provided or the clinical outcome. Guild Insurance sees numerous cases annually which related to professional behaviour and conduct. This sort of complaint may initially seem less serious than those relating to poor clinical outcomes, however, having your professional conduct questioned and issues raised about inappropriate behaviour towards patients can be incredibly distressing.

    Some of these professional conduct complaints relate to conversations, both during and outside of the consultation. Once investigated, it’s usually found that the practitioner in no way intended to breach any professional boundaries or make the patient feel uncomfortable. However, this is what’s occurred. The information below has been created to help practitioners understand what they should be doing and saying differently to avoid facing complaints similar to the following examples.

    Examples of inappropriate conversations

    • A patient complained alleging the practitioner made them feel uncomfortable by asking questions about them moving in with their partner. The practitioner claimed it was only intended to be a friendly chat during treatment, however the patient felt judged when the practitioner made a comment about them living with their partner while not married.
    • A patient complained of feeling uncomfortable as the practitioner lowered the patient’s pants during treatment without consent. Following investigation, it was found the treatment provided and lowering the patient’s pants was, in this instance, clinically justified. However, distracted by a chat they were having about weekend activities, the practitioner forgot to continually talk to the patient about treatment and didn’t seek the patient’s informed consent before moving their clothing.
    • A patient complained about questions the practitioner asked about dating. The practitioner claimed the conversation was just intended as a friendly chat; however, the patient felt the practitioner was trying to initiate an intimate relationship.

    Tips about professional conversations

    Don’t become too friendly with your patients.

    While it’s clinically beneficial to build a rapport with patients, professional boundaries need to be maintained. And this means there are conversations you would have with a friend or family member that you shouldn’t have with a patient. Conversations should be had in a professional manner to avoid becoming too casual, relaxed, or jokey when talking to patients. Often comments made in light humour, or to build rapport, can lead to difficult situations and potentially embarrassing accusations or reputation damaging conditions on your registration. What may be funny to you may not be to someone else. The relationship with a patient should always remain a professional one; keeping in mind the patient is paying for a healthcare consultation, not a social conversation.

    Limit non-professional or non-treatment related conversations.

    These types of conversations can easily complicate and confuse a professional situation. When a practitioner asks personal questions of their patient, this is most likely intended to just be a friendly chat. However, patients often report being confused and uncomfortable and don’t understand why they’re being asked questions not related to treatment. While some conversations may be fine, such as asking how a person’s weekend was, things can easily change when more questions are asked, such as about the partner they spent the weekend with.

    Explain to patients why questions are being asked.

    If you need to ask some personal or lifestyle questions to assist with history taking or to better understand an injury or pain, be careful to explain why you’re asking. This is particularly important when asking about partners, sexual activity, or sensitive body parts.

    Don’t forget to keep talking about treatment.

    When non-treatment related discussions are had, this detracts from time that should be spent discussing treatment. The discussion about treatment shouldn’t just be had at the beginning of the consultation, it’s an ongoing conversation throughout. Not only can chats about something other than treatment make a patient feel uncomfortable, but they may also mean the patient isn’t fully informed about their treatment.

    Consider the situation of the patient during a conversation.

    During treatment, patients are often sitting or lying in positions which may make them feel vulnerable or exposed, particularly if they aren’t fully clothed. Personal conversations had during this time are likely to compound the uncomfortable feeling. It doesn’t mean to say that when the patient is fully clothed sitting at your desk it will be okay to ask about a personal matter. However, keep in mind that a patient could easily misinterpret the intentions behind your questions or conversation, if they’re already feeling uneasy.

    Consider the method of communication.

    SMS, email, and other forms of electronic communication encourage brief messages and don’t often adequately convey the full intent or tone of the message. Therefore, if communicating in this way, practitioners need to be mindful that patients may easily misinterpret the message and make assumptions. Also, don’t forget that electronic communication, as with all communication with a patient, needs to form part of the clinical record.

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