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ABANDONMENT
Many chiropractors are vaguely aware that accepting a person as a patient comes with some obligation and responsibility for that person's health and well-being. Abandonment, as a concept, got a lot of play forty years ago when the last M.D. stopped making house calls. Some people felt that their physicians had, indeed, abandoned them by refusing to come around to their home and treat them. In fact, technology had just caught up with them, and doctors knew that they could no longer offer the quality of care in a patient's home that they could give in a hospital or office, complete with all the modern tools of the medical trade. Some patients were distraught enough at losing the institution of the house call to file lawsuits, and it got some publicity. Since then, we haven't heard a lot about patient abandonment, and it is only rarely discussed.
There are, however, some other areas of practice which need to be discussed in terms of abandonment, and avoiding accusations of non compliance in this area. The general principle with which we deal here is this: until we accept a person as a patient, and the patient accepts us as his/her chiropractor, we have no obligation to them, except as a fellow human being. We owe them only what we owe any other person, e.g. fairness, courtesy and respect as an individual. The moment we accept a person as a patient, and they us, as their chiropractor, our duties to that person step up a few notches of intensity, and we are now engaged in a doctor/patient relationship, complete with new levels of obligatory ethical conduct. Some (but not all) of the elements of professional ethics are:
- maintaining objectivity and impartiality
- being duly diligent
- exercising professional responsibilities faithfully
The diligence aspect of professional ethics requires that a doctor be available to speak to a patient and consider whether or not immediate care is necessary. If not available, diligence requires that a doctor make provision for a qualified substitute to communicate with the patient and evaluate the patient's level of need and deliver necessary care.
The act of entering into this relationship may be concluded by a written terms of acceptance, a document of understanding, or more informally by a handshake, or even an implied understanding. Obviously, the recommended format these days is a written document enumerating the doctor's responsibilities, which is signed, witnessed and kept in the patient file.
Some of the areas of practice that may involve issues of abandonment are:
- after hours and weekend visits
It is advisable to discuss your policy on extraordinary care with new patients, or print it in your practice brochure. Doctors should be available to discuss the possibility of the need for care at unusual times, but need not run to the office at every patient's whim. Obviously, we should respond to a reasonable request if there is justification, but frequently, reassurance and explanation will satisfy the patient. Depending on your style of practice you may define "emergency" in different ways. If you have a wellness practice and only offer subluxation care, you may feel that there is rarely or never a
chiropractic emergency, however, if you offer condition related care, there will be many occasions where the condition dictates immediate care, day or night. Your patients may not always get the educational message you are promoting, and may request immediate service inappropriately. Whatever your response to the request, it is considered advisable to document the contact for later entry in the patient's file.
The keyword is availability. With call forwarding, call transfer, caller ID, cell phones, car phones, vibrating beepers, e-mail and fax everywhere it is difficult not to be available. Answering machines and voicemail will take a message for us, if we manage to be unavailable. The important thing is what we do with all of this availability. We should return calls promptly or make sure that someone does. If chiropractors are to be unavailable for more than a few hours, it is advised to have another D.C. cover for you and answer your calls. Old-fashioned answering services are still available, and many people prefer talking to a person, rather than a machine or computerized voice mail systems. "If you have a C-1 subluxation, press 1, if you have an L-5…."
- long weekends and extended vacations
Any deviation from normal office schedule requires some effort on the part of the doctor. A long weekend out of town will require that you make arrangements for another D.C. to cover for you, answer your calls and see your patients, if necessary. Your temporary replacement should be selected carefully, and should be a responsible and capable doctor who takes fill-in duty seriously. Short-term absences do not require on-premises fill-in service, but it's nice if you can get it. Your answering service should give your substitute's number and/
or address, or an assurance that your substitute is monitoring messages regularly. For absences of a week or more, you may wish to consider a locum tenens, a replacement doctor who works in your office and keeps your hours. For extended absences it is also advisable to notify patients in advance for planning purposes. Posting a notice at your front door and at the sign-in area for a week or two ahead of your time off is certainly helpful. If you have a regular newsletter, you would want to mention your time-off in the previous month's edition. If you have a website, posting a calendar of time off will advise patients, and prospective patients.
Closing a practice permanently or moving to another location requires a larger effort by the doctor. Notification of all current and recent past patients by mail is considered a minimum endeavor. Adequate time must be given to allow patients to pick up records for transfer to other doctors. It is not legally required that we help patients find a new chiropractor, but it is a courtesy that patients will appreciate. If a D.C. is selling the practice, a considerable part of the valuation is the expectation of many patients continuing care with the new doctor, and every attempt is usually made to assure an orderly transition. In many geographic areas, it is customary, but not generally required, that retiring doctors place a notice in the local newspaper to apprise the community of the imminent retirement.
I personally know of no chiropractor who has been sued for abandonment of a patient. Most of us don't mind the occasional after hours call, and accept the responsibility that comes with the professional license. Availability is a big part of the doctor/patient relationship, as is the obligation to make provisions for our patients when we are not available.
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