A parent's demands: Making sound decisions when facing pressure from patients An article for physicians by physicians
Originally published June 2010 P1002-6-E
Physicians are not required to accede to patient expectations and demands that are medically inappropriate.
The Canadian Medical Association Code of Ethics (articles 1, 30 and 44) states that a physician should: consider first the well-being of the patient, be considerate of the family while acting in the patient’s interest, and use resources wisely. The Québec Code of Ethics for Physicians sets out similar ethical principles (articles 3, 12 and 59). The following case reveals the difficulty of balancing these obligations.
The news media were full of reports about listeriosis when a mother brought her child to a walk-in clinic. Although the child did not appear ill, the mother was anxious about possible infection. She demanded a specific blood test for her child.
Taking blood from a child can cause pain and emotional upset. Rather than simply acquiescing with the mother’s demand, the physician took a history. The history did not support the mother’s concerns, and knowing that there were no local cases, the physician attempted to alleviate the mother’s concern. The mother was not satisfied.
The physician then reviewed an e-mail the local public health department had sent only that morning in response to the concerns aroused by the media. This outlined the criteria and indications for testing, and confirmed for the physician that in the absence of clinical signs of illness, there was no need for the test the mother was requesting. The physician then returned to the examining room, shared the information she’d received from the public health agency and asked the mother for permission to examine the child to ensure there was no other reason for concern.
The mother became angry. She refused to have the child examined and threatened legal action if her demand for the blood test was not satisfied. The physician again explained that there appeared to be no indication for the specific test demanded, but again offered to examine the child to ensure proper advice. The mother accused the physician of refusing to treat her child and again threatened legal action.
The physician told the mother this breakdown in the patient-physician relationship made it impossible for him to treat the child. He offered several options including:
seeing a colleague in the same walk-in clinic
attending a different walk-in clinic
attending a hospital emergency department
The mother refused all of the options and left. She stopped at the receptionist’s desk to obtain one of the physician’s business cards. The physician made brief but adequate notes of the visit and the disagreement.
Physician faces complaint
The mother then complained to the regulatory authority (College) that the physician had refused to treat her daughter. The College sent a copy of the mother’s complaint to the physician and requested a written response and a copy of the clinical record for the visit. The physician complied with the request.
The College noted that the factual statements of the mother and the physician were consistent but the perception of the complainant differed from that of the physician. However, based on the information available including the documentation from the visit, the College concluded that the physician had acted quite appropriately in reviewing the available literature on the subject, being aware of the current status of the disease in question, and attempting to give the patient (the child) an adequate assessment and offering several other options to address the mother’s concerns.
The College investigation concluded that the physician’s medical care had been fully appropriate.
Here is what the College considered this doctor did correctly:
An adequate and appropriate history was taken.
When the physician’s assessment was at odds with that of the mother, the physician took the time to review recent information and confirm the recommended approach.
The physician explained the reasons for not acquiescing with the mother’s demands. When it was clear the mother did not accept the advice being given, the physician gave several reasonable options.
At the conclusion of the interaction, the physician documented the events clearly.
The physician’s response to the College was factual, measured and professional.
The bottom line
Although some patients may have expectations or even demands that are medically inappropriate and may complain to the College, physicians are not required to accede to patient demands that are medically unnecessary. Should the patient lodge a complaint, the College will generally expect the physician to have provided sound medical advice in a professional way.
College complaints can have serious outcomes and can foreshadow additional medico-legal difficulties. If your College has notified you that it has received a complaint, contact the CMPA.
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