Medicolegal Issues

The end of the line: Concluding your practice when facing serious illness

Current Psychiatry. 2017 December;16(12):42-47

References

1. LoboPrabhu SM, Molinari VA, Hamilton JD, et al. The aging physician with cognitive impairment: approaches to oversight, prevention, and remediation. Am J Geriatr Psychiatry. 2009;17(6):445-454.
2. Dellinger EP, Pellegrini CA, Gallagher TH. The aging physician and the medical profession: a review. JAMA Surg. 2017;152(10):967-971.
3. Dall T, West T, Chakrabarti R, et al. The complexities of physician supply and demand: projections from 2014 to 2025. Association of American Medical Colleges. https://www.aamc.org/download/458082/data/2016_complexities_of_supply_and_demand_projections.pdf. Published 2016. Accessed September 26, 2017.
4. Draper B, Winfield S, Luscombe G. The older psychiatrist and retirement. Int J Geriatr Psychiatry. 1997;12(2):233-239.
5. Merenstein B, Merenstein J. Patient reflections: saying good-bye to a retiring family doctor. J Am Board Fam Med. 2008;21(5):461-465.
6. Lord R, Ritvo S, Solnit AJ. Patients’ reactions to the death of the psychoanalyst. Intern J Psychoanal. 1978;59(2-3):189-197.
7. Power A. Forced endings in psychotherapy and psychoanalysis: attachment and loss in retirement. New York, NY: Routledge; 2016.
8. Robutti A. When the patient loses his/her analyst. Italian Psychoanalytic Annual. 2010;4:129-145.
9. Traesdal T. When the analyst dies: dealing with the aftermath. J Am Psychoanal Assoc. 2005;53(4):1235-1255.
10. Deutsch RA. A voice lost, a voice found: after the death of the analyst. In: Deutsch RA, ed. Traumatic ruptures: abandonment and betrayal in the analytic relationship. New York, NY: Routledge; 2014:32-45.
11. Ward VP. On Yoda, trouble, and transformation: the cultural context of therapy and supervision. Contemp Fam Ther. 2009;31(3):171-176.
12. Moffic HS. Mental bootcamp: today is the first day of your retirement! Psychiatr Times. http://www.psychiatrictimes.com/blogs/couch-crisis/mental-bootcamp-today-first-day-your-retirement. Published June 25, 2012. Accessed October 31, 2017.
13. Shatsky P. Everything ends: identity and the therapist’s retirement. Clin Soc Work J. 2016;44(2):143-149.
14. Collier R. The challenges of physician retirement. CMAJ. 2017;189(2):E90-E91.
15. Onyura B, Bohnen J, Wasylenki D, et al. Reimagining the self at late-career transitions: how identity threat influences academic physicians’ retirement considerations. Acad Med. 2015;90(6):794-801.
16. Silver MP. Critical reflection on physician retirement. Can Fam Physician. 2016;62(10):783-784.
17. Clemens NA. A psychiatrist retires: an oxymoron? J Psychiatr Pract. 2011;17(5):351-354.
18. Packard FR. The earliest hospitals. In: Packard FR. History of medicine in the United States. Philadelphia, PA: Lippincott; 1901:348.
19. Galatzer-Levy RM. The death of the analyst: patients whose previous analyst died while they were in treatment. J Amer Psychoanalytic Assoc. 2004;52(4):999-1024.
20. Fajardo B. Life-threatening illness in the analyst. J Am Psychoanal Assoc. 2001;49(2):569-586.
21. Dewald PA. Serious illness in the analyst: transference, countertransference, and reality responses. J Am Psychoanal Assoc. 1982;30(2):347-363.
22. Howe E. Should psychiatrists self disclose? Innov Clin Neurosci. 2011;8(12):14-17.
23. Rizq R, Voller D. ‘Who is the third who walks always beside you?’ On the death of a psychoanalyst. Psychodyn Pract. 2013;19(2):143-167.
24. Babitsky S, Mangraviti JJ. The biggest legal mistakes physicians make—and how to avoid them. Falmouth, MA: SEAK, Inc.; 2005.
25. Armon BD, Bayus K. Legal considerations when making a practice change. Chest. 2014;146(1):215-219.
26. American Medical Association. Opinions on patient-physician relationships: 1.1.5 terminating a patient-physician relationship. https://www.ama-assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-1.pdf. Published 2016. Accessed September 29, 2017.
27. Lee v Dewbre, 362 S.W. 2d 900 (Tex Civ App 7th Dist 1962).
28. Medical Association of Georgia. Issues for the retiring physician. https://www.mag.org/georgia/uploadedfiles/issues-retiring-physicians.pdf. Accessed October 1, 2017.
29. Massachusetts Medical Society. Issues for the retiring physician. http://www.massmed.org/physicians/practice-management/practice-ownership-and-operations/issues-for-the-retiring-physician-(pdf). Published 2012. Accessed October 1, 2017.
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31. 243 Code of Mass. Regulations §2.06(4)(a).
32. Sampson K. Physician’s guide to closing a practice. Maine Medical Association. https://www.mainemed.com/sites/default/files/content/Closing%20Practice%20Guide%20FINAL%206.2014.pdf. Published 2014. Accessed October 1, 2017.
33. HealthIT.gov. State medical record laws: minimum medical record retention periods for records held by medical doctors and hospitals. https://www.healthit.gov/sites/default/files/appa7-1.pdf. Accessed September 29, 2017.
34. 45 CFR §164.316(b)(2).
35. 42 CFR §422.504(d)(2)(iii).
36. Pope KS, Vasquez MJT. How to survive and thrive as a therapist: information, ideas, and resources for psychologists in practice. Washington, DC: American Psychological Association; 2005.
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39. Frankel AS, Alban A. Professional wills: protecting patients, family members and colleagues. The Steve Frankel Group. https://www.sfrankelgroup.com/professional-wills.html. Accessed October 31, 2017.

Legal obligations

Retirement does not end a physician’s professional legal obligations.²⁴ The legal rules and duties for psychiatrists who leave their practices are similar to those that apply to other physicians. Mishandling these aspects of retirement can result in various legal, licensure-related, or economic consequences, depending on your circumstances and employment arrangements.

Employment contracts in hospital or group practices often require notice of impending departures. If applicable to Dr. F’s situation, failure to comply with such conditions may lead to forfeiture of buyout payments, paying for malpractice tail coverage, or lawsuits claiming violation of contractual agreements.²⁵

Retirement also creates practical and legal responsibilities to patients that are separate from the interpersonal and emotional issues previously discussed. How will those who need ongoing care and coverage be cared for? When withdrawing from a patient’s care (because of retirement or other reasons), a physician should give the patient enough advance notice to set up satisfactory treatment arrangements elsewhere and should facilitate transfer of the patient’s care, if appropriate.²⁶ Failure to meet this ethical obligation may lead to a malpractice action alleging abandonment, which is defined as “the unilateral severance of the professional relationship … without reasonable notice at a time when there is still the necessity of continuing medical attention.”²⁷

Further obligations come from medical licensing boards, which, in many states, have established time frames and specific procedures for informing patients and the public when a physician is leaving practice. Table 1^24,28-31 lists examples of these. If Dr. F works in a state where the board hasn’t promulgated such regulations, Table 1^24,28-31 may still help him think through how to discharge his ethical responsibilities to notify patients, colleagues, and business entities that he is ending his practice. References 28-30 and 32 discuss several of these matters, suggest timetables for various steps of a practice closure, and provide sample letters for notifying patients.

Physicians also must preserve their medical records for a certain period after they retire. States with rules on this matter require record preservation for 5 to 10 years or until 2 or 3 years after minor patients reach the age of majority.³³ The Health Insurance Portability and Accountability Act of 1996 requires covered entities, which include most psychiatrists, to retain records for 6 years,³⁴ and certain Medicare programs require retention for 10 years.³⁵

Depending on Dr. F’s location and type of practice, his records should be preserved for the longest period that applies. If he is leaving a group practice that owns the records, arranging for this should be easy. If leaving an independent practice, he may need to ask another practice to perform this function.²⁵

A ‘professional will’

Dr. F also might consider a measure that many psychotherapists recommend^13,19,36 and that in some states is required by mental health licensing boards or professional codes^37,38: creating a “professional will” that contains instructions for handling practice matters in case of death or disability.³⁹

Table 2^36,39 lists topics that a psychiatrist’s professional will might cover. If Dr. F creates such a document, he should let office personnel and a close family member (eg, his spouse) know that it exists so they can see that it’s implemented, if necessary. Dr. F also may wish to get one or more colleagues to agree to implement the document’s provisions and let those colleagues know where to find the practice details they’ll need—for example, where Dr. F has stored a sealed list that contains patients’ names and contact information.^19,36

Bottom Line

Continuing to practice psychiatry while having a serious or terminal illness poses additional emotional, ethical, and legal challenges beyond those faced by healthy physicians. Psychiatrists whose physical conditions threaten their ability to continue working should think carefully about how they will prepare their patients, colleagues, office staff, and themselves for leaving practice.

Related Resources

Butcher T. Closing a medical practice, part 1. Healthcare Law Blog. https://www.healthcarelaw-blog.com/2016/11/closing-practice-part-1.html.
Butcher T. Closing a medical practice, part 2. Healthcare Law Blog. https://www.healthcarelaw-blog.com/2016/12/closing-medical-practice-part-2.html.
Medical Mutual Insurance Company of Maine. Closing your practice – retirement - relocation - selling your practice. https://www.medicalmutual.com/risk/practice-tips/tip/closing-your-practice-retirement-relocation-selling-your-practice/44.
Steiner A. The empty chair: making our absence less traumatic for everyone. Psychotherapy.net. https://psychotherapy.net/article/psychotherapist-retirement#section-blueprint-for-therapeutic-continuity.

Acknowledgment

The author thanks Christopher P. Marett, MD, MPH, for his helpful comments on the preparation of this article.

The end of the line: Concluding your practice when facing serious illness

References

Legal obligations

A ‘professional will’

Bottom Line

Pages

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