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‘Belligerent’ patient not an excuse for unprofessional behaviour

By Lonny Rosen & Elyse Sunshine

The Inquiries, Complaints and Reports Committee (ICRC) of the College of Physicians and Surgeons of Ontario required a gastroenterologist to attend at the College to be cautioned in person about his unprofessional behaviour and communication with patients, specifically for his failure to obtain consent from a patient before conducting a procedure. The doctor applied to the Health Professions Appeal and Review Board (the Board) for a review of the decision, and the Board concluded that the decision was reasonable.

Background facts  

The complainant patient was referred by his family physician to the gastroenterologist for investigation and treatment of a distended abdomen. The patient asked the doctor to “take it easy” during his examination, as some areas were painful. According to the patient, the doctor told him to turn over and, without warning, commenced a digital rectal exam. The patient asked him to stop because it hurt a lot. The doctor responded: “Do you want to listen to me or not? Get out!” The patient tried to put on his clothes, but was in pain and bleeding when he left the office. The patient then complained to the College.

The doctor responded to the complaint by explaining that it was absolutely necessary for him to do the examination so he could check for a life-threatening condition. He felt that failing to perform the examination would have been grounds for reporting him to the College. The doctor also submitted that the patient acted in a manner that was belligerent, antagonistic and angry towards him. The receptionist noted that there was also a verbal altercation between the patient and the doctor before the examination and the doctor told her, “I guess I lost my patience.”

ICRC decision

The ICRC was “extremely troubled” by this case, noting that the College’s Policy on Consent to Medical Treatment requires that there be clear communication with a patient when a procedure is going to be performed. Consent must be provided and documented. The doctor’s notes did not refer to the issue of consent nor any discussion related to the procedure.

ICRC was also concerned that the doctor had been the subject of several previous complaints to the College, and ultimately concluded that the doctor should attend in person to be cautioned.

The Board’s decision

When reviewing a decision of the ICRC, the standard of review is one of “reasonableness.” The question is whether the ICRC’s decision could reasonably be supported by the information provided and can withstand a somewhat probing examination. The Board panel hearing the review had to consider whether the decision fell within a range of possible, acceptable outcomes that were defensible in respect of the facts and law.

The Board noted that the issue was not about the appropriateness of the procedure performed by the doctor but rather whether he performed it in a professional manner and whether the doctor obtained the necessary consent. These were different questions, and raised different issues, than what the doctor raised at the hearing of the review. In other words, the doctor addressed the necessity of the procedure, but not the professionalism issues raised in the complaint. The Board concluded that the ICRC’s decision to have the doctor attend to be cautioned was supported by the available information and was reasonable:

There is very little of the background information in dispute . . . The fact that a patient, in the words of the [doctor], is belligerent, antagonistic and angry, does not change the obligation of a physician to deal with all individuals, including difficult ones, in a professional manner. Nor does such an attitude on the part of a patient affect a physician’s obligation to obtain informed consent prior to undertaking treatment in accordance with College policies. (para.41)

Conclusion

While having a difficult patient can be extremely taxing, it is important for all health professionals to remember and to adhere to their professional duties and obligations and the necessity of obtaining consent, regardless of the patient’s behaviour. Clear communication and a professional manner can often alleviate many difficult situations in the health professional-patient relationship, but where an interaction becomes heated or uncomfortable, absolute professionalism and careful documentation is required.

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