Could your doctor give you the pink slip?

Marriages sometimes end in divorce. So too might the relationship between you and your doctor. While it's more common for patients to fire their GP, it may surprise you to know that your GP can do the same.

Physicians don't call it firing the patient. They refer to it as terminating or ending the doctor-patient relationship. We know that it happens from time to time. Surveys suggest that it's rare for physicians to dismiss patients from their practices. One study from Northern Ireland found that just over 6500 patients were removed from doctors' practices over a twenty-year period. It worked out to 2.43 removals for every 10,000 patients per year. The authors of the study called it a relatively rare event. For something that unusual, the topic sure seems to attract a lot of anecdotal stories posted in blogs, newspaper articles and trade magazine features aimed at physicians.

There are a myriad of reasons why doctors remove patients from their practices. Some are obvious. If a patient forges a prescription for opioids either by changing the number of tablets or patches on an existing prescription or by forging a new one from scratch that's grounds for automatic termination. It's easy and justifiable to fire the patient who is verbally abusive to the doctor and the staff. A pattern of missed appointments is also grounds for termination. That means being a no-show with the doctor, skipping tests like MRIs and booked appointments with a specialist. If you sue the doctor, or complain to the licensing body, that creates a chilly climate. Not paying a doctor's bill is a common reason but only in the U.S.

Some doctors fire patients who reject their advice and who don't fill their prescriptions, but that needs to be a pattern over time. Some doctors fire patients they find frustrating because they have chronic conditions they can't cure. Sometimes, it's a personality clash in which the doctor finds the patient challenging and argumentative. Rarely, there have been reports of physicians who try to send patients packing if they don't give up smoking.

Provincial colleges say physicians are entitled to end the doctor-patient relationship when there's a breakdown of trust and respect. Examples include forged prescriptions, threats of harm, and inappropriate behavior towards the doctor, staff or other patients. Another reasonacceptable to regulators include a conflict of interest that compromises the doctor's ability to put the patient's interests first. So is a communication breakdown that makes it impossible to provide quality care. The colleges also say that a doctor can discharge patients when his or her practice becomes too large to manage.

Then, there are unacceptable reasons - according to regulator. Both the colleges and the Canadian Medical Association Code of Ethics say physicianscannotfire a patient based on race, ancestry, place of origin, color, ethnic origin, religion, sex, sexual orientation, gender identity, marital or family status or disability. Theycan't end the doctor patient relationship should the patient refuse to follow the doctor'sadvice, or should the patient refuse to pay the annual block fee for services that some provinces permit doctors to charge.

Removal from a doctor's practices requires a very specific protocol be followed. The colleges say the doctor must have a bona fide reason for termination, and must tell the patient clearly. Ideally, it's done in person. The doctor must also write a termination letter, which is handed to the patient during the visit. If a visit can't be scheduled, the letter is sent by registered mail with signature required.

The doctor should be helpful as the patient seeks a new physician, but is not obligated to find you a new one. Until you find a replacement, regulators say your soon-to-be former doctor must provide ongoing care. That means renewing prescriptions and following up on abnormal lab tests and x-rays and providing urgent care. If you're being tested for a serious medical problem, the doctor needs to see it through,or refer you to another physician who can complete the work-up.

The doctor must transfer a copy of the patient's records and not charge an arm and a leg to do so. He or she must inform the office staff so they stop booking appointments. The doctor may also need to inform the patient's other health care providers, with the patient's consent.

Doesthe patient have recourse in the face of a termination? Like many things in medicine, it depends.

I know some physicians who call the patient in to discuss termination before going through the actual process. Think of it as two or three strikes and you're out. One doctor told me she hands the patient a draft termination letter and uses it to get the patient's attention. At that stage, it's still possible to set terms to continue. If you get an actual termination letter, it's probably too late. You can contact the college for advice, as some may help try and mediate a reconciliation.

However, if you contact the college to complain about the termination, the college is obliged to process and investigate the complaint, which will sour the relationship even further. At the end of the day, you may need todecide if you want to keep a physician who hands you a pink slip.

I doubt I would.