Ethics in practice. Terminating the physician-patient relationship.

A.G. is a thirty-six-year-old reading teacher who presented to an orthopaedic surgeon with patellofemoral pain. After an appropriate evaluation, the physician suggested a course of physical therapy and anti-inflammatory medication. The patient asked for and received time off from her work, stating that her job required her to climb stairs. At multiple follow-up visits, A.G. was found to be poorly compliant with physical therapy and home-exercise programs. Her only interest appeared to be in securing the doctor's letter of support for an extended medical leave. At each visit, she demanded that the physician write a letter stating that she was unable to work as a reading teacher due to knee pain. At one point, she became belligerent with the medical office staff when the letter was not prepared. When her physician tried to elicit information about whether there were any unaddressed obstacles to rehabilitation treatment, A.G. did not answer the questions. Instead, she explained that her job required her to climb stairs and that she was unable to return to work because of the continued knee pain. The physician explained that, on the basis of his examination and assessment, he expected that her pain would improve if she complied with the treatment plan. After multiple visits, the orthopaedic surgeon counseled the patient that he did not see that his attempts to help her were providing any benefit and that perhaps it would be best for her to seek help from another physician. A.G. replied that she did not want to start going to another doctor. She stated emphatically that he was her doctor, that she was paying him, and that she wanted a letter saying that she should be granted an extended medical leave from work because of her inability to climb stairs. After this encounter, the surgeon thought it best to terminate the professional relationship.