Don't practise without a formal written agreement

The College receives numerous distress calls from physicians in the midst of crumbling practice arrangements. There are many variations. Sometimes it is long-term associates seeking to leave. It may be a clinic medical director or group feeling abandoned and abused by the conduct of a departing colleague. Increasingly, it is physicians in novel arrangements with other organizations such as university student health services, hospitals, a provincial health services provider, or non-physician owners of a primary care clinic. As the crisis unfolds, the College too often becomes unproductively embroiled in the dispute. The College has neither the authority nor the capacity to provide legal or mediation services.

Physicians in these difficult circumstances appropriately cite their obligation to ensure that patients are protected. The College’s first question to them is whether they took proactive steps to address these legal, professional, and ethical issues by insisting they were comprehensively covered in a written agreement or contract before seeing their first patient. In most cases, there is no agreement and nothing exists in writing. This type of situation is unacceptable and may even be characterized as unprofessional.

The College’s professional standard on Medical Records includes these statements:

  • Physicians have an ethical, professional and legal obligation to ensure that before they create a medical record they comprehensively address the issues of ownership, custody, confidentiality and enduring access for themselves and their patients.
  • The College cannot arbitrate ownership of medical records retrospectively.

Every time a physician provides a medical service to a patient, s/he takes on a bundle of obligations such as ensuring continuity of care, follow-up of reports and management of records. Physicians must ensure in advance that everyone involved in the practice arrangement (colleagues, clinic owners, EMR vendors, other professionals, administrators) is engaged in a manner that will allow physicians to fulfill their obligations to patients.

Some of these obligations are set out in the College’s Professional Standards and Guidelines, including, Medical Records, Primary Care Multi-physician Clinics, After-Hours Coverage, Conflict of Interest, Telemedicine, and Ending the Patient-Physician Relationship. Some derive from the common law duty of care. Both the College and the CMPA are available to discuss these issues, but neither has a mandate to assist with individual contracts.

For review:
Medico-legal issues to consider with individual contracts
CMPA assistance with general contracts

Physicians dealing with private business matters should seek the assistance of their personal lawyers. Although physicians may be concerned with legal costs, the consequences of failing to obtain timely legal advice may be even more expensive in the long run, as well as personally stressful. Some physicians advise that the clinical activity where the problem arose was too small to justify legal advice or a contract—a few shifts in a walk-in clinic, for example. Based on the multitude of sad stories brought to the College’s attention, it would be wise to question whether minor commitments are worth the risk. The lesson may be that a professional association too small to warrant a formal contract should be declined.

The bottom line is that every professional working relationship will end eventually, usually leaving one or more physicians significantly inconvenienced. Under section 16 of the Health Professions Act, the sole duty and object of the College is public protection. The College has a very limited role in assisting physicians in their business affairs or protecting them from each other. The College’s job is to ensure that patients are not harmed by the business decisions their physicians make.

The College urges all physicians currently practising in a setting without a contract or equivalent written agreement to take immediate steps to ensure that they have one.