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December 3, 2009

Formation of the Physician-Patient Relationship: The Oregon Court of Appeals Clarifies, but Questions Remain

December 3, 2009

When is the physician-patient relationship formed? In the modern era of telephonic consults and remote records review, can a relationship be formed with a physician who has never even met the patient? Oregon law has historically been limited on the question of when the relationship between physician and patient has been formed, but a recent Oregon Court of Appeals case decided on October 28, 2009, Mead v. Adler,[1] goes to the heart of the formation question. Mead clarifies that a duty of care and a physician-patient relationship exist where a physician has undertaken to diagnose, treat or prescribe. This putative expansion of physician liability where there may be some doubt whether a relationship was formed also begs the additional question: when may a physician reasonably sever ties with his or her patient?

Oregon Case Law Limited Prior to Mead v. Adler

Historically, the provider/patient relationship arose under a theory of express or implied contract.[2] A person would seek treatment from a physician, and the physician would accept the person as a patient by initially examining the patient, rendering a diagnosis or treatment – mutual consent was required. That contract-based approach, however, while still one way to assess formation of the physician-patient relationship, has essentially been overtaken by a tort-based approach focusing on the existence of a special relationship arising from the physician's actions – even in the absence of mutual consent, a meeting of the minds or other traditional indicia of a contract.[3]

Until recently, Oregon law did not address the question of when a physician-patient relationship was formed. Indeed, ORS Chapter 677[4] and the OARs make no reference at all to the formation of the physician-patient relationship. Early case law only hinted at it. In Dowell v. Mossberg, the Oregon Supreme Court noted in dicta: "Failure to exercise due care in the treatment of a patient is a breach of a legal duty which arises, not out of contract, but out of the relationship of physician and patient." [5] Probably the closest approach to articulating the elements of a physician-patient relationship in Oregon tort law was in 1985, in Sullenger v. SETCO Northwest, Inc. [6] In Sullenger, a minor child was cared for and admitted to the hospital by the patient's attending physician, who testified that he did not seek the defendant pediatrician's opinion, did not seek the defendant's consultation, and did not seek the defendant's approval of treatments being rendered.[7] Rather, the facts were that while exiting the patient's room the attending physician asked the defendant pediatrician if he would take the child's case, and the defendant pediatrician declined. These facts were unchallenged by the plaintiff. The facts showed that the defendant pediatrician did not examine the patient, review charts, review nurses notes, x-rays, or any other tests results. On this basis, the Oregon Supreme Court affirmed the defendant physician's motion for summary judgment, finding that no physician-patient relationship existed which could give rise to a duty of care.[8]

October 2009: Oregon Court of Appeals Addresses Physician-Patient Relationship in Context of On-Call Physician

Oregon's first reported case on the formation of "on-call" physician-patient relationships has now been reported in Mead v. Adler.[9] Mead decides whether a neurosurgeon formed a physician-patient relationship with the injured plaintiff when an ER physician telephoned the defendant neurosurgeon for a consult on plaintiff's low back pain. The emergency physician had ordered an MRI, the results of which led her to believe that the plaintiff was developing cauda equina, a very serious neurological condition related to a herniated lumbar disk. The ER physician and defendant disagreed about the contents of the phone conversation, but the court found the following facts undisputed: (1) defendant was the on-call neurosurgeon; (2) he took the ER physician's call and listened to a description of plaintiff's symptoms; (3) defendant felt that plaintiff did not need neurosurgical treatment; and (4) defendant thought plaintiff should be admitted by her primary physician for observation and pain management. Plaintiff's condition deteriorated over the ensuing four days, until the defendant ultimately performed surgery. Plaintiff did, indeed, have cauda equina, and suffered permanent impairment.[10]

Plaintiff filed suit against the hospital, a consulting neurologist and the neurosurgeon for medical malpractice. At trial, the plaintiff moved for a directed verdict on the issue of whether by undertaking to evaluate and diagnose, even by phone, the defendant impliedly consented to the formation of a physician-patient relationship, which thereby created a duty of due care. The trial court denied the plaintiff's motion for directed verdict and permitted the question of whether a physician-patient relationship existed to go to the jury, which then issued a verdict in favor of the defendant neurosurgeon. On appeal, the Court of Appeals reversed and remanded for a peremptory instruction to the jury that a physician-patient relationship existed as a matter of law.[11]

The Court of Appeals' reasoning is based on part on a review of Oregon case law discussing the duties arising from "special relationships," with the court concluding:
A special relationship arises out of the responsibility of one person to act on behalf of and in the best interests of the other. An implicit aspect of the special relationship is that it is consensual--the party to whom the duty is owed authorizes the party who owes that duty to exercise independent judgment on the former party's behalf, and the party who owes the duty voluntarily assumes that responsibility.[12]
Following this reasoning, and citing to a Kansas case, the Mead court found that: "In the absence of an express agreement by the physician to treat a patient, a physician's assent to a physician-patient relationship can be inferred when the physician takes affirmative action with regard to care of the patient."[13]

The Court went on to discuss the novel question under Oregon law of whether an on-call physician's advice to an emergency room physician over the telephone concerning a specific patient will give rise to a physician-patient relationship. After much review of case law from other states, the Court held:
In summary, the consensus of the jurisdictions that have considered the question is that a physician-patient relationship can arise by implied consent of the physician based on indirect contact between the physician and patient through telephone communication between a hospital emergency room physician and an on-call physician concerning the care of an emergency room patient; the pivotal inquiry is whether the on-call physician affirmatively participates in the care of the patient. That affirmative participation exists if the on-call physician undertakes to diagnose or treat the patient. *** [W]e also conclude that an on-call physician who affirmatively undertakes to diagnose or treat an emergency room patient over the telephone has impliedly consented to a physician-patient relationship for purposes of negligence liability.[14]
The advice rendered by the defendant was not "merely casual or informal advice to a colleague."[15] The defendant neurosurgeon was contacted by the ER physician because of his on-call status and the defendant rendered an opinion on the appropriate course of care. The court found the Mead facts distinguishable from the casual "curbside consult" that one physician may provide to another as a professional courtesy.[16]

Is a Physician-Patient Relationship Formed When a Physician Merely Issues an Order or Prescription without Personally Seeing the Patient?

A developing area of the law – now reinforced by the Mead case – is when a physician-patient relationship may be established even where the physician does not personally see the patient. Many jurisdictions – now including Oregon – have ruled that, if a physician is "on-call," a physician-patient relationship may exist between a patient seeking services in a hospital ED and the on-call physician. Indeed, that "special relationship" may exist even when the on-call physician refused to see the patient or was unavailable to attend the patient.[17] The Mead case, discussed above, is an example of a special relationship arising from on-call status and a consultation in the physician's on-call capacity.

Other, more fleeting physician contacts, however, may still give rise to a physician-patient relationship:
Florida: Physician on inactive courtesy staff, home sick at the time, merely permitted an acquaintance to use his name to seek admission to the hospital for emergency treatment. Court found a triable issue of fact as to whether physician "accepted" decedent as a patient, and reversed summary judgment in favor of defendant physician.[18]

Georgia: Defendant physician placed prescriptions by phone as an accommodation to plaintiff, an extended family member who subsequently developed glaucoma. Plaintiff testified that he inquired of physician concerning the eye drops and drug in question; he sought out physician's counsel and physician gave him certain advice regarding diet and fat intake. Physician testified that during his first conversation, he warned plaintiff that he did not like plaintiff using the drug and advised him to see his ophthalmologist. The appeals court found a triable question of fact as to whether a physician-patient relationship existed, which precluded summary judgment. The appeals court denied the defendant physician's petition for reconsideration and the Georgia Supreme Court denied certiorari. There is no further history in the public record, and we assume the matter was settled after remand.[19]

Georgia: A physician-patient relationship was not created where the plaintiff telephoned defendant physician, who had treated her previously for an unrelated condition, physician listened late at night to her recital of symptoms, told her she would have to wait to see him in the morning, and recommended she continue the immediate course of treatment prescribed by another physician.[20]

Pennsylvania: Sole contact between patient and physician was a telephone call in which the physician informed patient's husband of the hospital's admission policies. In accordance with the hospital's standard procedure, the physician, after ascertaining that the woman had a private physician and the private physician's diagnosis, informed the husband that she could not be admitted unless arrangements were made for admission by the private physician. The husband was then unable to re-contact the private physician or, following that attempt, to re-contact the hospital physician. The woman subsequently suffered another attack, sustaining a cerebral hemorrhage. Court affirmed summary judgment for the hospital physician and hospital, finding that no physician-patient relationship had been formed because the hospital physician did not undertake to render medical service.[21]

Texas: Doctor husband did not have physician-patient relationship with his wife on the night she died, even though he had been treating his wife for stress and anxiety for four years and had prescribed medications as recently as two months before, where wife did not seek medical care or advice or medication from her husband on the actual night of death; doctor testified that he was not acting as her physician but as her husband that night. He did not see her take any medication, and any medication she took that night was without input from him. Plaintiff estate's take-nothing judgment in negligence action against doctor husband was affirmed.[22]
There is no "majority rule" on these issues, and the Florida case above probably sets the lowest bar for formation of a physician-patient relationship.

In light of these cases, and expanding on the ruling in Mead, a reasonably coherent – and fairly conservative – rule might be stated as follows:
If a physician affirmatively undertakes to diagnose, treat or prescribe, his or her responsibility for failure to possess and use the skill and care of an ordinary physician is not dependent upon an express agreement of employment or a promise to pay for services. A duty of care and a physician-patient relationship exist where a physician has undertaken either gratuitously or for a consideration to render a medical service, no matter how slight. Mere contact with a patient or the administrative facilitation of services by another provider, however, is not enough to form a physician-patient relationship.

What constitutes patient abandonment?
A good distillation of the holdings concerning physician abandonment may be found in Am Jur 2d:
A claim for "abandonment" involves the termination of the professional relationship between the physician and the patient at an unreasonable time or without affording the patient the opportunity to procure an equally qualified replacement. It is a corollary to the physician's right to withdraw from a case upon giving proper notice that he is under a duty to continue his attendance upon the patient until all the conditions for his rightful withdrawal are complied with, and that a breach of this duty may render him liable. *** Absent good cause to the contrary, where the doctor knows or should know that a condition exists that requires further medical attention to prevent injurious consequences, the doctor must render such attention or must see to it that some other competent person does so until the termination of the physician-patient relationship.[23]
Thus, patient abandonment would generally be characterized as the breach of a duty under tort law analysis.

Oregon, not surprisingly, does not have any case law on point, nor is patient abandonment directly addressed in Oregon statute or administrative rules.[24] Other jurisdictions are instructive, however. In California, the Court of Appeals considered the matter of a physician's refusal to treat an indigent woman in labor while inquiring about her ability to pay. Because the defendant physician had initially admitted plaintiff patient to the ED and transferred her to the labor and delivery floor before inquiring on her ability to pay, he had accepted the patient for treatment and could not abandon her.[25]

In a Utah case, the defendant physician hospitalized and treated the plaintiff patient for an infected finger. Against the physician's advice, the patient left the hospital. The physician instructed the patient to return for further treatment if the infection worsened. When the infection worsened, the physician examined the patient and told him to return to the hospital. Once at the hospital, the physician refused to treat the patient because of a previously owed bill. The patient was operated on at another hospital and his finger was eventually amputated, leading to his suit for malpractice. The court found that the physician, upon undertaking the operation during the patient's second admission, was under a duty to continue his attention as long as the case required.[26]

The court found the physician's duty is to provide continuing care until the physician has properly withdrawn from the relationship. The physician's ongoing duty of care may be terminated by: (1) the cessation of the necessity which gave rise to the relationship; (2) by the discharge of the physician by the patient; or (3) by the withdrawal from the case by the physician after giving the patient reasonable notice so as to enable the patient to secure other medical attention.[27] A physician has the right to withdraw from a case, but if the case requires further medical or surgical attention, the physician must either provide care or, before withdrawing from the case, give the patient sufficient notice so the patient can procure other medical attention if the patient so desires.[28]

[1] 321 Or App 451 (2009).

[2] See 61 Am Jur 2d Physicians, Surgeons and Other Healers §130 (2008) ("The relationship of physician and patient is [formed] if the professional services of a physician are accepted by another person for the purposes of medical or surgical treatment. Because this relationship may result from an express or implied contract, the voluntary acceptance of the physician-patient relationship by the affected parties creates a prima facie presumption of a contractual relationship between them.").

[3] Id.; see also Mead, 321 Or App at 459-60. Because the Mead case is not yet published, there are no page cites.

[4] Of note, Oregon's Good Samaritan statute provides that emergency medical assistance does not, by itself, create a physician-patient relationship. ORS 30.800(3).

[5] 226 Or 173, 190 (1961) (emphasis added).

[6] 74 Or App 345 (Or 1985).

[7] Id. at 347.

[8] Id. at 348-49 ("The duty to aid another person arises out of a relationship between the actor and the other").

[9] See supra note 3.

[10] 321 Or App at 456.

[11] Id. at 456-57.

[12] Id. at 458.

[13] Id., citing to Adams v. Via Christi Regional Medical Center, 270 Kan 824, 837, 19 P3d 132, 140 (2001).

[14] Id. at 461-62 (emphasis added).

[15] Id. at 464.
[16] Id.

[17] Hiser v. Randolph, 126 Ariz. 608 (Az Ct App 1980). In Hiser, Plaintiff's decedent entered the ED in a diabetic coma and the defendant on-call physician in the ED refused to treat her, stating that she should be treated by her regular physician who had seen her in the ED the previous night. The patient died the next day. The Arizona court found that the defendant physician, by assenting to the hospital bylaws, and accepting payment from the hospital to act as the on-call emergency room doctor, personally became bound to insure that all patients treated in the emergency room receive the best possible care. Id. at 777.

[18] Giallanza v. Sands, 316 So. 2d 77 (Fla App Div 4 1975).

[19] Walker v. Jack Eckerd Corp., 209 Ga App 517, cert den (1993). 

[20] Clanton v. Von Haam, 177 Ga App 694 (1986).

[21] Fabian v. Matzko, 236 Pa Super 267 (1975).

[22] Rampel v. Wascher, 845 SW2d 918 (Tex App 1992), writ den (1993).

[23] 61 Am Jur 2d Physicians, Surgeons, and Other Healers § 218 (2008).

[24] But see Oregon's Death With Dignity Act, ORS 127.625(d): "If there is no health care representative for an incapable patient and the health care decisions are not in dispute, the health care provider shall, without abandoning the patient, either discharge the patient or make a reasonable effort to locate a different health care provider and authorize the transfer of the patient to that provider." (Emphasis added.)

[25] Hongsathavij v. Queen of Angels Etc. Medical Ctr., 62 Cal App 4th 1123, 1138 (1998) ("A physician cannot just walk away from a patient after accepting the patient for treatment. A physician cannot withdraw treatment from a patient without due notice and an ample opportunity afforded to secure the presence of another medical attendant. [Internal citation omitted]. In the absence of the patient's consent, the physician must notify the patient he is withdrawing and allow ample opportunity to secure the presence of another physician.").

[26] See Ricks v. Budge, 91 Utah 307, 314 (1937) ("The obligation of continuing attention can be terminated only by the cessation of the necessity which gave rise to the relationship, or by the discharge of the physician by the patient, or by the withdrawal from the case by the physician after giving the patient reasonable notice so as to enable the patient to secure other medical attention. A physician has the right to withdraw from a case, but if the case is such as to still require further medical or surgical attention, he must, before withdrawing from the case, give the patient sufficient notice so the patient can procure other medical attention if he desires.").

[27] Id.

[28] Id.

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