"I need a general physical" in the urgent care center

[salud23]

Hello Colleagues,

I'm EM residency trained and ABEM boarded. I have no primary care training. One of my current gigs is at an urgent care center. Some of the people who work here are IM or FM trained, but others are EM trained. Here is my problem. Patients come in asking for their "general physical" or "annual physical". It seems to me that a doctor who is giving an annual physical also needs to know something about which screening labs to order, and should be providing some kind of anticipatory guidance and should be screening for chronic disease. None of these things were part of my residency training. I've provided these patients with referrals to primary care in the community, only to have them get mad because supposedly they have been told that they can come to the urgent care center and get an annual physical. One of the higher-ups told me that, "We do annual physicals here." He also said that, "We're their doctor now because they can't get timely appointments." I explained that claiming I'm doing annual physicals isn't in my scope of practice, wasn't in my residency training, and is not something I have been trained to do. He told me to just do an exam and order some labs. Since I spent too much time earning my license and board certification, and I believe I'd be putting them at risk by claiming I'm doing an "annual physical", I decided that to pass on that suggestion/command.

Some of my primary care colleagues who are working in this urgent care center know exactly what to order and what to do for patients who say they need a checkup or annual physical, because they did this stuff in residency. Others refuse to do it because they don't believe that urgent care is the right setting to be doing primary care. I continue to refuse (and get static for it) to allow anyone to even think I'll do an "annual physical" because I was not trained on health maintenance and disease prevention, which is the point of an annual exam. Instead, as an EM physician, I'm trained on sick vs not sick, emergency vs non-emergency, rule out the life threat if one is present, and send to clinic anything I can't fix here right now. What do you all think about urgent care centers trying to force emergency medicine trained physicians to tell patients that we do annual physicals?

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[Franzd'Epinay]

In my experience, it is rare that the sort of person who cares to have an annual physical does not care to establish care with a real PCP. Often these patients have some other motive behind the visit. I don't mean anything nefarious, but stuff like "I need a physical to start college", "I just moved and need a new script for my antihypertensives", "I need a return-to-work form", "I need a clearance before my arthroscopic surgery", or "I need a clearance prior to my amateur MMA fight".

I do agree with you that regular annual physicals are not generally in our wheelhouse. Maybe perusing some AAFP guidelines might give you a decent starting point if you have to see these patients (coupled with your current strong suggestion to steer these patients to real PCPs).

 

[salud23]

In my experience, it is rare that the sort of person who cares to have an annual physical does not care to establish care with a real PCP. Often these patients have some other motive behind the visit. I don't mean anything nefarious, but stuff like "I need a physical to start college", "I just moved and new a new script for my antihypertensives", "I need a return-to-work form", "I need a clearance before my arthroscopic surgery", or "I need a clearance prior to my amateur MMA fight".

I do agree with you that regular annual physicals are not generally in our wheelhouse. Maybeperusing some AAFP guidelines might give you a decent starting point if you have to see these patients (coupled with your current strong suggestion to steer these patients to real PCPs).

Sometimes I've asked persons why they came to urgent care for a general physical. Some say it's because they cannot get a timely appointment with a local doctor. There is some truth to this; in Sept 2022, when I was trying to make an appointment for a routine physical for my child, the center where I take him said they didn't have any appointments until November, but they would not schedule a November appointment in September. They told me to call back the first Monday in November, which I did. I then had to call about six or seven times before somebody picked up the phone. They said the scheduler wasn't in yet and I had to call back later; because this was done on a day off, I could keep calling back until I finally got him a visit scheduled. This is not unique to where my child goes for primary care. I live in an urban area and this is a common problem; I've experienced it trying to make my own appointments, and patients say they are coming to urgent care because of similar results when they tried to make their own appointments. As a matter of convenience, people then decide to come to either the ER or urgent care center, expecting us to take care of their primary care needs.

You are right that others are coming in for clearance physicals for various reasons, but usually they tell us this up front. There is a significant cohort of people who really are coming for primary care. They often say they have had no primary care for years (one guy said he hadn't seen anyone for 20 years) and they are ready to "get checked out". The risk of not doing a sufficiently comprehensive exam is significant, as I didn't train to do this during residency. Even if I guessed all the right tests to order, there would need to be an organized way to keep a list of EACH test, AND make sure the patient is aware of each result when they return. I don't work here every week (let alone every month) and don't really care to be responsible for looking for people telling them that this test result or that one needs some sort of follow up from somebody plans to see them on an ongoing basis.

Do you see any potentially adverse situations arising from an ER doc trying to play primary care doctor for these patients?

 

[TeddyBoomBoom]

No F’ing way I’m signing off on a “general physical” in an urgent care.

Not my training. No follow up.

Can you imaging meemaw/peepaw gets some sort of weird cancer at 70 and you get blamed bc you didn’t order some weird cancer antigen marker at the 65 yr UC “physical”?

Or gets pneumonia bc you didn’t order the right pneumonia vaccine”?

Etc etc


Nope nope nope

 

[pkwraith]

You can likely get lucky just doing this on young health people (who don't actually need physicals or exams), at least until you get unlucky. I can probably sort of get in some sort of ballpark just based on medical school, residency cross exposure and looking through guidelines and literally referring patients to specialists for things that a primary care doctor should be able to handle.

What are you going to do when you palpate a thyroid nodule? US for everyone? TSH for everyone? ENT referral for everyone?
What happens when you do a breast exam and find a painless nodule? Do you know when to get an US or mammography based on age and other factors or just monitor?
Someone is due for a pap smear now according to USPSTF?
And disability forms...

 

[salud23]

No F’ing way I’m signing off on a “general physical” in an urgent care.

Not my training. No follow up.

Can you imaging meemaw/peepaw gets some sort of weird cancer at 70 and you get blamed bc you didn’t order some weird cancer antigen marker at the 65 yr UC “physical”?

Or gets pneumonia bc you didn’t order the right pneumonia vaccine”?

Etc etc


Nope nope nope

Great point. I will keep your words in mind the next time I have to hear it from a higher up that somebody complained because I referred them to a community health center and told them that I personally cannot do an annual physical for them.

 

[salud23]

You can likely get lucky just doing this on young health people (who don't actually need physicals or exams), at least until you get unlucky. I can probably sort of get in some sort of ballpark just based on medical school, residency cross exposure and looking through guidelines and literally referring patients to specialists for things that a primary care doctor should be able to handle.

What are you going to do when you palpate a thyroid nodule? US for everyone? TSH for everyone? ENT referral for everyone?
What happens when you do a breast exam and find a painless nodule? Do you know when to get an US or mammography based on age and other factors or just monitor?
Someone is due for a pap smear now according to USPSTF?
And disability forms...

I agree with your comments. I remember pointing out some of these women's health issues are supposed to be part of an annual exam, and that I am not boarded in a specialty where we routinely check these things. The higher up acted like I was just being difficult, but I couldn't see why I should risk my license and somebody else's long term health just for the sake of getting a good patient satisfaction score for the encounter.

And no, I have absolutely NO idea of when to get US or mammography, nor do I know when to start screening overweight 20 year olds for metabolic syndrome or prediabetes/diabetes. These discussions with those whose bonuses depend on my getting good patient satisfaction scores tend to end with them ignoring my concerns when I express them, but I'm glad to see I'm not the only EM trained doc who believes that primary care exams should be done by primary care docs.

 

[GonnaBeADoc2222]

They are pressuring to do this because they want money.

They dont care what you're boarded in or what your expertise is. They view you as a billing generator.

I would start making moves to exit this place, or at least prepare to leave in the likely case the environment gets worse.

 

[RustedFox]

I agree with your comments. I remember pointing out some of these women's health issues are supposed to be part of an annual exam, and that I am not boarded in a specialty where we routinely check these things. The higher up acted like I was just being difficult, but I couldn't see why I should risk my license and somebody else's long term health just for the sake of getting a good patient satisfaction score for the encounter.

And no, I have absolutely NO idea of when to get US or mammography, nor do I know when to start screening overweight 20 year olds for metabolic syndrome or prediabetes/diabetes. These discussions with those whose bonuses depend on my getting good patient satisfaction scores tend to end with them ignoring my concerns when I express them, but I'm glad to see I'm not the only EM trained doc who believes that primary care exams should be done by primary care docs.

Puh-lease. All you need is 500 hours of shadowing and an NP degree, and you can do anything, in any field.

 

[forchinet121]

If you want to lose your license this is a great idea, otherwise he’ll no

 

[VA Hopeful Dr]

In my experience, it is rare that the sort of person who cares to have an annual physical does not care to establish care with a real PCP. Often these patients have some other motive behind the visit. I don't mean anything nefarious, but stuff like "I need a physical to start college", "I just moved and need a new script for my antihypertensives", "I need a return-to-work form", "I need a clearance before my arthroscopic surgery", or "I need a clearance prior to my amateur MMA fight".

I do agree with you that regular annual physicals are not generally in our wheelhouse. Maybe perusing some AAFP guidelines might give you a decent starting point if you have to see these patients (coupled with your current strong suggestion to steer these patients to real PCPs).

The AAFP doesn't recommend the head-to-toe annual physicals anymore, going for more of what's called Targeted Screening. If you're going to do this, you 100% must be up to date on USPSTF screenings.

 

[bravotwozero]

Do you see any potentially adverse situations arising from an ER doc trying to play primary care doctor for these patients?

Lol, is this a rhetorical question? I sure hope it is

 

[Mount Asclepius]

Urgent care. Where medicine goes to die.

It exists because of systems’ failures and monetary gain.

Primary care is in the purview of primary care physicians.

Emergency physicians should practice emergency medicine.

 

[medninja]

I’m maybe the longest lurker, non-poster, to have ever seen existed. Well, better late than never, I think this stuff is pretty low risk. We’re not trained to do annual physicals, but my residency also didn’t train me to do EM. I learned it on the job, a high risk job, unlike UC. Just keep doing what you’ve always done and expand your practice. We’re all going to have to with the burgeoning of residencies even worse than mine, a well established long running chimera of excellency.

 

[thegenius]

Hello Colleagues,

I'm EM residency trained and ABEM boarded. I have no primary care training. One of my current gigs is at an urgent care center. Some of the people who work here are IM or FM trained, but others are EM trained. Here is my problem. Patients come in asking for their "general physical" or "annual physical". It seems to me that a doctor who is giving an annual physical also needs to know something about which screening labs to order, and should be providing some kind of anticipatory guidance and should be screening for chronic disease. None of these things were part of my residency training. I've provided these patients with referrals to primary care in the community, only to have them get mad because supposedly they have been told that they can come to the urgent care center and get an annual physical. One of the higher-ups told me that, "We do annual physicals here." He also said that, "We're their doctor now because they can't get timely appointments." I explained that claiming I'm doing annual physicals isn't in my scope of practice, wasn't in my residency training, and is not something I have been trained to do. He told me to just do an exam and order some labs. Since I spent too much time earning my license and board certification, and I believe I'd be putting them at risk by claiming I'm doing an "annual physical", I decided that to pass on that suggestion/command.

Some of my primary care colleagues who are working in this urgent care center know exactly what to order and what to do for patients who say they need a checkup or annual physical, because they did this stuff in residency. Others refuse to do it because they don't believe that urgent care is the right setting to be doing primary care. I continue to refuse (and get static for it) to allow anyone to even think I'll do an "annual physical" because I was not trained on health maintenance and disease prevention, which is the point of an annual exam. Instead, as an EM physician, I'm trained on sick vs not sick, emergency vs non-emergency, rule out the life threat if one is present, and send to clinic anything I can't fix here right now. What do you all think about urgent care centers trying to force emergency medicine trained physicians to tell patients that we do annual physicals?

I dunno man. You are going to have to work this out with your boss. If you don't want to see annual physicals, then maybe you pass them off to someone else, tell them to come back in later, or not work there.

I do agree that ER trained docs have no formal training in annual physicals.

 

[thegenius]

Sometimes I've asked persons why they came to urgent care for a general physical. Some say it's because they cannot get a timely appointment with a local doctor. There is some truth to this; in Sept 2022, when I was trying to make an appointment for a routine physical for my child, the center where I take him said they didn't have any appointments until November, but they would not schedule a November appointment in September. They told me to call back the first Monday in November, which I did. I then had to call about six or seven times before somebody picked up the phone. They said the scheduler wasn't in yet and I had to call back later; because this was done on a day off, I could keep calling back until I finally got him a visit scheduled. This is not unique to where my child goes for primary care. I live in an urban area and this is a common problem; I've experienced it trying to make my own appointments, and patients say they are coming to urgent care because of similar results when they tried to make their own appointments. As a matter of convenience, people then decide to come to either the ER or urgent care center, expecting us to take care of their primary care needs.

You are right that others are coming in for clearance physicals for various reasons, but usually they tell us this up front. There is a significant cohort of people who really are coming for primary care. They often say they have had no primary care for years (one guy said he hadn't seen anyone for 20 years) and they are ready to "get checked out". The risk of not doing a sufficiently comprehensive exam is significant, as I didn't train to do this during residency. Even if I guessed all the right tests to order, there would need to be an organized way to keep a list of EACH test, AND make sure the patient is aware of each result when they return. I don't work here every week (let alone every month) and don't really care to be responsible for looking for people telling them that this test result or that one needs some sort of follow up from somebody plans to see them on an ongoing basis.

Do you see any potentially adverse situations arising from an ER doc trying to play primary care doctor for these patients?

Adverse outcomes? Probably not unless they are like > 60 years old. But not for the 18-40 crowd. Malpractice? Yes. It is malpractice (at least in spirit). But whether there is harm from this is quite low.

It does suck getting PCP's right now.

And thankfully an annual physical exam is basically worthless.

 

[GonnaBeADoc2222]

I’m maybe the longest lurker, non-poster, to have ever seen existed. Well, better late than never, I think this stuff is pretty low risk. We’re not trained to do annual physicals, but my residency also didn’t train me to do EM. I learned it on the job, a high risk job, unlike UC. Just keep doing what you’ve always done and expand your practice. We’re all going to have to with the burgeoning of residencies even worse than mine, a well established long running chimera of excellency.

This is such a terrible take.

Urgent care is for urgent care.

Preventive screening is for primary care.

Get out of here with this acquiescence to admin.

 

[ScepticSkeksis]

Bro, get a new job. This one sucks.

 

[emergentmd]

I have worked in FSER doing school physicals, UC does school physicals. Its pretty low risk.

I would never do an annual physical not because its really that high risk but its poor medicine. I am not an FM doc. I will likely not see this person again for future physicals, I will not want to call in monthly refills of meds. If they need a physical to go back to work, school, etc so be it.

But no way will I be their primary care doc.

 

[BigPikachu]

I’m a family physician who has worked in emergency departments and urgent care.

Generally, I tell patients that come in to ED or UC for a preventative healthcare consult to go see their primary care physician. ED and UC is for acute medical problems.

Having said that, if it’s not busy in ED or UC, and the patient will benefit from a comprehensive checkup, I do it and ask him to follow-up with myself or a colleague in the clinic the next week.

This is not dissimilar to an approach for the inverse case where patients present to community or outpatient clinics with acute medical issues that really should have gone straight to ED or UC.

 

[EctopicFetus]

I think UC is fine for this. Seems this is the sort of stuff most of them advertise around me. "school physicals" and such. If you advertise for this then you should do it. I do think this is in the scope of UC but not EM.

 

[Dr Mantis Toboggan]

I think UC is fine for this. Seems this is the sort of stuff most of them advertise around me. "school physicals" and such. If you advertise for this then you should do it. I do think this is in the scope of UC but not EM.

In my state the school physical is just a checklist. Any intern could run down it easily.

 

[VenusinFurs]

I'm FM and I think especially if the patient is over 40 and has come in looking for an "annual physical" and not like a work clearance or sports physical (I'm not sure how comfortable you are with those sorts of things) you absolutely should not do it. This is also really not an appropriate urgent care visit though I understand you can't really gatekeep those in the year of our lord 2023, where medicine is basically a dying supernova star.

 

[VenusinFurs]

I think you should tell your admin to blow it out their ass and get a job at a different UC