Is urgent care an appropriate place for doing general physicals?

[salud23]

Hello, I'm an emergency physician working in urgent care. Here's my question. Sometimes, patients come in saying they haven't seen a doctor in a few years and that they want "a general physical and bloodwork." Every time I hear that, I think, "Wow, that's really vague." I also realize that whenever I've gone for a general physical, it's more than just somebody listening to my heart and lungs. There is also some sort of general conversation about labs and tests; there is also some kind of anticipatory guidance. Since this is not part of the residency training in emergency medicine, I don't feel qualified to represent myself to someone as having the necessary knowledge base to do anyone's annual general physical, and refer them to primary care. Then then become enraged, and say stuff like, "A doctor is a doctor. Aren't you a doctor?" Attempts to explain that the knowledge base I acquired during an emergency medicine residency focused on looking for potential life threats, fixing/stabilizing them, giving initial treatment for non-emergencies, and then referring people to primary care. Not even the urgent care center is primary care; it's just supposed to be there for minor illnesses. Annual physicals are meant to look for disease while still in its early stages and aims to prevent disease from developing, if possible; this is one of the goals of primary care. It's made worse by the fact that some of the business/corporate owners of this urgent care place believe that if the patient wants an annual exam, the doctor should just give it to them. They also don't seem to want to understand that emergency docs aren't trained to be doing annual exams and might not now what to look for.

As my primary care colleagues, what do you all think? What are some things that you think could might go wrong if ER docs start doing "annual physicals" in urgent care centers just to keep patients and center owners happy? Thanks for your input.

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[cj_cregg]

I agree that physicals/preventive care is certainly one of the aspects of urgent care that EM does not prepare you well for, and I'm sorry you're being put in a position to manage that. You are absolutely right that a good annual physical that is best for our patients is more than just a literal physical exam (and in fact, that's probably the least important part of it). Certainly you could look up USPSTF, CDC, or specialty organization guidelines to figure out who needs what when with regards to screenings and vaccines and such, but that still opens a whole can of worms. Do you have vaccines on site for the ones people commonly need (childhood vaccines, shingles, pneumonia, tdap...)? If somebody has a weird something on a mammogram you ordered, are you supposed to be the person to follow up on that? If you find a new diagnosis like diabetes because you got a screening A1c, are you going to manage that long term? Are you expected to start chronic medications for those patients? Is your employer going to provide training to document, code, and bill for these services appropriately so you and your employer get paid fairly for the work you did? Are you going to be doing Medicare wellness visits (which is a whole other mess when it comes to documentation and billing)? Do you have consistent access to prior records of screening/vaccines/etc for patients to even know when they're due for stuff? If you start doing preventive care stuff, are you/your employer now going to be evaluated/paid based on quality metrics by insurance companies that are trending towards value based care?

I don't think it would be impossible to do wellness visits in an urgent care depending on the physicians and practice setup, but you do need to have a good answer to all of the above questions and more if you're going to do it right. Unfortunately it sounds like your employer doesn't know what they don't know and are putting you in that position as well. Are there any FM, IM, or peds docs working in your practice that can advocate against this as well, or at least advocate for it to be implemented in a way that makes more sense?

 

[VA Hopeful Dr]

Cross posted in EM, closing this one.