In brief
- Review key elements of the patient’s medical record before establishing a diagnosis.
- Support continuity of patient care, which includes documenting each patient visit in the medical record.
- Be familiar with and follow established processes at the clinic for patient follow-up and effective communication among clinic staff. If these processes are not robust, provide your feedback to the clinic’s administration.
- When patients do not have a primary care provider, consider working with other physicians at the clinic to monitor and manage patients with chronic conditions.
- Recognize that the expected standard of care in a walk-in clinc is the same as in any other clinical setting.
Walk-in clinics and the demand for primary care
Although walk-in clinics are intended for episodic care, in the current resource constrained environment many patients are relying on walk-in clinics for primary care. All Colleges require physicians working in walk-in clinics to ensure appropriate follow-up care for any investigations or referrals made in relation to the patient’s presenting medical problem. Some Colleges expect physicians to provide additional, ongoing care to those patients who do not have a primary care provider and who regularly attend the same walk-in clinic.
Communicating with the healthcare team
Managing clear communication between team members can be difficult for walk-in clinic physicians, particularly when patients require ongoing care or follow-up and do not have a primary care physician.
Case example: A physician is unreachable after prescribing a potentially contraindicated medication
An elderly patient presents to a walk-in clinic complaining of a persistent cough. The patient is afebrile, but chest auscultation reveals bilateral crackles. After reviewing the patient’s list of medications, the physician prescribes azithromycin for presumed pneumonia and orders a chest X-ray to confirm the diagnosis. Upon receiving the prescription, the patient’s pharmacist has concerns this treatment would interact with the patient’s antiarrhythmic medication, and attempts to reach the prescribing physician.
However, the physician, who works part-time in the clinic, is unreachable by phone. The pharmacist does not dispense the antibiotic and advises the patient to follow up with their family physician.
Days later, the walk-in clinic physician, unaware the antibiotic was not dispensed, directs staff to inform the patient that their x-ray confirmed pneumonia.
The patient subsequently follows up with their own family physician who prescribes an appropriate antibiotic. The patient complains to the College that they were prescribed a contraindicated medication by the physician at the clinic and that the physician took no steps to prescribe a different medication or respond to the pharmacy.
What did the College say?
The College committee appreciated that, subsequent to the complaint, the physician voluntarily took steps to be more accessible to other members of the healthcare team. The committee was concerned that the physician, having prescribed a contraindicated medication that could have posed a serious risk to the patient, was unavailable to correct the situation. It counseled the physician to make themselves more accessible to other members of the healthcare team.
Risk mitigation strategies
- Provide clinic staff with clear instructions about who to notify of patients’ telephone calls or calls from healthcare providers. Respond in a timely manner when contacted.
- Always document the patient encounter in the medical record, providing the rationale for the care plan and facilitating continuity of care.
- Advocate for robust processes and procedures at the walk-in clinic to ensure that someone can answer questions from other healthcare providers in a timely manner if the attending physician is unavailable or no longer with the clinic.
Managing diagnostic tests
The processes around ordering, reviewing, and following up on diagnostic and lab tests can be unclear to physicians owing to the variability of policies and procedures at different walk-in clinics. Even when working part-time or on contract in a walk-in clinic, physicians remain responsible for ensuring there are procedures in place for the appropriate management of diagnostic and lab test results.
A patient with no family physician needs prescriptions renewed
A 58-year-old patient presents at a walk-in clinic. They are new to the city, cannot find a family physician, and have not been assessed in nearly a year.
They have non-insulin-dependent diabetes, hypertension, and chronic kidney disease. They are on oral hypoglycemics and a calcium channel blocker for hypertension control. Their BP is 180/100, but they are asymptomatic. They ask the physician to renew their prescriptions.
The physician agrees to renew the hypoglycemic medications and calcium channel blocker. Given the patient’s hypertension and the physician’s concern for renal protection, they add an ACE inhibitor. The physician gives the patient a lab requisition and advises them to follow-up in a few weeks to review their blood pressure and lab results.
The physician then goes on vacation for two weeks. When they return, they learn that the patient had the lab work done the day after the appointment. The results showed that their creatinine was elevated at 268 micromol/l. Their potassium was 5.4 mmol/L. However, these results were left for the physician’s review and no further action was taken. Eight days after seeing the physician, the patient is admitted to hospital with severe hyperkalemia.
The patient launches a College complaint, claiming that if medications were going to be prescribed in the absence of baseline labwork, extra caution should have been exercised.
What did the College say?
The College committee noted that the physician could have written a very short prescription and told the patient to have an earlier clinical review given the lack of baseline information. The committee suggested the physician could have gathered records from previous treating providers.
Alternatively, the College noted that the physician could have delayed adding a new medication until the baseline investigations were available. If there was an urgent need for intervention before investigation, the physician could have considered a very clear and timely follow-up of the patient.
The committee advised the physician when absent to ensure colleagues were alerted to pending test results that might require timely adjustments to a clinical plan.
Risk mitigation strategies
- Review whether adequate protocols are in place to enable appropriate ordering, management, and follow-up of investigations. If these protocols are not in place, advocate for them.
- Document clearly in the medical record the proposed treatment plan and any changes that might be required once test results are received.
- Try to gather information from previous providers or from provincial/territorial health information systems (e.g., laboratory test result repositiories) when it is important to clinical decision making. Consent to share information between physicians within a patient’s circle of care is generally implied. However, it is good practice to let your patient know that you would like to contact other physicians within their circle of care, since some patients might object to you doing so.
Reviewing delegated work
While walk-in clinics facilitate same-day visits, they may introduce challenges to quality of care in some instances, such as when a patient is new and has multiple comorbidities. Clinics may increase efficiency by assigning tasks to other staff members, such as requiring a nurse or physician assistant to obtain a medical history from the patient. However, a physician who fails to review the medical history risks proceeding with incomplete information.
Case example: A physician fails to examine a breast lump
A young patient presents to a walk-in clinic complaining of heart palpitations, which have increased in severity and frequency. During the initial intake interview, they explain to the nurse that they are also experiencing fatigue, difficulty breathing, and a fluctuating right breast lump. They later describe the same symptoms to the walk-in clinic physician, except for the breast lump.
The physician does not review the nurse’s notes, which includes documentation of the lump. As the patient leaves the appointment, they ask about the lump. The physician does not examine the patient and declares it to likely be a cyst. They advise the patient to return to the clinic if it changes in size or becomes painful. Months later the patient is diagnosed with stage II breast cancer and undergoes a partial mastectomy, chemotherapy, and radiation.
What did the College say?
The College criticized the physician for failing to examine the patient’s breast, and noted that they were seeing too many patients per shift. The College required them to sign an agreement that limited the number of patients they would see during a shift, and that they attend a course on reviewing and maintaining documentation.
Risk mitigation strategies
- Review all key elements of the patient’s medical record, for example, nursing notes, vital signs, relevant past entries, test results, and consultation reports before establishing a diagnosis.
- Provide the patient with clear instructions and document this discussion. The information should enable the patient to understand the diagnosis and be aware of the signs and symptoms that may indicate the evolution of the disease or potentially point to a different diagnosis. It should also convey the importance of following up and specify whom to contact for follow-up.
- Encourage patients to return to the walk-in clinic or to follow up with their family physician (if they have one) for concerns not adequately addressed in the visit.
Additional reading
