Walk-in clinics offer convenient, same-day care for episodic patient concerns, typically without an expectation of the patient joining the physician’s roster.1 Such care can be valuable to patients with busy schedules, who have acute conditions, and for those who do not have a family physician. They are often valued by patients for their convenience, but may present challenges and risks to physicians. A lack of continuity, which may hinder quality of care, is an issue of concern.
Provincial/territorial medical regulatory authorities (Colleges) state that patients in walk-in clinics are entitled to care that is of the same “appropriate and professional standard” as in any other setting.2 In practice, the distinctive characteristics for physicians working in walk-in clinics, such as seeing patients episodically and in large volumes over short time periods, can heighten challenges.
Recognizing the unique medical-legal challenges faced by physicians who work in walk-in clinics, the CMPA looked at civil legal cases and College and hospital complaints that closed between 2014-2018 and involved a walk-in clinic. This analysis revealed patient safety issues such as a lack of team communication, poor management of test results, and the absence of reviewing delegated work.
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.
Case example: A physician is unreachable after prescribing a potentially contraindicated medication
An elderly woman 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 conflict 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 her family physician. Days later, the walk-in clinic physician notifies the patient that she has pneumonia. The patient subsequently follows up with her own family physician who prescribes an appropriate antibiotic. The patient complains to the College that she had been prescribed a contraindicated medication by the physician at the clinic.
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 himself 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.
- Document the patient encounter in the medical record, providing the rationale for the care plan and facilitating continuity of care.
- Advocate for policies and procedures that ensure someone can answer questions from other healthcare providers in a timely manner when the attending physician is unavailable or no longer with the clinic.
Managing diagnostic tests
The processes around ordering, reviewing, and following up on diagnostic 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 that diagnostic processes are followed.
Case example: An incorrect diagnostic test is ordered
An elderly woman presents to a walk-in clinic after falling down the stairs and hitting her head. She complains of headache and some memory loss. The walk-in clinic physician requests a medical office assistant to complete a requisition and book an urgent CT scan of the head. When the patient arrives at the hospital, she discovers that the walk-in clinic staff had incorrectly booked her for a mammogram. The patient complains to the College about the booking error and inconvenience of attending an additional appointment. The walk-in clinic determines that the mammogram booking was intended for a different patient and that the woman’s name and information was entered in error.
What did the College say?
The physician claimed that the error was due to a mix-up by front office staff and not through any fault of her own. She claimed that staff are supplied by the owners of the clinic and that supervising them is not part of her role. However, the College disagreed, and found that the walk-in clinic physician was ultimately responsible for the conduct of the medical staff, even though she was an independent contractor at the clinic. They advised her to assure that reliable processes be implemented so that correct tests are ordered.
Risk mitigation strategies
- Advocate for and review whether adequate protocols are in place to enable appropriate ordering, management, and follow-up of investigations.
- While not a required practice, consider completing patient requisitions personally when possible, to reduce the risk of errors.
- Consider the medical-legal risks of delegating tasks to administrative staff. Note that, in Québec, health professionals are only permitted to perform acts authorized by their relevant governing legislation and in accordance with specified requirements, if any. Accordingly, Québec physicians can only request that another health professional perform a reserved act if the legislation governing this other health professional authorizes them to perform that act.
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 to the physician 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 woman presents to a walk-in clinic complaining of heart palpitations, which have increased in severity and frequency. During the initial intake interview, she explains to the nurse that she is also experiencing fatigue, difficulty breathing, and a fluctuating right breast lump. The woman later describes 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, she asks about the lump. The physician does not examine the patient and declares it to likely be a cyst. He advises 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 he was seeing too many patients per shift. The College required him to sign an agreement that limited the number of patients he would see during a shift, and that he 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 discharge instructions. The information should enable the patient to understand the diagnosis and to 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.
The bottom line
Walk-in clinics provide episodic care to patients without expectation of a longitudinal relationship. They serve a valuable role for patients who require same-day appointments with flexible hours. However, the unique setting may raise unexpected challenges for physicians aiming to provide the safest medical care possible to their patients.
Consider the following to help reduce medical-legal risks associated with providing care at a walk-in clinic:
- Review the 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 the processes are not robust, provide your feedback to the clinic’s administration.
References
- Chen CE, Chen CT, Hu J, et al. Walkin clinics versus physician offices and emergency rooms for urgent care and chronic disease management. Cochrane Database of Systematic Reviews 2017, Issue 2. Art. No.: CD011774. doi: 10.1002/14651858.CD011774.pub2.
- College of Physicians and Surgeons of Nova Scotia [Internet]. Professional Standard on the Standard of Care for Walk-in Clinics. [Updated 2015 May 22; cited on 2019 May 17]. Available from: https://cpsns.ns.ca/wp-content/uploads/2017/10/Standard-of-Care-for-Walk-in-Clinics.pdf
