Q: I’m still have a lot of loan debt so I’m doing some shifts in an urgicare to help pay that off.  I saw a patient yesterday for cramps and vomiting.  He was insisting that he had food poisoning but he had a significant abdominal surgical history (bowel repair after a shrapnel wound when he was serving in Iraq) and I was concerned about small bowel obstruction due to adhesions. He did not have hyperactive bowel sounds but that may not be present, so I wanted a flat and upright abdominal X-ray series.  He refused. I explained the potential seriousness to him but he walked out. The last thing that I said to him was that if his symptoms persisted or got worse that he should go to an ER. He was not so ill that I could say that his leaving was evidence of him being irrational and so able to be kept from leaving. I documented everything and the NP signed my note as well, so I think that I am covered legally. However, I am still concerned.  I spoke to the urgicare and they said that they don’t do follow-ups.  What if I called him personally to check if his situation resolved or whether he sought other emergency care? As a family practitioner I am used to follow-up, but am I too limited here? 

A: Personal follow-up is not an option to consider in this setting. 

Urgicares are what their name implies – they are for rapid care of non-life threatening situations.  They are not geared to pursuing a clinical matter and will just recommend going to an ER if necessary or post-treatment follow-up with the patient’s own doctor. 

When he left the urgicare, this patient severed the physician-patient relationship with you and any fiduciary role of the facility to him. Calling him on your own at this point would therefore have the dual effect of re-establishing your role as the physician, but now in a setting that you have no actual control over, and of pulling the urgicare back in through your ostensible presentation of yourself as its employee.  

Further, you would also be indicating to any later evaluator that the situation was so severe that you are still worrying about it, which is not what you felt at the time.  However, you would now be raising the question of whether you should have taken more action when he was still present. You could actually create liability for yourself, and vicariously for the urgicare, where none currently exists. 

Your standards as a family practitioner, a role in which you have an ongoing involvement with your patients, is at odds with the limitations of the urgicare setting, but as of now you have good documentation in place that you appropriately advised and warned a competent patient, who then left against that good medical advice but while medically stable enough to do so.   

If his condition progressed, which would itself necessitate care, you would be fully defensible as to stopping at this point.