Incidental Findings on DOT PE

[Guest UVAPAC]

So I have noticed that a lot of patient's who come in for DOT physicals do not have a primary care physician, and use walk-in clinics for illness/issues.  (I do advise them all to establish a primary care physician for routine blood work and preventative screenings and document this.)

 

We have had numerous cases (primarily in males) with trace of blood, small blood, and even moderate blood in urine on urine analysis.  I usually notate that we discussed this finding together, and that I advised follow up with primary care.  I also make them a copy of their U/A and document this as well.

 

My question is if one of these people end up with bladder or kidney cancer, and don't follow up with a primary care doctor, ultimately to have metastatic disease... what is my liability in this?  As a medical examiner I am truly screening the patient for medical problems, not treating their medical problems.  I am certain some people simply brush off my advice, and ignore further workup.

[GetMeOuttaThisMess]

Bottom line, you could be named regardless since you were the one that picked it up. In some scenarios which I've read you could get named/involved for not having arranged for follow up, even though you aren't the PCP. One way to avoid this? 3 mos. clearance with required follow up documentation from provider detailing work up/findings and keep with exam.

 

Why not just repeat it yourself, and if negative, clear the driver? Which of the two results was the accurate one, unless you're doing/obtaining a micro review?

[rev ronin]

I doubt the liability from a DOT physical: they're not your patient, and a patient-provider relationship does not exist, because you are examining them for fitness for duty only.

[thinkertdm]

I (personally) would discuss the findings as well as the importance of follow up- and don't forget to document everything you discussed.  Remember, if they die from bladder cancer, you would be the last person who saw that blood in their urine.  It would be nice to show a jury that you made an attempt to relay this to the patient.  Documentation is the key, and it would not be inconceivable to include a statement in their patient paperwork stating that any abnormal incidental findings would be relayed to the patient, but it was their responsibility to follow up- and they could sign it.  I may even send the results as well as a letter stating they needed this to be looked into via a certified letter, to show they received it.

 

A jury would not be happy if you just shrugged and did no follow up.  I'm not too sure about actually arranging an appointment, because the patient would not be happy about seeing a provider that their insurance wouldn't cover.  On the other hand, if you have a free/low cost place, you can set them up there, at least then its documented.

Just my thoughts.   

[GetMeOuttaThisMess]

I doubt the liability from a DOT physical: they're not your patient, and a patient-provider relationship does not exist, because you are examining them for fitness for duty only.

For some individuals, you may be their PCP, or if they don't have one, as noted, you were the one to find it so it DOES fall on you.

[rev ronin]

For some individuals, you may be their PCP, or if they don't have one, as noted, you were the one to find it so it DOES fall on you.

Yes, if you have a PCP relationship, that's different.  I would imagine it's a bigger deal if we bill as an annual preventative medicine exam.  But well over 50% of our DOT physicals are cash pay patients whose PCPs, if they have one, no longer do DOTs.  They aren't establishing a patient/PCP relationship.  Having said that, I DO recommend f/u on non-DOT-relevant things, just because it costs me nothing and they're already there.  But I'm pretty confident that in doing so, I'm exceeding my obligations.  If someone has a legal cite that differs with me, I'd love to hear it.

[Reality Check 2]

I am fortunate that I ONLY do DOTs on our family practice patients.

 

If they have microhematuria then I have a history to look at and I can make the referral on the spot for further evaluation.

 

I also get to snag them for tdaps and colonoscopies etc.

 

I wish a lot of these drivers didn't count on a 1-2 year DOT exam to be a substitute for a PCP relationship and real health maintenance. 

 

If you want to take it a step further - get business cards for a urology group or write out an Rx for a urology consult and document it in the chart, photocopy, scan etc. Tell the patient that you are SENDING a referral or a copy of your clinic note to said urologist and they will be contacting the patient. 

 

Then, you have done more than due diligence and given them a plan and a contact. If they choose not to follow up then you have tried. If they come in for another DOT and still have the hematuria - then, hold it hostage and say you tried to get them to investigate last time and now it could be problem that could make them unsafe behind the wheel. 

 

Folks don't get it a lot of times and lawyers thrive on stupidity. Do your best, advise the patient properly, give good intel and make the effort. Best you can do.

[GetMeOuttaThisMess]

I am fortunate that I ONLY do DOTs on our family practice patients.

 

If they have microhematuria then I have a history to look at and I can make the referral on the spot for further evaluation.

 

I also get to snag them for tdaps and colonoscopies etc.

 

I wish a lot of these drivers didn't count on a 1-2 year DOT exam to be a substitute for a PCP relationship and real health maintenance. 

 

If you want to take it a step further - get business cards for a urology group or write out an Rx for a urology consult and document it in the chart, photocopy, scan etc. Tell the patient that you are SENDING a referral or a copy of your clinic note to said urologist and they will be contacting the patient. 

 

Then, you have done more than due diligence and given them a plan and a contact. If they choose not to follow up then you have tried. If they come in for another DOT and still have the hematuria - then, hold it hostage and say you tried to get them to investigate last time and now it could be problem that could make them unsafe behind the wheel. 

 

Folks don't get it a lot of times and lawyers thrive on stupidity. Do your best, advise the patient properly, give good intel and make the effort. Best you can do.

 

 

I used to go one step further in this process.  Whatever the issue was that warranted the referral, I always printed out the appropriate section from the FMCSA guidelines so the specialist/PCP would be more aware of why we were referring pt. to them and kept a copy in the chart of same.  Example of why one might assist in calling for a PCP appt. for an incidental finding, going back to ED days, if you had a fx. that you had immobilized you would call the on-call orthopod to "make them aware of pt. and finding" but behind the scene it actually allowed for documentation that you spoke with the appropriate party who will see individual in office establishing a trail for follow up.  If specialist declined ("no insurance"), then we would note this and provide them cards of several other orthopedic groups and would leave it to their discretion.  Occasional f/u calls would be received regarding not being able to see anyone but at that point you have documented an attempt and you can then refer pt. to facility of last resort, i.e. county hospital, state hospital, etc..