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Private Office Walk-in Patients

The most basic consideration in patient screening in the office is whether the patient is calling for an appointment in the future or is standing in the office requesting care. There are many options for dealing with a patient on the telephone, but the patient in the office requires an immediate decision. The law does not impose a duty to treat every patient who walks into a private medical office; however, there are several exceptions that do recognize a duty to treat certain patients. More important, it would be ethically impermissible to turn away a patient for whom this would mean certain injury. The basic duty to a walk-in patient is to determine which patients to treat and which to refer. Few physicians understand their duty to provide immediate treatment to forestall further injury. In the private office, this duty is limited to situations in which a patient presents with a major problem such as a heart attack in progress or anaphylactic shock. The situation is most likely to occur if the physician's office is in an office complex with nonphysician tenants--a risk particularly for physicians in shopping center offices. This type of event is unusual, but it is potentially catastrophic and demands some type of screening for all walk-in patients.

In the limited context of an unknown walk-in patient in a private medical office, the first level of medical screening is to determine if the patient needs emergency treatment. For most patients, this simply requires asking the patients why they want to see the physician. Patients should not be relied upon for a definitive diagnosis, but they can recount the natural history of the complaint. If the symptoms were of sudden and recent onset or if the patient appears seriously ill, it is critical that a more complete medical examination be done at once.

If the patient is found to need urgent care, that care must be rendered to the extent that the practitioner is capable. The central problem for a physician facing a medical emergency outside his or her expertise is determining the extent of care that must be rendered before the patient can be transferred. For example, any physician should be able to manage anaphylactic shock; a dissecting aneurysm will require emergency transport to a fully equipped surgical center. The issue is the physician's general knowledge and the available facilities, not his or her self-selected specialty. A gynecologist and an allergist would have the same duty to treat a patient in anaphylactic shock, although the gynecologist would have no obligation to treat a routine allergy patient. If the patient can be managed without transport, the physician may determine later if he or she wants to continue the physician-patient relationship beyond the acute episode.

If the physician determines that the patient is not in need of urgent treatment, certain obligations remain. If the physician chooses to accept the person as a regular patient, these obligations will be discharged. If the physician chooses not to continue treating the patient, then he or she must ensure that the patient is told all the pertinent information about the condition, including the need for further treatment. If the condition is such as to require continuing treatment, the physician must be sure that the person understands the need for this treatment. The physician must be careful to distinguish between telling the patient that no treatment is required and telling this person to seek treatment elsewhere. The best course is to refer the person formally to the appropriate physician or hospital for treatment.

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