Risk Management for Adult Primary Care Physicians

Balancing clinical excellence with effective practice management is no easy task. Success often requires mastering medical knowledge, along with patient referrals, follow-up care, supervision of advanced practice providers, and meaningful patient interactions. These represent a few of the challenges presented to primary care physicians. The strategies below provide a framework for the delivery of patient-centered care while managing risk.

Referrals

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Primary care physicians face a variety of complex patient conditions, and knowing when to refer is a key component of their practice. When making referrals, consider these tactics.


• Document the reason for referring the patient.
• Before contacting the other physician, explain to the patient why a referral is necessary and what they should expect at the appointment with the specialist. Document this conversation in the medical record.
• Have clear protocols for urgent vs. routine referrals. For example, if the referral is urgent, ensure that the appointment is made before the patient leaves the office.
• Provide the patient with the specialist’s information, including address and directions.
• Contact the specialist directly. Once an appointment has been scheduled, provide information about the patient, including medical records, test results, and any other relevant documents to avoid duplicate efforts.
• Track the referral, and let specialists know that you expect to receive pertinent records or consult notes from them.
• When consult reports or communications arrive, document your review of the results and any treatment recommendations timely.
• When needed, contact the patient to discuss the specialist reports and how it affects their treatment. Document your discussion with the patient.
• Maintain open dialogue with the specialist to better understand and meet the patient’s diagnoses or needs.
• Ask that specialists contact you if patients fail to schedule or cancel appointments.
• If the patient does not comply with the referral, ask the patient why at their next appointment. Document the response. Offer to find another referral or encourage the patient to comply with the original referral recommendation.

Follow up
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Follow these general risk management strategies to help improve follow up and facilitate continuity of care.

• When ordering tests, assist the patient with scheduling when needed and ask testing facilities or consultants to contact you if the patient does not come to the appointment. If the patient chooses not to have the test performed after you have fully explained the risks and benefits involved, document this discussion with the patient in the medical record.
• Use a reliable system to track test results and ensure they are reviewed and communicated to patients. Most electronic medical records (EMR) systems have order tracking capabilities.
• Establish protocols for handling missed or cancelled appointments. Have clear escalation procedures for patients who have not gone for ordered testing, or whose concerning findings require urgent follow-up.
• Engage patients in their own care and treatment plan by educating them about needed follow-up labs and testing. This encourages them to follow through with the plan to have the test(s) performed. It is important to document these conversations and any education in the progress notes.
• If you are seeing a patient for follow up after a hospital discharge, ask staff to request the hospital discharge summaries and review any orders and/or recommendations before the patient’s follow-up visit. If needed, staff members could create a flag or task in the patient’s chart to remind providers to review the hospital records. Direct staff members to obtain copies of pertinent hospital records and labs, tests, and/or radiology reports for the office chart.

Supervision
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When physicians supervise advanced practice providers (APP), they assume responsibility for the actions of that person. Develop a comprehensive job description and written protocols describing the delegation of duties for the APP to follow.

Specific elements for APP supervision may be outlined in state laws. For example, in Texas, the Texas Medical Board rules outline requirements for delegating prescriptive authority. TMB rules regarding the supervision of advanced practice providers (both PAs and APRNs) can be found in chapters 169 and 185 of the Board rules, and the Texas Occupations Code Chapter 157.

When delegating to others, it is important to clearly document all orders given, including prescriptions; shared responsibilities; all protocols, guidelines, and plans, including prescriptive authority agreements and any amendments to it; and annual reviews, meetings, discussions, and patient feedback.

For the APP, documentation guidelines and when to consult with the physician should be well defined.

Patient interaction
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Effective communication is the foundation of strong physician-patient relationships. Yet, the realities of modern primary care — with its short appointment times, high patient volumes, and administrative burdens — make it difficult for physicians to establish meaningful, long-term connections with patients. Despite these systemic pressures, building rapport and trust remains essential for delivering quality care.

Here are some ways to establish rapport and encourage collaboration.

• Use the patient’s name and make eye contact while reviewing their chart.
• Acknowledge delays or wait times if they occurred. Encourage staff to keep patients updated on delays
• Start with an open-ended question like “What brings you in today?” and listen without interrupting for the first 30-60 seconds.
• Briefly acknowledge any life updates from previous visits (“How’s your grandson doing in college?”)
• When using an EMR, try to position your body to face the patient as much as possible.
• Avoid multitasking during the first minute of interaction.
• Summarize your understanding of their concerns to show you've listened.
• Explain what you're doing during physical exams.
• Share your thought process briefly but clearly.
• Use teach-back and return demonstration methods to confirm patient understanding.
• Document shared decision-making conversations.
• Address patient concerns promptly and document responses.
• Include family members/caregivers when appropriate (with proper consent).
• Document difficult conversations, especially if a patient disagrees or declines recommended treatment or when delivering bad news.
• End visits by asking “What questions do you have?” rather than “Do you have any questions?”
• Thank patients for bringing concerns to your attention.
• Express appreciation for their efforts in managing their health.

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