Practitioners are sometimes asked to do specific types of physical exams in a variety of circumstances. These exams fall into the categories of pre-participation physicals (such as sports and pre-employment physicals) and certification assessments (such as disability determinations).  Though these exams can be routine in nature, they represent risks which can come from more than one source in the same situation.

Consider, for example:

ü  If a practitioner fails to diagnose a medical condition while doing a physical (or inform the patient of what he found) he may be sued by the patient and/or the organization requesting the exam.

ü  A practitioner may do one of these exams on one of his established patients, but  often he will be asked to do the exam for someone he has not treated before. Just because the provider does not have past knowledge of the patient, does not mean he will  be released from liability. The patient may consider the exam to be the formation of a doctor-patient relationship, and courts have supported this assumption.

ü  In some cases, patients have successfully sued physicians for injuring or re-injuring them during the exam or attendant testing, especially in worker compensation and other disability determination exams.

ü  Because some of these exams, such as pre-employment, disability, and school physicals, involve state and/or federal regulations, the practitioner faces possible disciplinary action from his licensing board if he fails to meet his legal obligations.

In short, there are a number of risks to be considered. This article will describe common types of physical exams and the inherent risks associated with them.

PRE-PARTICIPATION EXAMS

The Sports Physical (also applies to Camp Physicals)

A sports physical evaluates the athlete’s current state of general health and maturity, especially as it relates to their fitness and injury status.

This physical has two important components – the medical history and the physical examination itself. The history should include both patient and family history of significant disease, especially cardiac and respiratory conditions. Past injuries and illnesses are important to note – especially history of collapse, heat-related conditions, and allergies. The examining physician must record an accurate history of the patient’s immunizations, especially tetanus. It is also recommended that the practitioner establish knowledge of the patient’s history of drug and alcohol use, as well as the use of performance-enhancing substances.

The exam itself focuses on general health, cardiac health, respiratory status, vision, and menstrual history for females. For males, this will also include an exam of the genitalia to establish maturity level. An alert examiner will take note of the patient’s emotional state since athletes, especially young players, are often subjected to serious stresses.

The examining practitioner may also evaluate musculoskeletal abilities in posture, range of motion of joints, gait, and possible presence of scoliosis. Flexibility and endurance may be tested.[i]

The Risks:

When a complete annual physical by the patient’s treating physician is replaced by a limited sports physical, the child loses an opportunity to obtain a more accurate evaluation of their physical progress. The child’s treating physician loses the opportunity to counsel adolescents and pre-adolescents on issues affecting children their age such as drinking, smoking, drugs, sex and other emotional issues like depression. The routine full physical is also an opportunity to address wellness advice and guidance.[ii] It is incumbent upon the practitioner who does the sports physical to stress to the child and the parents that this physical does not replace a routine visit to the treating physician.

1. Sports physicals done strictly as preparation for playing in a particular sport may not identify otherwise hidden cardiac risks which lead to sudden cardiac death during or following physical exertion.
2. A sports physical on a young athlete can be less accurate if handled by a physician who does not spend the majority of their time treating children. Lack of familiarity with a growing child’s physical make-up and requirements can lead to error.
3. To avoid allegations of practicing outside the scope of their specialty and training, and possible allegations of misdiagnosis or failure to diagnose, the examining practitioner will need to involve specialists from other disciplines when there is any possibility the patient may have a medical condition which requires specialty follow-up. This is especially true of missed cardiac problems in sports physicals. This risk, in general, applies to all types of physicals described herein.  
4. Also, to address some of the general risks discussed in the introduction, the examiner will need to document the exam carefully. This risk also applies to all types of physicals described herein.  

School Physicals

School physicals focus most heavily on the child’s history of illness and immunization. They are required to comply with any state and/or local regulations. These physicals look for patterns in growth and development, and they usually are the practitioner’s only opportunity to discuss relevant psycho-social issues with the child and parent.

The Risks:

Risks associated with school physicals are similar to those found in sports physicals. They also include the following:

Historical evidence of wellness, illness and immunization obtained only from the child or the parents may not be complete; instead, this information should be obtained from prior records of treating physicians and/or clinics.