Is a primary care physician (PCP) responsible for conducting a pre-employment physical and ordering a Purified Protein Derivative (PPD) test for tuberculosis (TB) screening?

Role of Primary Care Physicians in Pre-Employment Physical and PPD Testing

Primary care physicians (PCPs) are not responsible for conducting pre-employment physical examinations and PPD tests when they are not the ordering provider, as these are typically ordered by the employer and should be performed by designated occupational health providers or employer-contracted medical services.

Pre-Employment Physical and PPD Testing: Responsibility Framework

Pre-employment physical examinations and PPD (Purified Protein Derivative) testing for tuberculosis screening are typically part of an employer's occupational health requirements, not part of routine primary care. The CDC guidelines provide clear direction on this matter:

• Pre-employment physicals and PPD testing are typically initiated and required by employers, not by PCPs 1
• Administrators of healthcare facilities (and by extension, other employers) should ensure that personnel receive appropriate skin testing at intervals determined by their occupational risk 1
• During pre-employment physicals, baseline PPD skin testing should be performed for workers with potential exposure to tuberculosis 1

Designated Personnel for Pre-Employment Testing

The CDC guidelines specify that:

• All PPD tests should be administered, read, and interpreted by "specified trained personnel" 1
• Test results should be recorded in the employee health record and an aggregate database 1
• The employer is responsible for ensuring that physicians and other personnel working in their facilities receive appropriate skin testing 1

When PCPs May Become Involved

There are specific circumstances when a PCP might become involved in the pre-employment screening process:

• If the patient has a documented history of a positive PPD test, the PCP may need to provide this documentation to the employer 2
• If a patient develops symptoms suggestive of TB (persistent cough ≥3 weeks, weight loss, night sweats, bloody sputum, anorexia, or fever), the PCP should evaluate them promptly 1
• PCPs may be asked to evaluate abnormal findings discovered during pre-employment screening 2

Common Pitfalls to Avoid

• Misunderstanding of responsibility: PCPs should clarify to patients that pre-employment physicals and PPD tests are typically the responsibility of employer-designated healthcare providers
• Documentation issues: If a patient has previously tested positive for PPD, ensure proper documentation is provided to avoid unnecessary repeat testing 1
• Inappropriate billing: Billing insurance for pre-employment examinations that should be employer-paid can constitute insurance fraud
• Inadequate follow-up: If abnormalities are found during pre-employment screening, proper follow-up is essential to prevent progression of any identified conditions 2

Algorithm for Determining Responsibility

1. Determine who ordered the test:

   • If ordered by employer → Employer's responsibility
   • If ordered by PCP for clinical reasons → PCP's responsibility

2. Determine the purpose:

   • Employment requirement → Employer's designated provider
   • Clinical suspicion of TB → PCP's responsibility

3. Consider documentation needs:

   • Previous positive PPD → PCP may provide documentation
   • New testing needed → Employer's designated provider should perform

4. Address abnormal findings:

   • If pre-employment screening reveals abnormalities → PCP may need to evaluate and treat
   • Routine employment clearance → Not PCP's responsibility

Pre-employment physicals represent an opportunity for preventive health assessment when performed, but they are not typically the responsibility of the patient's regular PCP unless specifically contracted to provide this service 3.