Comparison of three methods of pre-employment medical evaluations

BACKGROUND: Increasing efforts are being made to prevent sickness absence and to increase worker efficiency, including the use of costly pre-employment medical assessment of white-collar workers and labourers, excluding occupations for which medical supervision is required by law. AIM: To investigate whether filling out an occupational health questionnaire (OHQ) as pre-employment assessment was more efficient than previously used protocols which included a physical examination and laboratory tests performed for each applicant. METHODS: Retrospective study comparing three groups of job applicants: Group A--applicants examined by an occupational physician (OP); Group B--applicants examined by a general practitioner (GP) whose medical records were subsequently evaluated by an OP and Group C--the applicant filled out an OHQ which was evaluated by an OP. RESULTS: The study included 1940 pre-employment assessments divided into groups A (618), B (256) and C (1066). The restriction rate was 2.1, 1.2 and 2.3%, respectively. The lowest restriction rate (1.4%) was among applicants 29 years old and younger and the highest one (3.6%) among 50 years and older. The most frequent diagnoses among restricted applicants were musculoskeletal and circulatory diseases (15 and 12%, respectively). CONCLUSIONS: The restriction rate achieved by medical examinations either done by an OP (Group A) or by a GP (Group B) was the same as in OHQ (Group C). The use of a self-administered questionnaire evaluated by an OP is the preferred method of pre-employment evaluation for non-hazardous occupations.     

The assessment of fitness to travel

The majority of health problems encountered in association with travel stem from pre-existing, perhaps latent, illness in the individual which may be exacerbated by the rigours and hazards of travel. It is essential that the advising physician understands the hazards that are likely to be encountered during travel in order that they may develop informed decisions regarding fitness for travel and give appropriate advice. In an occupational health setting, the employer has a responsibility to safeguard the health of their employees whilst travelling on behalf of the organisation and will also have to fund any treatment abroad or the cost of repatriation. The dictating factor in determining fitness to travel will often be fitness to travel by air, consequent to the reduced partial pressure of oxygen and pressure changes in-flight. The majority of significant health problems encountered during travel are attributable to coronary heart disease and detailed guidance exists to determine fitness for travel. For many health problems little if any evidence based guidance exists and decisions will therefore have to be based on an understanding of the hazards likely to be encountered during travel. Access to appropriate standards of medical care abroad and the difficulties and expense of repatriation, should this be necessary, are also important factors to consider in addition to the basic determination of fitness for travel itself. This paper outlines the main factors to be considered when assessing fitness to travel and also examines available guidance for some of the more commonly encountered conditions.     

Is there value in routinely obtaining a report from the general practitioner as part of pre-entry health screening of students for nursing studies?

BACKGROUND: Reports from general practitioners (GPs) are requested on applicants for nurse training, but there is no published evidence of the merit of this practice. AIMS: To assess the benefit of GP report in health assessments of student nurse applicants. METHODS: An audit was made of information obtained by health declaration form (HDF), nurse's assessment, GP report and, when performed, a physician's assessment for each applicant. Agreement between the health questionnaire and GP report was analysed by kappa statistics. RESULTS: Of 254 applicants, 246 (97%) were declared 'fit to work', four (1.6%) were deemed 'fit with restrictions' and four (1.6%) were considered 'unfit to work'. The most common problems declared were psychiatric and skin problems. The agreement between health declaration and the information provided by GPs was classed as almost perfect for diabetes and only fair to moderate for all other measures. The reports provided additional information on problems not declared by applicants, but all of these were passive problems. The four unfit candidates all had psychiatric illness, but in all cases the occupational health assessment was sufficient to make this decision or to request further information. In the 'fit with restrictions' category, three of the four GP reports (75%) helped in correctly assigning the applicants to this category. In one of these eight cases a passive problem had not been declared. CONCLUSIONS: The additional information in GP reports does not affect the conclusion regarding fitness for training in most cases and does not provide sufficient information to merit it being sought routinely.     

Biomarkers, screening and ethics

Rapid scientific advances, such as those in biomarker technology,have made a significant impact on the ethics and practice ofoccupational health. Biomarkers are extensively used in occupationalhealth practice. In the pre-employment stage, preventive orpredictive testing can be performed. Preventive testing aimsto avert accidents that may occur if a medically unfit workerundertakes a job that he is unable to perform. For safety sensitivejobs, routine testing of a worker's functional capacity in theactual job would suffice in most cases. However, a recentlyquotes application of a test is the screening for mutationsof the cardiac myosin-heavy chain and troponin genes among asymptomaticpersons with a family history of sudden death from hypertrophicobstructive cardiomyopathy. Predictive testing hopes to forecastthe risk of a worker developing an illness. The aims may vary.One aim may be to exclude a susceptible worker from workingin a hazardous environment. Another aim may be to avoid employmentof a worker who is likely to develop an illness which couldlead to higher employer health care costs. A pertinent questionto consider is whether the test undertaken is to benefit theindividual or to fulfil some administrative or financial need.Among exposed workers, screening may be conducted for biomarkersof exposure or effect. As the aim is to prevent the onset ofclinical illness, the physician must take responsibility forinitiating requests for screening. The appropriate responseto the effect of technical and societal advances on ethics isthe updating of ethical guidelines by the profession. However,in the context of unvalidated biomarkers being used for screening,it may be necessary to require a regulatory body to ensure thatthe tests are accurate and effective, and that they are notused to discriminate against individuals.     

Reasons for Rejection: Why People Fail to Qualify as Firefighters

In the decade beginning 1 January 1985, 916 individuals (includingfive females) were medically examined with a view to joiningthe full-time service of Strathclyde Fire Brigade (SFB). Onehundred and nine (11.9%), including two females, were rejected.The five main causes of failure were: ocular (n = 46, 42.2%);lack of stamina (n = 21, 19.2%); ‘others’ (n = 12,11.0%); cardiovascular (n = 9, 8.3%) and orthopaedic (n = 6,5.5%). Thirty-two had chest X-rays. One abnormality was found— an azygous lobe — but it played no part in thedecision to decline the applicant. There was little life- orhealth-threatening pathology found. The most serious cases weremurmurs consistent with mitral stenosis and regurgitation (oneeach), one case of ocular melanoma, four cases of hypertensionand two cases of haematuria/ proteinuria (++). This study showsthat potentially serious findings can occasionally be detectedin a population of 18–30 year olds who might be expectedto be of better than average fitness, and that routine chestX-rays are not helpful in the selection process.     

Assessment of non-cognitive traits through the admissions multiple mini-interview

CONTEXT: Contemporary studies have shown that traditional medical school admissions interviews have strong face validity but provide evidence for only low reliability and validity. As a result, they do not provide a standardised, defensible and fair process for all applicants. METHODS: In 2006, applicants to the University of Calgary Medical School were interviewed using the multiple mini-interview (MMI). This interview process consisted of 9, 8-minute stations where applicants were presented with scenarios they were then asked to discuss. This was followed by a single 8-minute station that allowed the applicant to discuss why he or she should be admitted to our medical school. Sociodemographic and station assessment data provided for each applicant were analysed to determine whether the MMI was a valid and reliable assessment of the non-cognitive attributes, distinguished between the non-cognitive attributes, and discriminated between those accepted and those placed on the waitlist (waiting list). We also assessed whether applicant sociodemographic characteristics were associated with acceptance or waitlist status. RESULTS: Cronbach's alpha for each station ranged from 0.97-0.98. Low correlations between stations and the factor analysis suggest each station assessed different attributes. There were significant differences in scores between those accepted and those on the waitlist. Sociodemographic differences were not associated with status on acceptance or waiting lists. DISCUSSION: The MMI is able to assess different non-cognitive attributes and our study provides additional evidence for its reliability and validity. The MMI offers a fairer and more defensible assessment of applicants to medical school than the traditional interview.     

Auditing stress

Stress is now recognized as an occupational hazard and it is incumbent on all employers to carry out an assessment in order to assess the risk to health. A stress audit would be an appropriate tool to use. An audit should concentrate on organizational issues. Most audits use a questionnaire and it is sensible to use one which has already been validated. Results should be fed back to the employer in a form which is easily understandable and which contains clear recommendations for action. A repeat audit after one year is advised.     

Job applicant failed to prove adverse employment action

U.S. District Judge James G. Carr granted summary judgment to an employer accused of denying a job to an applicant because he had AIDS. When Joseph A. McIntyre applied for a job in the kitchen of Independence House, the head cook was aware that he had AIDS. The cook placed him on the schedule, gave him a personnel manual, and told him he had the job, contingent upon a medical exam and interview with the manager. When McIntyre met the manager, he told her he was planning to move out of town; the manager reportedly said she was looking for a permanent employee. McIntyre assumed this meant the offer was withdrawn. He still completed the medical exam and employment paperwork, but did not report to work. The employer arranged the physical, took in the paperwork, and demonstrated its willingness to hire McIntyre whose claim was rejected due to no apparent discrimination on the part of the employer.     

Occupational health in the European Union

Despite extensive legislation in the European Union, employees remain exposed to occupational risks and there is still a significant burden of work-related ill-health. The trend for more people to work in service industries rather than manufacturing has resulted in a change in the nature of risk and pattern of occupational illness. Worker access to occupational health services ranges from 15 to 96% and depends on the country in which employees live and the type of operation in which they work. The increasing number of small enterprises provides a particular challenge when trying to provide occupational health support to the European Union's 158.4 million workers. European law alone is not sufficient to improve the health of those at work and further action is needed at state, employer and professional level. New initiatives seek to improve the health of the Union's workforce, including a drive for better compliance with new law by every member state. Governments are working with key stakeholders through partnering strategies to develop innovative approaches for better access to quality occupational health services. Furthermore, targets for reduction in occupational ill-health have been identified. Where country laws do not mandate the provision of occupational health services, employers need to see the benefit of providing occupational health support. Finally, the medical profession is making procedures for self-regulation more rigorous and professional bodies are actively engaged in issuing professional standards and guidelines. Ultimately, the individual practitioner is responsible for ensuring that he or she develops and maintains the necessary knowledge and skills to provide competent services.     

The intention to utilize occupational health services

Workers' intention to utilize the Occupational Health Service(OHS), conceived as a cost-benefit assessment of an action,is described for a series of conceivable situations. Data wereacquired during interviews with a sample of 313 employees withan over-representation of workers with work-related health problemsin three different companies. Only for problems that are perceivedas medical, individual and work-related, do a substantial numberof workers intend to utilize the occupational physician. Forhealth and work-related problems of a collective character,the line of supervision is mostly preferred for use as an adviser.Workers' intention to utilize OHS is positively correlated withtheir attitude towards the occupational physician. No associationswere found with self-reported health status, working environmentor actual utilization of the OHS. It is concluded that the intentionto utilize the OHS is an independent factor affecting the actualutilization and it should be seriously taken into considerationwhen evaluating or implementing the coverage by the OHS.     

Medical assessment for licensing of taxi drivers by Scottish Local Authorities

In the UK, licensing of taxi drivers is dealt with by localgovernment authorities. In Scotland, before the recent reorganizationof local government, taxi licensing was under the jurisdictionof District Councils, so a telephone survey was conducted ofall 52 mainland Scottish District Councils to ascertain theprocedures which were being employed in assessing medical fitnessto drive a taxi, for which there is no national standard. Medicalenquiries relevant to fitness to drive were being made by 41(79%) of local authorities, but in 38 (73%) this was limitedto a single question about health. No enquiry regarding healthstatus was being made by 11 (21%) District Councils (all serving< 100,000 population size). Only three Scottish DistrictCouncils conducted a routine medical examination of all applicants.Thirteen of the 15 large (> 100,000 population size), and20 of the 21 medium-sized (50,000–100,000) Scottish DistrictCouncils carried out medical examinations either when a relevantmedical disorder was declared by the applicant, or when theapplicant was above a defined age (which varied between localauthorities). The small local authorities (population < 50,000)examined only those applicants who declared medical disorders.This survey has shown considerable variation and limitationsin the approach of the previously existing Scottish DistrictCouncils to the assessment of medical fitness to drive of applicantsfor taxi licences. It is suggested that national standards andguidelines are required for medical fitness to drive in relationto taxi licensing.     

Maritime health emergencies

BACKGROUND: Commercial ships flying the US flag must conform to Coast Guard standards and have medical care available onboard. Consultation with a physician is required if medication is to be prescribed. AIM: To evaluate the epidemiology of medical contacts for US ships at sea. METHOD: Retrospective analysis of cases where shipboard caregivers made contact with US emergency medicine physicians for advice. RESULTS: There were 866 cases and 1720 contacts in 48 consecutive months of study. Eighty-eight per cent of cases were men with a mean age of 43.7 years (SD 13.7). Eighty-four per cent of cases were medical, 14% were injuries and 2% were purely psychiatric. Fifty-eight per cent of medical cases, 50% of psychiatric cases and 42% of injury cases were handled with a single contact. Injuries and psychiatric cases required a higher number of contacts per case compared with medical cases (P < 0.01). Five categories of illness accounted for 43% of medical cases (respiratory infections, abdominal problems, genitourinary complaints, rashes and dental issues). Psychiatric cases required the most medication, with 12% requiring four medications. The most common categories of medication given were pain relievers (non-steroidal anti-inflammatory drugs, opiates, heartburn relief) and antibiotics. CONCLUSIONS: Even with pre-screening of seafarers and the potential dangers of life at sea, the majority of cases requiring physician advice are not related to trauma. However, cases of injury or acute psychiatric problems required more physician interaction and medication than medical cases.     

Effects of treatment can be a disability, court says

A three-judge panel of the 7th U.S. Circuit Court of Appeals affirmed an employer's decision to terminate an employee who was undergoing questionable alternative therapy to treat hypercholesterolemia. When Margaret Christian informed her employer, St. Anthony Medical Center, that she would need to take an extra day or two off each month for pheresis to treat her high blood cholesterol, she was fired. Christian alleged that she was fired because her employer anticipated that she would be disabled by the pheresis. Christian was not covered by the Americans with Disabilities Act (ADA) in this instance because while treatment of a medical condition can qualify as a disability in some cases, pheresis was not the treatment recommended by Christian's physician. Employers may use this argument to avoid accommodating disabilities that result from voluntary behavior.     

Severe headache associated with occupational exposure to Stoddard solvent

We report a case of recurrent headaches in a woman with a workplace exposure to airborne (misted) lubricating fluid containing Stoddard solvent. For 2 months, the employee was seen by her family physician, a neurologist and an ophthalmologist. All attempted to diagnose the cause of and treat her headaches. Despite extensive testing, no etiology was discovered. Her headaches continued despite the use of medications. The employee, suspecting an occupational connection, changed the lubricating fluid at her workstation to a non-Stoddard solvent. Within 2 days she reported the complete resolution of her headaches with no further recurrences. A thorough occupational history and literature review supported exposure to Stoddard solvent as the probable source of her headaches.     

Physician health and wellness

BACKGROUND: Impaired physician health can have a direct impact on patient health care and safety. In the past, problems of alcoholism and substance abuse among physicians have received more attention than other conditions-usually in the form of discipline. While patient safety is paramount, the medical profession may be more successful in achieving the required standards by fostering a culture committed to health and wellness as well as supporting impaired physicians. OBJECTIVE: To develop ethical guidelines regarding physician health and wellness. METHODS: The American Medical Association's (AMA's) Council on Ethical and Judicial Affairs developed recommendations based on the AMA's Code of Medical Ethics, an analysis of relevant Medline-indexed articles, and comments from experts. The report's recommendations were adopted as policy of the Association in December 2003. RESULTS: Individually, physicians can promote their personal health and wellness through healthy living habits, including having a personal physician. The medical profession can foster health and wellness if its members are taught to identify colleagues in need of assistance and initiate appropriate methods of intervention, including referrals to physician health programs. CONCLUSIONS: Physicians whose health or wellness is compromised should seek appropriate help and engage in honest self-assessment of their ability to practice. The medical profession should provide an environment that helps to maintain and restore health and wellness. Physicians need to ensure that impaired colleagues promptly modify or cease practice until they can resume professional patient care. In addition, physicians may be required to report impaired colleagues who continue to practice despite reasonable offers of assistance.     

Audit in occupational medicine: an audit of fitness to drive among voluntary drivers in an NHS trust

BACKGROUND: A health surveillance programme, to assess fitness to drive, was initiated for voluntary drivers in an NHS Trust because of reports of increasing frailty and slow reactions among some drivers. After discussion between the occupational health department, voluntary services manager and personnel department it was considered appropriate to apply Driver and Vehicle Licensing Authority (DVLA) Group 2 fitness to drive standards to those voluntary drivers who drove the Trusts minibuses. RESULTS: An audit of the initial health surveillance of 47 drivers is presented. The mean age of the voluntary drivers was 66.4 years. A large number of medical problems with the potential to affect driving were discovered (average of 1.9 medical problems per driver).The outcome was that five voluntary drivers were found unfit to drive the hospital minibus and one voluntary driver was found unfit for car driving. CONCLUSIONS: A fitness assessment form for drivers is presented. This form is primarily for the use of occupational health nurses, to help them to decide when referral to an occupational health physician is indicated.     

Multidisciplinary team evaluation of upper extremity injuries in a single visit: the UPPER Program.

Musculoskeletal disorders are the leading cause of disability among people between 18 and 64 years of age. Patients with musculoskeletal injuries of the upper extremities are usually evaluated and treated by an individual physician and therapist. However, for patients who have problems, especially after being treated by a hand surgeon and a certified hand therapist, there are few other management options. A multidisciplinary assessment program for patients with chronic upper limb pain has not been described in the literature. As part of The University of Michigan RERC (Rehabilitation Engineering Research Center), the UPPER Program (UPper extremity Protocol Evaluation in Rehabilitation) was developed to evaluate patients who have disabling upper limb musculoskeletal disorders. At the center of the program is a multidisciplinary team composed of a physiatrist (physical medicine and rehabilitation specialist), occupational therapist, physical therapist, exercise physiologist, vocational counselor and pain psychologist. The UPPER Program elements include a pre-evaluation questionnaire, individual team member assessments and a team meeting. It is followed by a patient appointment with the team physician to review the results and recommendations. The essential details of the program are presented in this article so it can be reproduced elsewhere.     

Doctor who lost her job due to HIV allowed to continue suit

U.S. District Judge Wayne R. Anderson rejected as premature a defense motion to dismiss an Americans with Disabilities Act (ADA) claim filed by a physician who states she was denied employment at the Family Health Care Associates Clinic after she was diagnosed as HIV-positive. The judge said that depositions will have to be taken before he is willing to accept arguments that Dr. Bari Parks posed too great a risk to the health and safety of her patients. Courts have held that HIV-positive surgeons and surgical technicians do not qualify for protection of the ADA or the Rehabilitation Act because their condition constitutes a direct threat. Parks was to begin work as an OB/GYN specialist at a clinic but was hospitalized and diagnosed with HIV. At first her employer assured her that health care expenses would be insured and the illness would not affect her employment. On the day she was cleared to return to work she was told that her starting date would be postponed and she would have to inform all patients that she was HIV-positive. After six-weeks with no response about her employment, Parks filed a complaint with the Equal Employment Opportunity Commission (EEOC). The EEOC issued her a right-to-sue letter in 1996.     

Pre-employment health assessments for food handlers: a survey of occupational physicians in the food industry

The format of pre-employment health screens within the food industry varies considerably. The aim of this study was to produce a consensus on the content of a screen that will enable employees to handle food with minimum risk to the product and employee. A questionnaire was sent to the 63 members of the Food Industry Medical Association, of whom 45 (71%) responded. As a minimum, a questionnaire completed by the applicant is thought to be sufficient. Applicants reporting health problems need to be assessed by a health professional.     

A screening questionnaire for HAVS?

AIM: To define the diagnostic power of simple questions most applicable for a hand-arm vibration syndrome (HAVS) assessment screening questionnaire. METHOD: Using a binary logistic regression we analysed 365 physician led HAVS health surveillance assessments to identify which questions could form the basis of a screening questionnaire. RESULTS: Four sensorineural related questions regarding tingling and numbness in response to the cold and after using vibrating tools, and two vascular-related questions focusing on the patient's fingers going white on exposure to cold and numbness during an attack of whiteness were identified. CONCLUSIONS: Questions of high sensitivity for screening subjects for the vascular and neurosensory components of HAVS were identified, which can be used to identify those requiring further clinical investigation and functional testing.