Slide 1

OEMAC 2014

Kenneth Corbet MD FRCPC

Consultant, Occupational Medicine

Clinical Associate Professor

University of Calgary

September 28, 2014

Learning Objectives:

1. Describe the key (health-related) elements of a job

and identify relevant external medical standards

2. Outline how a screening fitness to work protocol

is developed.

3. Decide what medical information is needed to make

a fitness decision

Learning Objectives:

4. Determine whether work limitations or restrictions,

a practical assessment, or employee advice is

warranted

5. Evaluate the fitness to work process and outcomes.

Business Improvement Goal:

Fitness to work assessments are one element of

operational risk management - improve the relevancy,

validity, reliability, and efficiency of medical fitness to

work assessments.

Definitions

What does ‘Medically Fit to Work’ really mean?

“ … means the employee is able to perform the job

without danger to self or others, without reservations.”

Cowell JW. Guidelines for fitness-to-work examinations.

Canadian Medical Association Journal. 1986 Nov 1;135(9):985-8.

Has anyone in the audience dealt with problems

that arise from this definition?

What does ‘Medically Fit to Work’ really mean?

• An office-based fitness assessment does not establish

that the person is capable of performing the job

• Being ‘medically fit’ is not a ‘zero risk’ statement

• The unit of analysis of a medical fitness to work

assessment is a medical condition (i.e. a diagnosis)

Are these better definitions?

Fit = This person has no medical conditions that require

limitation or restriction of his or her work (i.e. tasks,

tools, equipment, schedules, PPE, work environment)

Limitations = can undertake the work, but not to the

usual expectations (e.g. speed, strength, schedule)

Restrictions = cannot or should not undertake a specific

aspect of the work (= serious and imminent risk).

Process Overview

� for medical conditions that

may impact health, safety, or

performance for training,

travel, or work.

SCREENINGINDIVIDUAL

ASSESSMENT

� of medical conditions to

determine whether work

limitations or restrictions are

warranted

Screening

Assessment

Key Job Elements

Key job elements can be used to characterize any job:

• postural and ambulatory demands (office- or plant-based)

• strength (light, medium, heavy)

• operation of vehicles, heavy equipment, and process controls

• regular night shifts (2400-0600 hours)

• emergency response roles

• type of personal protective equipment (PPE) required

• travel or foreign assignment (e.g. offshore, rotator)

• specific chemical, physical, or biological hazards

Relevant Medical Fitness Guidelines

Medical conditions relevant to safety sensitive positions:

o Canadian Medical Association Drivers Guide (2012)

o Canadian Council of Motor Transport Administrators (2013)

o Railway Association of Canada (2011)

Medical conditions relevant to emergency responders:

o National Fire Protection Association (2012)

Relevant Medical Fitness Guidelines

Medical conditions relevant to offshore positions:

• ILO/IMO (1997)

• Canadian Association of Petroleum Producers (2013)

• UK Offshore Oil and Gas Industry Association (2008)

• Transport Canada (2012)

Relevant Medical Fitness Guidelines

At the University of Calgary, we are developing an

on-line database that compiles and indexes, by medical

condition, the Canadian rail, motor, aviation, and marine

medical fitness guidelines …

… supplemented by clinical guidelines, citations from

indexed medical databases, and the gray literature.

http://www.ucalgary.ca/ftwguidelines/

Development of a Fitness to Work Protocol

Compile a list of medical conditions that are likely to impact

health, safety, performance in the job:

• Scope relevancy – is the medical condition relevant to the

employee’s work?

• Temporal relevancy – is the medical condition relevant to

the employee’s current fitness to work?

• Severity relevancy – is/was the medical condition severe

enough to pose a fitness to work concern?

Development of a Fitness to Work Protocol

• Identify the health history items, physical examination items,

and tests (singly or in combination) that best screen for each

medical condition = validity

• Compile the health history and physical examination items

into forms, provide testing recommendations, and identify

clinical resources for the examining physician = reliability

What about testing?

• Vision – acuity, colour (if relevant to the job)

• Blood and urine –high exertion, thermal stress, or

remote work … pre-placement vs. periodic exam

• Spirometry – SCBA/SA or asthma/COPD

• Audiometry – if using HPE or ‘noise exposed’

Remember … the screening component of

fitness to work assessment

… is a hunting trip, not a fishing trip.

Expectations

Expectations of the Candidate (Employee)

• provide an accurate history on certifying medical fitness

assessments

And while employed …

• notify their treating physician that they hold a safety

sensitive, offshore, or emergency response position

• notify OH of a worsening or new medical condition that

may impact medical fitness

Expectations of the Examining Physician

• Have qualifications or experience in the assessment

of fitness to work

• Be knowledgeable of the demands and working

conditions of the job

• Use appropriate clinical resources to assist

in the individual determination of medical fitness

Individual Clinical

Assessment

� for medical conditions that

may impact health, safety, or

performance for training,

travel, or work.

SCREENINGINDIVIDUAL

ASSESSMENT

� of medical conditions to

determine whether work

limitations or restrictions are

warranted

For each of an employee’s medical conditions, do

you need to:

• Undertake additional history and/or physical exam?

• Refer to relevant medical fitness standard?

• Discuss the case with a colleague?

• Request and review medical records?

• Refer for further assessment?

Request and review medical records

For offshore, safety sensitive, and remote positions, have

a low threshold for requesting recent medical records

that are relevant to fitness to work.

Develop standard templates, based on relevant medical

standards, to ensure you ask for the information

you need for a fitness opinion.

Request and review medical records for:

• Vision – glaucoma, cataracts

• Respiratory – asthma, COPD

• Cardiac – CAD, dysrhythmias, murmurs, abnormal ECG

• Epilepsy

• Mental Health – new medications, ‘major’ disorders

• Diabetes – insulin > oral medications

• Sleep studies or CPAP use

• Cancer – early remission

• Surgery – recent or upcoming procedures

• Medications – opioids, benzodiazapenes

Refer for further assessment

• Re-assessment of ongoing medical conditions

• High risk for specific undiagnosed conditions

e.g. sleep apnea

• Significant findings on screening (history, exam, tests)

… in most cases, referral is to the treating physician.

Fitness Opinion &

Employee Advice

Fitness Opinion

• Fit

• Fit with limitations or restrictions (specify, duration)

• Unfit (temporary or ‘permanent’)

• Pending review of further medical information

• Recommend a practical test prior to job assignment:

e.g. color vision, hearing of alarms/radio, mobility

… if not routinely assessed through training.

Health Advice and Follow-up

• Request supplemental medical reports? ( = medical

report required for a specific medical condition prior

to the next periodic medical assessment)

• Provide individual health advice and risk-based

education (duty to inform the person of results)

Program

Evaluation

FTW Program Evaluation

Input of key data for the purpose of individual tracking

and program evaluation (e.g. Medgate):

• profiles of demographics, health status, and risk factors

( = characterizing your employees as a population)

FTW Program Evaluation

• Efficiency of the assessment – can you reduce costs

and the time required for assessments, without

compromising validity?

• Effectiveness of the assessment - if an employee has

an illness, an injury, or a workplace incident within

the first year of employment, did (or should have) the

fitness assessment identified the ‘human factor’?

Discussion & Questions