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Competency 2 – Good Clinical Care: Appreciate priorities – clinical, financial, legal and ethical

Objective: to understand and manage the legal and ethical implications of advice on suitability for work

KNOWLEDGE:

Decision Making

ABC of Work Related Disorders: Assessing Fitness for Work by William Davies BMJ 1996; 313:934-938 (12 October)

Appreciate priorities – clinical, financial, legal and ethical.

Doctors often make decisions about fitness for work. In primary care this is often associated with the issuing of medical certificates for incapacity for work (sick notes).

The process by which a decision is made regarding fitness for work is often complex and there is a need to consider several areas.

Clinical implications

The doctor must consider the clinical implications for an individual returning to work. Consideration must be given to the following factors.

  • Whether an individual is fit both physically and mentally fit to return to their normal employment.
  • Whether modifying individual’s tasks at work would be required to enable them to return to work.
  • Whether returning to work is likely to harm the individual’s health

Financial implications

The financial implications of certifying a person unfit for work should be carefully considered. Absence from work can lead to financial gain or loss, depending on the individual’s employment status, their duration of absence and the contract they hold with their employer.

Legal implications

The fit note is a legal document. A doctor certifying an individual as unfit or fit to work can be held accountable for that decision and must understand their responsibilities in issuing a certificate.

Ethical implications

Doctors can be left with a moral dilemma when an individual requests a certificate. For instance: an individual may request a certificate to look after a sick relative even though they are well. The doctor needs to make a decision how they might manage such a request ethically.

Be aware of the medico-legal and ethical implications of decision making and accurate recording of data.

Doctors are accountable for their decisions. Clear and accurate note keeping is essential. All relevant information relating to the decision making process should be recorded accurately in the clinical notes. Clinical notes and the decision making process may be subject to scrutiny at a later date if a dispute regarding treatment, management and fitness for work arises. This is outlined in detail in the General Medical Council (GMC) guidelines ‘Good Medical Practice’ which has recently been updated 2006.

Individuals have a right of access to their notes and whilst at the time there may have been clear reasons to the decision made, without accurate and detailed data this may prove difficult to justify if a complaint should arise.

Take into account function and capability in addition to diagnosis

Decisions on fitness for work are complex. They are influenced not only by the nature and severity of a medical condition but equally by individual variability. Individuals vary in how their illness may impact on their function and capability. It is important therefore to assess each individual on their own functional capabilities. This should include understanding how not only their symptoms but also their treatments (where appropriate) impact on their function both in and outside of work. It is important to make an assessment of both their physical and psychological symptoms.

Hence 2 individuals with the same diagnosis or medical condition may respond differently.

Consider the following example:

Two female employees are being reviewed 3 weeks following a routine abdominal hysterectomy. The first lady is struggling with walking greater than 200 yards, standing for longer than 5 minutes and doing very little housework. In contrast to the second lady who is performing all household duties and is keen to return to work. According to ‘evidence return to work times’ 7 weeks is the suggested period of absence following an abdominal hysterectomy, but it is important to assess each individual in relation to their current functional ability, and job requirements.

This will need some detailed questioning about their daily activities, what their job entails, as well as facilities in the workplace to help support an early return to work.

An assessment of fitness to work should be adequately and accurately made by enquiring about an individual’s functional capability exploring both psychological as well as physical factors.

In assessing functional capacity there are many factors to consider. Some of these are discussed below.

  1. Physical state
    • The individual’s general appearance, posture (ability to stand) and mobility should be considered.
    • Cardio respiratory function should also be considered. i.e. limited exercise tolerance.
    • Neurological functioning. This should include
      • Co-ordination
      • Manual dexterity; pincer grip if appropriate
      • Balance; working at heights
      • Muscle power; ability to pull, push lift etc.
      • Sensory organs; vision, hearing
  2. Mental state
  • speech, communication, ability to cope with daily activities, handle pressure, and complete tasks should be assessed.

3. An outline of daily activities: this can give an indication of stamina, and motivation.

4. Medical history; an outline of this can provide valuable information regarding active and inactive medical conditions with subsequent consequences; medication, prognosis and any further treatment.

It is also important to consider requirements related to specific jobs such as the ability to climb ladders (for construction workers) to work outdoors (for grounds men) or to work in a cold store (e.g. food warehousing workers). Someone might be mobile at ground level but unable to climb or mobile in warm weather but less so in the cold. All of these factors need to be taken into consideration when assessing functional capacity in a work setting.