Occupational Medicine

Occupational Medicine 2008 58(5):318-322; doi:10.1093/occmed/kqn078

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Doctors’ health and fitness to practise: assessment models

John Harrison

Workplace Health and Wellbeing, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK

Correspondence to: John Harrison, Workplace Health and Wellbeing, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK. Tel: +44 (0)208 383 1514; fax: +44 (0)208 383 3395; e-mail: john.harrison{at}imperial.nhs.uk

	Abstract

Top Abstract Introduction Who assesses? Models of assessment Next steps Conclusions Conflicts of interest References

 
Abstract The assessment of doctors’ health and fitness to practise is recognized as a specialist area of occupational medicine practice. This paper will consider the involvement of specialists from a variety of disciplines in the overall assessment process and will discuss some current assessment models. The paper will make recommendations for further developments in this area.

Keywords      Assessment; doctors; impaired; physicians

	Introduction

Top Abstract Introduction Who assesses? Models of assessment Next steps Conclusions Conflicts of interest References

 
It has been argued that the assessment of doctors’ health and fitness for work is a specialist area of occupational medicine practice [1]. The compact between doctors, patients and the state is changing and there is a need for greater transparency in the methods of assessing fitness for practice [2]. This includes the health assessments that lead to decisions about fitness for work. However, there is a lack of published guidance about methods of assessment. A recent systematic review of the criteria and methods used for the assessment of fitness for work found only 39 publications for analysis [3]. Of these, only one paper was concerned with doctors. Guidelines for the psychiatric fitness for duty evaluations of physicians from the American Psychiatric Association provides detailed guidance on taking a history, gathering additional evidence, performing a psychiatric examination and writing a report [4]. This paper will discuss who assesses doctors’ fitness for work and will review models of assessment.

	Who assesses?

Top Abstract Introduction Who assesses? Models of assessment Next steps Conclusions Conflicts of interest References

 
It is apparent that the assessment of doctors’ health and fitness for work may be complex. Doctors may suffer from one or more medical conditions, which may or may not impact on fitness for work. Medical knowledge as well as medical culture may influence the way that doctors present as patients and to the occupational health physician. There is evidence that doctors are not good at looking after their own health and they may be reluctant to consult other doctors. In a review of the health of health care workers by the Nuffield Trust [5], the major findings were of ill-health related to psychological disturbances and unhealthy lifestyles, including excessive alcohol consumption. The review referred to a survey of junior doctors indicating that they tended to report frequent minor illnesses, rarely took time off work and commonly self-prescribed. In 1995, an Australian randomized sample postal survey of doctors’ attitudes towards their own medical care (with a 44% response rate) showed that while almost one-fifth had marital or emotional problems, 3% admitted to alcohol problems and 1% to drug problems; only 42% had a general practitioner (GP) and few had discussed their problems with them [6]. A 1999 New Zealand questionnaire study on a random sample of doctors found that although many claimed to be working under substantial stress, relatively few had regular health assessments. A Spanish questionnaire survey of 795 doctors showed that 49% did not have a family doctor, 82% self-prescribed and 47% did not attend occupational health appointments [7]. In the same year, a UK postal survey of GPs and consultants in the South Thames area found that although 96% of the doctors were registered with a GP, little use was made of their services. Almost a quarter of consultants would bypass their GP to obtain consultant advice. Most doctors prescribed for themselves and their family [8]. Only 11% of GPs reported availability of occupational health services compared with 95% of consultants, most of whom had never used them for preventive purposes. Perceived barriers were access, confidentiality, lack of occupational health services and difficulty in finding locum cover for GPs and consequent expense. A recent survey suggests that provision of occupational health for primary care staff has improved but that it remains difficult to access. In addition, general occupational health knowledge was reported to be limited among GPs [9]. This is likely to perpetuate their lack of trust in occupational physicians.

The most likely medical assessors of doctors’ health are organ-based specialists addressing particular health concerns. Occupational health physicians may be assessors, in some systems, in relation to employment processes, such as pre-employment health assessments and/or work performance concerns. Psychiatrists, orthopaedic surgeons or rheumatologists and cardiologists are the most likely specialists to be consulted in the UK. The complexities of mental ill-health in doctors, with implications for behaviour at work, substance abuse and suicide, imply the need for a close working relationship between occupational health physicians and psychiatrists when assessing fitness for work. The liaison psychiatrist with an interest in occupational health can assist not only in the rehabilitation of sick doctors [10] but also managing the ‘problem’ doctor with disruptive behaviour [11].

Occupational psychologists can assess the role of personality in performance at work and can make inferences about doctors’ behaviour when suffering from stress. Firth-Cozens [12] has described a ‘chronic fear of being disapproved of and criticized’ as drivers of achievement and perfection, but at the risk of depression associated with self-criticism and feelings of unworthiness and guilt. Such individuals may be unduly defensive and respond badly to feedback about their performance. Research into the role of personality on performance has been undertaken in many settings, but rarely in medicine. However, it is believed that the findings from studies carried out within management, military, social and health psychology fields may be relevant to medicine [13]. The aviation industry has been cited as a comparator for medicine with regard to health and safety [14]. Safety attitudes of airline pilots have been studied and so-called ‘macho’ pilots—those who wanted total control with feelings of invincibility—were deemed to make the worst pilots [13]. The ‘big five’ personality factors—five factor model of personality—are considered to be reliable predictors of job performance in a wide variety of occupations. Conscientiousness, emotional stability, openness, extraversion and agreeableness make up the big five, of which conscientiousness is said to be the most consistently valid predictor of performance in occupations. Work on employees who ‘derail’, that is employees whose health, conduct or performance puts their employment or registration at risk, has identified some themes that appear to be persistent [13]. These are

(i) problems with interpersonal relationships

(ii) failure to meet business objectives

(iii) inability to build or lead a team

(iv) inability to change or adapt to a transition.

In complex cases, such as those involving interpersonal relationship difficulties or apparent unusual behaviour of the doctor being referred, the importance of informant information comes to the fore. When trying to identify the impaired doctor, it is recognized that social or personal difficulties can precede problems in professional practice [15]. Evidence from friends or family can assist the occupational physician to corroborate the medical history obtained or to challenge lack of insight. Similarly, detailed and accurate information from work colleagues can help elucidate claims and counterclaims about work performance. The utilization of skills laboratories and the recently devised workplace-based clinical assessments [16] could assist fitness for work assessments in the future, work colleagues becoming assessors of aspects of practice.

	Models of assessment

Top Abstract Introduction Who assesses? Models of assessment Next steps Conclusions Conflicts of interest References

 
To date, models of assessment have concentrated on either the evaluation of doctors who have got into trouble in clinical practice or screening for health problems at the point of entry into a new job. The assessment of the impaired physician is well established in the USA, and in the UK, doctors may be referred to either the National Clinical Assessment Service (NCAS) or the General Medical Council, the statutory licensing body. In Europe, it appears from published literature that national or local hospital policies for dealing with impaired physicians are lacking in many countries [17].

Physician health programmes (PHP) have been established in the USA, linked to licensing boards and medical societies. The remit of the programmes is to identify, treat and monitor impaired physicians [11]. In addition, individual hospitals have been mandated by accreditation organizations to establish non-disciplinary processes to address physician health, including an internal physician wellness committee whose role is to investigate complaints about physicians with suspected impairment and to make appropriate referrals for evaluation and treatment. The definition of physician impairment includes the ‘disruptive physician’ whose conduct may affect patient care or the ability to work with health care teams. The model relies on observers reporting physicians. However, identifying illness in colleagues may not be straightforward. Changes due to substance abuse often occur initially outside the workplace such that by the time performance at work has become evident an illness may have been longstanding [15]. Doctors’ responses towards other impaired or incompetent doctors may also depend on their status. In one study, house officers were much more likely to personally confront colleagues of similar status than confront senior physicians where there were concerns about impairment [18]. They were more likely to report seniors to the chief resident and all doctors considered to be incompetent. A more recent study, again in the USA, found that physicians would report other physicians to a PHP, but they were more likely to hypothetically report physicians suspected of substance abuse than those who were emotionally or cognitively impaired [19]. It is also recognized that, culturally, doctors displaying unusual behaviour are given more latitude than would be given to others [15]. Published guidance for PHP evaluators on the assessments of fitness for duty focuses on psychiatric assessments [4,11]. However, the importance of a recent physical examination by a qualified internist or sub-specialist is emphasized. The psychiatric assessment and mental state examination focuses on work history and performance problems. Triangulation can be obtained via questions about peer review problems, complaints or referrals to the licensing authority. The importance of corroborative data from the spouse, other important people and the referring body is also emphasized. Where concerns about cognitive function are raised, an expanded mental state examination is required, with onward referral for neuropsychological assessment, as required. Tests for possible substance abuse are performed separately by appropriately qualified personnel. Reports from the evaluator usually contain opinions relating to diagnosis and possible treatment options. The level of detail appears to be influenced by the nature of the referring body, whereby issues of confidentiality become more apparent if the referral is made by the employing hospital, rather than the state licensing body.

In the UK, some assessments of impaired physicians may occur at a local hospital level, usually where the health care organization employs a specialist occupational physician, but complex or persistent problems are now referred to NCAS. NCAS (formerly the National Clinical Assessment Authority) was created in 2001 to address unresolved longstanding concerns about the performance of doctors [20]. It is part of the National Patient Safety Agency. At the end of March 2006, there were 414 active cases that had been referred from 294 organizations, 282 of which were National Health Service provider organizations in England, Wales and Northern Ireland. (The NCAS did not accept routine referrals from Scotland, although ad hoc referrals were possible.) This included 102 of 173 (59%) acute trusts in England. Not all referrals lead to a full assessment by the NCAS. In many cases, advice and support is provided to assist local resolution of problems. However, where concerns are significant, recurrent and substantiated and appear to be related to professional practice rather than a disciplinary or health matter, assessments are carried out [21]. Forty-seven cases were assessed in 2005–06, which was an increase of 44% on the previous 12-month period. Although a criterion for not accepting a referral is that the reason for poor performance should not be due to an overt health problem, it is recognized that hidden or inadequately assessed ill-health may contribute to poor performance at work. Analysis of the first 4 years of the NCAS reveals that 20% referrals involved health problems [22]. Donaldson [23] acknowledges the complex interplay between work, health and well-being in a profession such as medicine and refers to the work of NCAS. Although not the most prominent aspect of the findings from NCAS on ability to practise safely, it is clear that ill-health, which in many cases was not apparent to the referring body, featured in the recommendations from NCAS to the referring body following assessment. In 11 of the first 50 cases (22%), health concerns were addressed [24]. This compares with 45 cases where concerns related to clinical practice and 44 cases relating to work environment, organizational functioning and relationships. The NCAS assessment framework comprises three separate stages: an occupational health assessment, a behavioural assessment and an assessment of clinical practice in the workplace. The occupational health assessment is carried out by a specialist occupational physician. The behavioural assessment is carried out by an occupational psychologist using personality assessment questionnaires followed by an in-depth interview. The questionnaires are the NEO-PIR, a personality test designed to measure the major domains of personality [25] and the Hogan Personality Inventory [26], a measure of how individuals might react in certain circumstances, such as when stressed. The assessment of clinical practice is carried out by two trained clinical assessors and a trained lay assessor at the place of work. This gives the assessors an opportunity to talk to other employees in the referring organization and to assess management systems and culture, as well as the individual performance of the doctor. Reports from each stage of the assessment are fed back to NCAS to provide content for the final report, which is drafted by a separate team. The overall assessment is formative and the final report provides information and recommendations to the doctor and the employing organization about areas of good practice as well as areas for improvement.

The NCAS occupational health assessment has evolved considerably since 2001. It began as a conventional occupational health assessment comprising a clinical assessment of existing health problems and an assessment of the relationship between health and work. The initial remit was to determine fitness to undergo the remaining parts of the NCAS assessment and to advise on the relevance of existing health problems when making recommendations for change in the final report. The remit has expanded to carry out a psychiatric screening, using the Hospital Anxiety and Depression Scale [27] and a detailed psychiatric history. A further expansion to testing for alcohol misuse has been added, to be followed by clinical screening for cognitive impairment later in the year, using the revised Addenbrookes Cognitive Examination [28]. Onward referrals for specialist psychiatric, neuropsychiatric or neuropsychological assessments, where deemed appropriate, are part of the assessment framework that is funded by NCAS.

	Next steps

Top Abstract Introduction Who assesses? Models of assessment Next steps Conclusions Conflicts of interest References

 
Current models of assessment, however sophisticated, are essentially reactive. There is a need for a proactive approach to physician health and well-being that encourages individual responsibility for health and fitness for practice and that promotes systems to encourage early intervention when health and performance deteriorates. The rationale for paying particular attention to the health of doctors and their fitness for work relates fundamentally to patient safety. Doctors whose clinical practice affects decisions about individual patient care must be considered to be in safety critical jobs. This means that if their performance is sub-standard patients may be harmed. Concern may be about an acute event that would incapacitate a doctor, for example, a surgeon conducting an operation or a chronic fluctuating problem causing impairment of functioning. With regard to the latter, it might be the behaviour of the doctor as much as the decision-making capabilities that is the cause for concern. The assessment of the health and fitness to work of doctors should, therefore, be in the context of a health and safety system, but also a quality assurance system, such as clinical governance [29]. To refer again to the aviation industry, medical checks are carried out on pilots routinely, according to age and type of flying. A recent review of 1000 fatal accidents between 1956 and 1995 revealed that 47 had a medical factor of which over half were cardiac in origin [30]. In most cases, pilots of aircraft are part of an onboard team and commercial aircraft have two pilots to guard against the eventuality of one pilot becoming incapacitated. It is also appreciated that 10% of the flying task is safety critical (take off and landing). Medical incapacitation of up to 1% per annum is considered unlikely to affect the target accident rate for the industry and medical screening is designed to keep incapacitation rates below this level (R. Johnston, personal communication). In addition, there are organizational resources designed to mitigate the impact of impaired performance. Crew resource management (safety training and involvement of the cabin crew) operates in the event of a sudden or subtle incapacitation. Feedback to the pilot followed by subsequent time on the flight simulator aims to address the problem. Team resource management is a process of giving feedback on the performance of colleagues as part of a no-blame culture. There is a mandatory occurrence reporting system providing information on incidents to the Civil Aviation Authority.

The closest similarities between flying and medicine are probably in the surgical, interventional and investigatory disciplines, where standard operating procedures either exist or are possible. Such activities are team based. Technical skills as well as judgement are required and these can be assessed using simulators, in some cases. However, other branches of medicine do not fit the analogy. For example, general practice and psychiatry may involve doctors working in relative isolation with complex patient interactions. However, clinical governance, which should incorporate processes akin to crew resource and team resource management, applies to all branches of medicine and occupational health assessments should occur in this context.

Should doctors have regular medical screening? As with any question about screening it is necessary to determine what is being proposed, why, the cost and how it will benefit the population being screened, as well as the public [31]. In an occupational health setting, the implications of findings on fitness for work and future employability must be addressed as well as the provision of medical treatment. A recent study in the USA has questioned the value of an annual physician check-up, while supporting the uptake of established public health screening programmes [32]. There is also some evidence that untargeted physical examination of Royal Air Force personnel is of little value in addition to screening tests when performed as part of routine health surveillance [33]. The aim of medical screening in doctors, from a health and safety perspective, should be to identify underlying health conditions that are likely to increase the risk of medical events or impaired performance during safety critical procedures with an associated increase in the risk of an adverse patient outcome. There is a need, therefore, for analysis of doctors’ activities and the current control systems for preventing such adverse outcomes. Research into the influence of underlying medical conditions on the occurrence of serious untoward incidents would help identify the priorities for screening programmes.

However, patient safety will be protected most effectively by changing medical culture and attitudes towards physician impairment and towards promoting health and well-being. It is estimated that ‘when all conditions are considered, at least one-third of all physicians will experience, at some time in their career, a period during which they have a condition that impairs their ability to practise medicine safely’ [34]. Unfortunately, there is evidence that, despite advances in medical technology and treatment options, many physicians remain wary of disclosing illnesses because of the perceived risk of professional, societal or legal sanctions [15]. The American Medical Association has put forward recommendations for addressing the issue of impairment based on its code of medical ethics [35]. It places obligations on doctors, as individuals, and as part of the medical profession to promote health and well-being and to act responsibly in identifying and supporting the impaired physician. The role of occupational health expertise is seen as a key element in assessing fitness for work. Occupational health services, with suitably qualified and experienced specialists, should play a central role in helping to prevent ill-health at work and in assessing illness and the need for rehabilitation and adjustments to working practices.

	Conclusions

Top Abstract Introduction Who assesses? Models of assessment Next steps Conclusions Conflicts of interest References

 
The need to replace ad hoc assessments of doctors’ fitness for work and fitness to practise is clear. The impaired physician may pose a risk to patient safety and it is important that concerns relating to health and behaviour are fully assessed taking into account individual and workplace factors. Countries such as the USA and the UK have started to develop models of assessment that have much in common although methods of delivery differ. There is an increasing realization that a proactive approach to assessment is required that begins with a promotion of general health and well-being of doctors and which includes the provision of appropriate treatment options and support to encourage participation. The role of occupational health expertise is becoming recognized as being of central importance in the assessment model. More research into the relevance of doctors’ ill-health to patient safety, when working as part of health care teams with embedded safety systems, is required.

	Conflicts of interest

Top Abstract Introduction Who assesses? Models of assessment Next steps Conclusions Conflicts of interest References

 
None declared.

	References

Top Abstract Introduction Who assesses? Models of assessment Next steps Conclusions Conflicts of interest References

 

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