Exercise Caution: Fitness Certificates and Medico Legal Risks

Case history

The patient needed a “fitness certificate” to be completed by a doctor before joining the local fishing club. Questions included whether the patient could safely tolerate the following situations:

•   Spine: able to tolerate brief impacts through the spine when sitting in a boat at sea.
•   Cardiovascular: able to outswim a great white shark over 100 metres and re-enter a boat.

Discussion

A “fitness certificate” involves a doctor providing a medical clearance that certifies a patient is physically able to perform specific activities or jobs. Such certificates involve assessing the risk of an adverse outcome, taking into account a patient’s physical function and health status. This must then be weighed against the physicality of the planned activity, including an understanding of the likely intensity, duration and frequency of the activity.

However, this information will usually not be available to the doctor and may be under (or outside) the control of the requesting party. Appropriate assessment by the doctor may be impractical, impossible, or overly onerous.

Fitness certificates may also expose a doctor to claims or complaints where harm arises in relation to the patient’s participation in the activity if this risk has not been properly assessed. Complaints may also arise where a doctor refuses to complete the request.

The request for a medical clearance is often an attempt by the requesting party to shift their legal liability to the doctor, where normally the requesting party has a responsibility to appropriately implement reasonable risk management policies and procedures.

Dealing with fitness certificate requests

Arguably, where a doctor has received an appropriate fee and patient consent, they have an ethical obligation to provide factual information required by the requesting party. However, this does not imply that the doctor must follow the format of the request and/or provide their opinion.

Under the Medical Board of Australia’s Code of Conduct (at 8.8 – Medical reports, certificates and giving evidence), a doctor has an obligation to be honest, accurate, and to take reasonable steps to verify the content of a report and not deliberately omit relevant information.

MDA National’s advice is to provide the requesting party with a relevant factual health summary including clinical information such as past history, co-morbidities, physical limitations and medications. Relevant negatives may also be significant (e.g. patient has not undertaken cardiac stress testing). Future management plans such as referrals and further testing should be included.

A request by a patient to deliberately omit relevant information should result in the doctor declining to assist. Opinions may be provided where the doctor is comfortable that these opinions are supported by appropriate facts and the doctor has relevant expertise. Otherwise leave such questions blank or suggest where further information might be obtained.

Sometimes it will be necessary to provide a referral to another health practitioner or other fitness assessor for further review. This may include medical referrals (e.g. stress tests, Occupational Health Physicians) or referrals to allied health providers (e.g. Accredited Exercise Physiologists, Physiotherapists) with specific expertise in this area.

Fitness certificates allow the requesting party to decide whether the patient is suitable for the task at hand or whether risk modification can be undertaken by the patient or the requesting party. It also allows the requesting party to seek further specific information where necessary.

Members seeking advice can contact our Medico-legal Advisory Service on 1800 011 255
or email advice@mdanational.com.au.

Summary points

• You do not need to answer every question or follow the format of the request. You should provide any information that you consider is relevant.
• Information provided might include a health summary, past history, co-morbidities, physical limitations, medications and future management plans.
• If necessary, refer the patient to other fitness assessors or health practitioners with specific expertise in this area for further review.
• Be honest and accurate in your response. Only include information that you can verify and do not deliberately omit relevant information. If the patient requests you to omit relevant information, you may decline to complete the request.