(The following information has been contributed by Dr. Michael Kotler, MD, as a co-author of a Fitness for Duty Testing book being written with lead author, Dr. Bunch, and associates.)
Occupational medicine professionals care for people working in a very broad range of industries. Moreover, the job descriptions of the workers in these industries cover almost every type of job imaginable. With that said, the unique demands of the oil and gas industry place it in a league of its own. As an industry, successful operations require that workers be capable of meeting very stringent physical and psychological standards, and rightfully so. There is a complex relationship formed by combining the client oil and gas company with the drilling contractor. This becomes even more complicated once the numerous independent, yet interdependent, subcontractors or “support” companies are added to the mix. Mandatory to the process, subcontractors will vary throughout the course of a project, from beginning to end, and are important to its success. The importance of these relationships, where they take place and the influence they pose on a project’s success or failure compels one to examine the role of fitness for duty as never before.
Every facet of the oil and gas industry is demanding and complex, beginning with exploration. Right this minute, there are small crews exploring the far corners of the world looking for hydrocarbons in quantities sufficient to warrant further investigation, drilling, and production. Fieldwork is typically very remote from corporate headquarters, which requires long and expensive travel. As a project ramps up, getting the vast numbers of workers, vital to a project, into a specified region is complicated, expensive and, typically, requires even more costly, noncommercial means of transportation, such as helicopters or crew boats to complete the journey. This applies equally for the less remote work sites such as the Gulf of Mexico.
With the involvement of thousands of workers accounting for millions upon millions of man-hours worked, routine costs alone are astronomical. Thus, it is mandatory for medical professionals to pay close attention to each remote worker’s fitness for duty, regardless of job description. Furthermore, it is imperative that they continue to maintain close medical surveillance and a proactive approach throughout the full extent of every remote project. This is something known as dynamic fitness for duty or work readiness because it remains in an ongoing or dynamic state. This will be discussed in more detail in another area. The overall financial burden, including wellness responsibilities for the offshore work force amounts to a massive amount of money. Regardless of the payer, whether it is the operator, the drilling contractor, third party contractor or even the worker himself, someone has to pay the bills. A properly executed and maintained fitness for duty program can have a tremendously positive financial impact on any remote project, not to mention the lives it might save.
The determination of fitness for duty begins with the post-offer, pre-placement process. However, before that process can be put into place, it is mandatory that the employer comply with all applicable statutes and regulations surrounding the HR Process. This is absolutely a necessity so that their employer remains in regulatory compliance with EEOC and important federal regulations such as the Americans with Disability Act (ADA).
It should be noted that the size and type of company would reflect, to a certain degree, how it is viewed by OSHA. It may also play a role regarding a company’s expectations for fitness. Certain jobs such as commercial drivers (i.e. bus drivers and truck drivers), crane operators, heavy equipment operators, merchant mariners, and boat captains mandate the worker be licensed. Eligibility for these individuals to work is determined by statute. It actually simplifies the process by making one’s eligibility to work very clear-cut.
Companies might also have their own physical examination or, as in the oil and gas industry, utilize certain universally recognized physical examinations, developed for purpose: specifically, Medtrack and OGUK . Physicals were designed as comprehensive screening tools, to predict the odds of a worker requiring urgent or emergent medical care while working at a remote location. This serves to protect both the company, as well as, the individual. The implications are self-evident. These physical examinations, done conscientiously, by properly trained professionals, who understand the environment and the nature of the work, along with a properly conducted functional capacity evaluation (FCE) are absolutely the best possible way to mitigate risk.
Despite the upfront costs, when done in conjunction with well thought-out ancillary testing, you can further avoid the unnecessary waste of potentially huge payouts for Medevacs, Hospital bills, repatriations, etc., not to mention the lives that might be saved. Just like a professional football recruit would be expected to pass a physical examination and skills test as part of the requirement to make the team; one might view the employee as an industrial athlete, giving the employers in this arena that same right. After all, both teams, the professional football team and the “oil and gas team” have a lot in common. They are both about to invest a lot of money and time in a new “team member” and want to be absolutely certain that their new “team member” is in good physical condition, will be able to contribute to the team, and not put any of his teammates at any unnecessary risk. The rules may be different, but the concept is identical.
Establishing Clearly Defined Policy is a Must
It is imperative that the company has well established and clearly defined, written policies and procedures regarding every aspect of the hiring process and physical examination program. This would include a clear definition of what constitutes fitness for duty. Every position must have a job title and job description. Furthermore, these must be individually verified or validated by a medical professional, typically a certified physical therapist with additional ergonomic training and credentials. Using a validated job description, as a guide, a comprehensive physical and functional demands test based upon the candidate’s actual job functions is the final step in the process. The entire process must be designed to provide the employer with an objective evaluation of a candidate’s physical capabilities to perform a specific job. As well, it must be capable of withstanding any potential scrutiny by an EEOC or ADA claim.
Two overriding considerations are paramount when designing a fitness for duty program for your company. Primarily, it should be practical and give you peace of mind knowing that the level of thoroughness is commensurate with the risk. Secondly, it must be cost-effective when examining the risk/benefit ratio. This allows you to justify any added expense.
Physical examination dollars should be budgeted around collecting the most pertinent information. In other words, you should look at the type of work that is being done and where, concentrating on gathering the most useful information to serve your purpose. It all starts by selecting the correct baseline physical examination(s). Two questions need to be answered:
Many physical examinations are mandated by the job; DOT, OGUK, Norwegian and Coast Guard just to name a few. These physicals are prescribed or mandated by regulatory or governmental agencies, many of them require that the examining facility and physician be specially credentialed in order to perform them. Regarding the oil and gas arena, the required physical examination(s) is often based upon the geographic area, state, or country under which a vessel is flagged. If it is not already prescribed as part of the physical, you must next consider which ancillary testing would best serve your purpose. This is dependent upon a number of factors, the two most important being the personal health of the individual employee and job safety. When discussing safety you are considering not only the employee being examined, but also his co-workers and the project as a whole. Safety is universal and must permeate every aspect of industry.
There is no substitute or alternative to a carefully executed medical history and physical examination. On the other hand, choices for ancillary testing are almost endless. Here is where the real discussion and decision making begins. As previously stated, you will need to use your physical examination budget wisely. For instance, there would be no reason to include a 2-view CXR, read by a B-Reader radiologist, typically used as a routine screening tool for Mesothelioma (footnote), in an industry that has nothing to do with asbestos or asbestos abatement. Additionally, one would not include routine screening for lead (footnote) in an industry that poses no risk of exposure to lead-based paint or its removal. Nor would one waste money doing routine urine phenol (footnote) screenings for an industry that poses no risk of exposure to benzene vapor. These are just a few examples to drive home the importance of using your ancillary testing budget judiciously. This money is budgeted for the gathering of information that has a real value for both the company, as well as, the employee.
Aside from examinations that are regulated (i.e. DOT, Coast Guard and North Sea) or those that are prescribed to meet compliance (i.e. for the flagged state of a vessel) determining what constitutes a meaningful fitness for duty physical examination should be determined through a thoughtful and calculated process. A company representative should sit down with an occupational medicine provider and work through which ancillary testing components make the most sense for their employees, their scope of work and their company. Ultimately, a number of key considerations must be factored in, such as job description, job location, and budget. Each of these, while individually significant, is very much interrelated, something that is often either overlooked or simply ignored. Budgeting appropriately upfront avoids misspending down the road. Shortcuts that save the company money from one pot, inevitably, end up costing ten times more from another. Things like Medevacs and other unscheduled transportation, urgent and emergent medical care, whether work related or personal, legal fees, Jones Act (Footnote ) costs, etc. can add up to very significant sums. All too often this, either directly or indirectly, is the result of an inadequate, or even worse, a completely absent fitness for duty program . Upfront savings that are created by excessively frugal hiring and return to work policies become lost somewhere down the line as the result of those same policies. What seems to be missed, ignored, or is just difficult to quantify are the savings realized by a properly executed program. In reality, total upfront savings adds up to but a fraction of the money wasted by not doing things properly from the start. It is the sum of the budgets and how the money is spent (or not spent), that affects the company’s bottom line. The idea is that monies well spent on the front end will realize significant savings on the back end. Companies definitely, albeit reluctantly, acknowledge that doing things correctly does come with a price. The challenge remains on how to measure the cost/benefit ratio. The upfront costs are easily tracked and defined; however, back-end costs remain entirely unpredictable, and will only be pinned down with ongoing tracking and study. Nevertheless, years of experience both in the office and in the field, have demonstrated that a robust fitness for duty program will have a huge influence on back end costs and, subsequently, the bottom line
Factors to Consider When Building a Fitness for Duty Program
When building a fitness for duty program, start by considering the above, and then concentrate on location/remoteness of the job, type of work/job descriptions, on-site medical back up, modes and expense of transportation, access and distance to advanced medical care, etc . At a minimum, each fitness for duty evaluation begins with a thorough head to toe history and physical examination. There are no shortcuts to this process. Each patient must be disrobed and placed in a patient gown. Physical examinations should never be done on a clothed patient. In this arena, the purpose of the physical examination may be to make certain an individual is fit for duty and can work safely. While patients, corporate executives and medical professionals, alike, say, “it is only a work physical,” physicians have a fiduciary responsibility to each person examined. Regardless of the payer, physicians must use their education and skill level not just for identifying fitness for duty, but to accomplish a true and thorough evaluation, looking for any type of occult or underlying disease process. One must always keep in mind that once a layperson passes a physical examination, they very appropriately assume themselves to be in good health, and not in need of any further work-up or care. What makes this so important is that their pulse and blood pressure, hearing and eyesight might all be normal. As might their musculoskeletal exam show them to be very capable of safely doing the job they were offered. However, lumps and bumps, such as an isolated lymph node abnormality or a small thyroid nodule, could be easily overlooked on a cursory physical exam and neither is very important regarding one’s ability to work, at least initially. However either one, if missed, could eventually cost someone their life. If they are left under the mistaken impression that the medical provider did a thorough physical examination, much like their primary care physician would, it would negate the need for them to see any other medical provider in the near term. A PASS needs to truly reflect the individual’s genuine state of health and have true meaning beyond his capability to do the work that s/he has been offered.
Once an individual is found to be in good health and cleared, passing the physical examination, s/he is also cleared to undergo the Functional Testing process. A Physical examination addresses one’s general state of health. Functional testing addresses one’s physical ability to do the job they have been offered. These are two very different things. Functional testing is typically administered by a physical therapist who has received specialty training in Ergonomics and Industry . They begin by examining the functional demands (footnote) of each individual job description (footnote) as provided by the employer. It is expected that these job descriptions have been validated (footnote) or will be validated prior to the commencement of testing. Functional testing, in the proper hands, serves a number of very important purposes. Most importantly, it demonstrates an individual’s capability to perform the job s/he has been offered or to which s/he would like to return. However, the process, particularly that of validation can also serve to identify and help correct ergonomic and operational problem areas noted at the work site. This alone has the potential to more than offset the cost of this service. It should be noted, as well, that functional testing serves to insulate and protect a company from frivolous EEOC and ADA claims, again adding to its practical and economic value.
Thus far, the determination of fitness for duty has centered around hands on physical diagnosis by a medical professional. Nevertheless, there is an extensive array of ancillary diagnostic testing to draw from depending upon what is trying to be accomplished. For particularly physical jobs, imaging (i.e. X-rays and/or MRI’s of the L-spine and C-spine) can provide valuable information to the examiner. For remote work, whether onshore, just off the coast, or across the globe, physicians and physical therapists have the ability to drill down on the overall health of a worker using the many ancillary testing modalities as predictors. In other words, an in-depth assessment of one’s overall health and physical condition can be used to predict the “odds” of an individual requiring urgent or emergent medical care while working at a remote work site. Whether personal or work related, emergency medical care, Medevacs, repatriations, etc., from a remote work site are very expensive and sometimes risky. In fact, the more remote they are, the more costly they become.
This is where the decision-making comes in regarding the cost/benefit ratio of the testing. The benefits are obvious, not just for the company, but for the employee as well. Repeatedly, while performing Medtrack or OGUK Physicals, employees have had to be placed on medical hold, preventing them from traveling to a remote work site. These are always difficult, sometimes painful, decisions to have to make. Despite how difficult it might be on everyone involved, once a physical condition that could potentially lead to a Medevac is identified there is no other choice. Even worse, the wrong decision could very well cost a person their life, and one must never forget that one single mishap could cost a company more than the cost of an entire fitness for duty program. That does not mean that the sky is the limit. This is where you must work with your medical provider to design a cost effective, yet appropriate program.
For workers doing moderate to heavy labor, a thorough Physical Examination must considered along with Functional Testing as the core of any fitness for duty evaluation. Additional ancillary testing will be driven by the industry, circumstances, and logistics. Two examples of industry-specific screening are lead and ZPP levels for possible lead based paint exposure and urine phenol for a potential Benzene exposure. This typically applies to industries employing sandblasters and petrochemical workers, respectively. Another example includes imaging or, for this example, chest X-rays which are read by B-reader radiologists for workers doing asbestos abatement. This process serves to protect both worker and employer. Baseline studies are a part of demonstrating a worker’s fitness to enter the industry. Routine follow-up studies demonstrate a worker’s ongoing physical condition and ability to safely continue their duties, again, serving to protect both company and employee. This is a win-win, and undeniably, well worth the expense.
It is essential to recognize that wellness and fitness for duty overlap.
Together, they play a critical role in maintaining a safe, efficient, and cost-effective operation. This is the area that provides the most room for discussion, particularly when looking at cost/benefit ratios. There are a myriad of screening panels, markers, imaging and other diagnostic tools. Granted, if they have one, this type of testing is most typically done by one’s primary care physician (PCP). As a rule, health-screening exams are generally determined upon evidenced-based considerations, such as a patient’s age, family history or the presence of a specific risk factor. For most companies and workers, this type of company sponsored testing could be considered excessive and cost prohibitive. The exception might be for companies offering comprehensive benefits (i.e. Health, Disability and Life Insurances). Because these extended health-screening exams have the potential to play a key role by lowering insurance premiums for the employer. The savings realized by a company’s proactive stance serves to both offset and justify the added cost of the additional testing. For global corporations and their employees, especially those with individuals whose jobs require them to travel extensively, often to remote locations, or for those employees who are permanently assigned to a remote work site, the added expense of carefully calculated ancillary testing pays for itself. For these individuals, fitness for duty takes on a completely new meaning and goes way beyond one’s ability to simply perform their job. Due to the long distances traveled and the fact that many of these individuals live out the vast majority of their careers far from home, this extra testing is of critical importance; in fact, it could be lifesaving. Mitigating the risk of a personal health condition from being exposed in the field limits the chance that an individual will become the subject of an unscheduled Medevac or medical repatriation. Most importantly, it diminishes the risk of someone suffering a catastrophic event in a remote area halfway around the world. Medical care in these remote locations is unpredictable and often questionable; getting one to an acceptable standard of care can be extremely challenging and very expensive. The cost of just one incident could easily exceed the entire ancillary testing budget for the year. For these areas, negating risk is the number one priority.
Ancillary testing is defined as any nonessential diagnostic testing being used to augment the baseline physical examination. The purpose is to be able to make the most accurate Health Risk Assessment possible for anyone traveling to a remote site for work. Obviously, knowing the risks up front empower one’s decision-making. Should a company decide to choose someone with an elevated health risk for a specific job because s/he possesses a particular fund of knowledge, at least you are doing it fully knowledgeable of the risks. This enables one to avoid surprises and be proactive instead of reactive, and, most importantly, allow for contingency planning up front.
Ancillary screening allows for the detection of potentially serious medical conditions early, while they are minor, and should be viewed by the employee as a benefit. It also enables someone to deal with a medical problem before it becomes an exponentially greater issue. It also gives the employee the opportunity to address the condition during his/her personal time off, using his/her physician and health insurance. For example, a positive finding like occult blood in a stool sample definitely requires further attention. Typically, it would start with a visit to one’s PCP to confirm the finding, order further diagnostic testing and, if indicated, consult a specialist, such as a gastroenterologist. This, in turn, would lead either to a clean bill of health or to a diagnosis and treatment. Continuing with this particular example, the list of potential causes, also known as, the “Differential Diagnosis”, is rather lengthy. Many of the causes for a hemoccult (+) stool, such as mild gastritis, an anal fissure or an internal hemorrhoid are typically benign and would not prohibit one from working in the most remote environment. Nevertheless, it is important to understand, that despite this screening having alerted you to, what turned out to be, a minor abnormality, it enabled the employee’s doctor to initiate early treatment. This type of proactive medical screening and care has proven itself invaluable in preventing an otherwise occult condition from suddenly exacerbating itself at a remote work site. Thus, with relatively little effort employees can be cleared for travel to the most remote places with total confidence. On the other hand, had the screening unmasked a bleeding ulcer, bleeding esophageal varices, or a bleeding tumor, the employee will require more extensive care leading to postponing or even completely cancelling deployment to a remote worksite. Had the employee not been properly screened, and one of these diagnoses been missed, then the company could be facing a very expensive worst-case scenario, and the employee facing a life-threatening illness in a remote environment with limited medical resources. Above all, avoiding scenarios such as the ones described above is relatively easy and extremely cost-effective when compared to the alternative.
Work readiness represents a very significant concept, and, frankly, deserves a more in-depth discussion than can be dedicated to it in this venue. It is important to understand that passing a pre-placement or fitness for duty examination simply states the employee’s overall state of health at a given moment in time. The reality of this must not be ignored, nor forgotten, regardless of how much time, effort and money is put into the process. While, it confirms the examinee’s health and fitness at the time of the examination, health and safety must be gauged on a continuum. Being “fit for duty” or “work ready” in any safety sensitive or remote work site is a concept that remains, as the name insinuates, in a permanently dynamic state.
The idea that an employee be “work ready” prior to traveling to a remote work site is not just a reasonable one, but should also be expected. Each day, when going on duty and throughout the duration of each tour, the expectation must remain that they are able to demonstrate the same physical capabilities they demonstrated on the day they were declared fit for duty. Granted, people have good days and bad, this refers to one’s overall state of health, fitness and ability, which enables him/her to work safely every single day. After all, that is the overriding purpose of the fitness for duty program. There are times when an employee shows up for work with a newly diagnosed medical condition, recovering from a personal injury or taking a newly prescribed medication. In these situations, the first thing that should be asked is whether this new medical condition, injury or medication would have caused him/her to be placed on medical hold or to outright fail his/her fitness for duty examination if s/he was to take it that same day. These questions are central to the concept of work readiness or dynamic fitness for duty.