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Out of curiosity, is nicotine testing becoming a common thing with hospitals and therefore residencies in the USA? If so, how difficult would it be to get a foreign residency in Canada/Australia? I understand that you go to residency where you intend to practice and I have no problem with that as I would want to move out to such countries immediately following med school.
 

JGimpel

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I'm not saying this applies to you at all, but I know of some If your program specifically asks if you're a smoker and you say that you're not, they have the right to test you for a continine level if you come in to work smelling like you or someone around you smoked. This could be a terminable offense if it comes up positive. If you come in smelling like you smoked, they might end up doing other tests on you if you have an accident at work. Watch out for the "patch," you may show up positive if you're trying to quit. I worked in a hospital that looked for this kind of stuff and just want to pass along some of the new stuff that's being implemented.
 
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OP
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I'm not saying this applies to you at all, but I know of some If your program specifically asks if you're a smoker and you say that you're not, they have the right to test you for a continin level if you come in to work smelling like you or someone around you smoked. This could be a terminable offense if it comes up positive. If you come in smelling like you smoked, they might end up doing other tests on you if you have an accident at work. Watch out for the "patch," you may show up positive if you're trying to quit. I worked in a hospital that looked for this kind of stuff and just want to pass along some of the new stuff that's being implemented.
Not a smoker so I won't smell like it but aren't programs doing pre-employment tests anyways, regardless of if you smell like smoke or not?

I am just worried that I would go through all that work through medical school only to then not be accepted to any residencies simply because of nicotine. Again, I am not smoking and what I do does not have an effect on anyone else's health. In fact, I would have zero problems paying extra for insurance due to this. Therefore, if the USA wants to implement draconian policies which do not have any relation with smoking or the effect on the health of others, I would gladly be willing to move to another country. I just want to know easy it would be to attain residency in another country given the fact that I would not want to ever practice within the USA.
 
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Law2Doc

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Out of curiosity, is nicotine testing becoming a common thing with hospitals and therefore residencies in the USA? ....
It's not common at all. However a nonsmoker can usually identify a smoker about 10 feet away, even if they've recently showered and washed their clothes. That smell hangs on you. Don't expect to get through an interview in a closed room and have them not identify you as a smoker. No test necessary.
 
OP
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It's not common at all. However a nonsmoker can usually identify a smoker about 10 feet away, even if they've recently showered and washed their clothes. That smell hangs on you. Don't expect to get through an interview in a closed room and have them not identify you as a smoker. No test necessary.
Again, I wouldn't have any smell whatsoever on me other than my BO if I didn't put on deodorant that morning.
 

notinkansas

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Is this serious? I've never had any hospital test people for nicotine. Administration can prohibit on premises and charge a higher premium. But in a free society, one is supposed to be able to do whatever one wants with ones own body. As long as it doesn't affect job performance, who cares. America used to be free- but that is rapidly changing. Evidently faster than I realized!
 

JGimpel

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I was just trying to offer of my experience. If one wants to be cut and dry about it, don't lie on your application if they ask if you smoke. Lying on an application is a terminable offense if your employer decides to go that route. If you decide to start smoking after you start working in a hospital, don't have any accidents and don't come back from breaks or lunch smelling like anything more than food and you should be fine. If you do have an accident at work, they will probably hit you with an extended urine dip test if they feel so inclined that would include continine and alcohol, which are both legal to consume but things you don't lie about in healthcare settings. If you have a sizable disability or life insurance payout based upon a sizable salary, be prepared to have a few tests done on you for that as well.
 
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Winged Scapula

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Not a smoker so I won't smell like it but aren't programs doing pre-employment tests anyways, regardless of if you smell like smoke or not?

I am just worried that I would go through all that work through medical school only to then not be accepted to any residencies simply because of nicotine. Again, I am not smoking and what I do does not have an effect on anyone else's health. In fact, I would have zero problems paying extra for insurance due to this. Therefore, if the USA wants to implement draconian policies which do not have any relation with smoking or the effect on the health of others, I would gladly be willing to move to another country. I just want to know easy it would be to attain residency in another country given the fact that I would not want to ever practice within the USA.
So....you're not a smoker yet you're concerned about "draconian" policies which might possibly, sometime in the future, test you for nicotine or anything else, which would of course be negative but those policies would lead you to seek residency training outside of the country?

What's the real question? Do you have an issue with any pre-employment testing? Are you worried you would test positive for something else? Or are you simply fighting against windmills, Quixote?

To answer your question: the US has the most open and liberal policy on accepting physicians trained outside of its borders for GME. Do not expect that Canada (which doesn't even have enough positions for its own citizens) or Australia (which puts non-citizens, trained outside of Australia, as last in line for residency positions) to offer you any easy road to graduate medical training.
 
OP
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So....you're not a smoker yet you're concerned about "draconian" policies which might possibly, sometime in the future, test you for nicotine or anything else, which would of course be negative but those policies would lead you to seek residency training outside of the country?

What's the real question? Do you have an issue with any pre-employment testing? Are you worried you would test positive for something else? Or are you simply fighting against windmills, Quixote?

To answer your question: the US has the most open and liberal policy on accepting physicians trained outside of its borders for GME. Do not expect that Canada (which doesn't even have enough positions for its own citizens) or Australia (which puts non-citizens, trained outside of Australia, as last in line for residency positions) to offer you any easy road to graduate medical training.
No, actually I am just referring to other forms of tobacco which do not affect patients in any way.

Nope, not worried that they would test for anything else. Living in a country which intrudes on your personal freedoms for legal substances is not a country I want to live in. Living in a country which degrades its medical professions and cuts their salaries due to outcries that they are paid too much is not a country I want to live in.

The hospitals are hand in hand with corrupt organizations such as the FDA and insurance companies. I do not wish to practice here but would rather just do medical school as the USA still has of the best institutions.
 

kindasorta

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So....you're not a smoker yet you're concerned about "draconian" policies which might possibly, sometime in the future, test you for nicotine or anything else, which would of course be negative but those policies would lead you to seek residency training outside of the country?

What's the real question? Do you have an issue with any pre-employment testing? Are you worried you would test positive for something else? Or are you simply fighting against windmills, Quixote?

To answer your question: the US has the most open and liberal policy on accepting physicians trained outside of its borders for GME. Do not expect that Canada (which doesn't even have enough positions for its own citizens) or Australia (which puts non-citizens, trained outside of Australia, as last in line for residency positions) to offer you any easy road to graduate medical training.
e-cigs, for starters
 

BrakngLyv

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It's not common at all. However a nonsmoker can usually identify a smoker about 10 feet away, even if they've recently showered and washed their clothes. That smell hangs on you. Don't expect to get through an interview in a closed room and have them not identify you as a smoker. No test necessary.
I interviewed at 5 programs this season with nicotine testing policies. I think it's more common than the above statement reflects.
 

peppy

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If you're worried about this, I suppose you could try making an anonymous phone call to employee health and/or GME
at each of the places you're interested in applying to. You can ask them if they require nicotine testing as a condition of employment and if they would make an exception for someone who uses e-cigarettes instead of real ones.
Personally, even though I don't smoke, I do feel that it's unfair to be so punitive to people who use a legal substance. If I were sick, I wouldn't care if my doc was a svelte marathon runner/vegetarian/red wine drinker who never touches drugs/cigarettes and always wears a seatbelt. I would just care if they knew what they were doing.
 
OP
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If you're worried about this, I suppose you could try making an anonymous phone call to employee health
at each of the places you're interested in applying to so you can ask them if they require nicotine testing as a condition of employment and if they would make an exception for someone who uses e-cigarettes instead of real ones.
To be honest, I doubt they will even know what those are half the time and if they do, they will believe a study done years ago which stated they were dangerous...which was due to the fact that they contained liquid from China.

I am still curious about if this is a new thing or if it is catching on rapidly.
 

Samoa

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Cleveland Clinic also tests incoming residents for cotinine, but I don't recall their policy regarding positive tests, since it wasn't relevant to me. I do recall that it struck some of my colleagues as draconian, though. Social smokers, most likely.
 
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I don't smoke, but on principle I wouldn't work at an institution that tried to ban my right to engage in a legal habit, i.e. smoking. They have every right to ban smoking on hospital grounds, but not to dictate what legal activities you do in your free time.
 

JGimpel

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Here's the rationale with the legal stuff: they test for alcohol too; if you know you're having a drug test that day and you still have to drink and smoke, you have a serious problem and those people are whom they're trying to weed out (no pun intended but highly encouraged.) If you can go a few days without either, these aren't the droids they're looking for. Other than that, if you come to work smelling of alcohol or smoke, you'd be an idiot not to shower there and change into some clean scrubs first. Wait a minute, if you come to work smelling like you've just come from last call, that usually raises some red flags no matter what, right?
 

FutureInternist

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Here's the rationale with the legal stuff: they test for alcohol too; if you know you're having a drug test that day and you still have to drink and smoke, you have a serious problem and those people are whom they're trying to weed out (no pun intended but highly encouraged.) If you can go a few days without either, these aren't the droids they're looking for. Other than that, if you come to work smelling of alcohol or smoke, you'd be an idiot not to shower there and change into some clean scrubs first. Wait a minute, if you come to work smelling like you've just come from last call, that usually raises some red flags no matter what, right?
But alcohol impairs your ability to function
I have never heard of someone "Driving while Nicotining"
 

Psychiatrized

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I know a handful of physician colleagues that chew nicotine gum or use lozenges regularly despite quitting smoking many years ago.

To say that they would be ineligible for employment is ridiculous! Also the notion that if you can't quit for a drug test means you have a "serious problem" well, yeah it is an addiction but if you are using nicotine replacements I don't think it is really a problem... just an expensive habit.
 

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But alcohol impairs your ability to function
I have never heard of someone "Driving while Nicotining"
I don't think it's about nicotine impairing anyone's judgement, it's really about the smell (at least that's the reason for the nicotine restriction at the Colorado Children's Hospital). They consider it exposing patients and other health care workers to second hand smoke/gross cigarette smoke. And I know it's not a popular position but I think it's a great thing. I cannot stand the smell of cigarettes/cigars and appreciate that some hospitals are trying to get rid of it.
 

JGimpel

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I know a handful of physician colleagues that chew nicotine gum or use lozenges regularly despite quitting smoking many years ago.

To say that they would be ineligible for employment is ridiculous! Also the notion that if you can't quit for a drug test means you have a "serious problem" well, yeah it is an addiction but if you are using nicotine replacements I don't think it is really a problem... just an expensive habit.
Chantix won't show up on those tests and most doctors should be able to afford the copay for that. The added benefit of awesome dreams on that stuff (per patients I've talked to) should make them switch for this better and cheaper alternative. As far as I know, the patch or the gum can run up to $100 for the month you try and quit and is not meant to be used long-term as is the gum. Chantix should be under $60 for a Tier 3 copay for most people, even cheaper if your healthcare plan offers incentives for you to quit. If you can't stop any of the types of nicotine I've described or having a morning eye opener CAGE style, you can't go it alone anymore and do need to seek the help of a professional. That's right on the box of the patch or gum.
 
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FutureInternist

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I don't think it's about nicotine impairing anyone's judgement, it's really about the smell (at least that's the reason for the nicotine restriction at the Colorado Children's Hospital). They consider it exposing patients and other health care workers to second hand smoke/gross cigarette smoke. And I know it's not a popular position but I think it's a great thing. I cannot stand the smell of cigarettes/cigars and appreciate that some hospitals are trying to get rid of it.
So the argument really is "Be presentable when you come to work" which I can buy
However, outlawing certain behaviours when they are legal is a bit much
If they have the same sanctions for someone who doesn't shower after a day off & comes in to work smelling like B.O. then are they going to require daily supervised showers?
The children are getting exposed to a whole lot more of it anytime they walk outside, no one is outlawing cars, buses etc. Plus, smelling of nicotine is not the same as blowing smoke in someone's face
If the argument is the health of the patients, then the first thing that needs to go is the cafeteria. A McD's at UT Houston, a Chik-fil-A @ MD Anderson!
 

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So the argument really is "Be presentable when you come to work" which I can buy
However, outlawing certain behaviours when they are legal is a bit much
If they have the same sanctions for someone who doesn't shower after a day off & comes in to work smelling like B.O. then are they going to require daily supervised showers?
The children are getting exposed to a whole lot more of it anytime they walk outside, no one is outlawing cars, buses etc. Plus, smelling of nicotine is not the same as blowing smoke in someone's face
If the argument is the health of the patients, then the first thing that needs to go is the cafeteria. A McD's at UT Houston, a Chik-fil-A @ MD Anderson!
There's no law, it's a just a private company's regulation. For a Children's hospital, it's more about not having bad role models as employees. As for the food thing, I totally agree, and in fact, a lot of hospitals are getting rid of fast food (and even non-diet sodas in their vending machines) and replacing with healthier alternatives, especially on the West Coast.
 

Stellar Clouds

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So the argument really is "Be presentable when you come to work" which I can buy
However, outlawing certain behaviours when they are legal is a bit much
If they have the same sanctions for someone who doesn't shower after a day off & comes in to work smelling like B.O. then are they going to require daily supervised showers?
The children are getting exposed to a whole lot more of it anytime they walk outside, no one is outlawing cars, buses etc. Plus, smelling of nicotine is not the same as blowing smoke in someone's face
If the argument is the health of the patients, then the first thing that needs to go is the cafeteria. A McD's at UT Houston, a Chik-fil-A @ MD Anderson!
There are two McDonalds in the Texas Medical Center. Neither is at UT Houston. One is at Ben Taub the other is at St. Lukes (home to the famous Texas Heart Institute...I love irony).
 

Stellar Clouds

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Here's the rationale with the legal stuff: they test for alcohol too; if you know you're having a drug test that day and you still have to drink and smoke, you have a serious problem and those people are whom they're trying to weed out (no pun intended but highly encouraged.) If you can go a few days without either, these aren't the droids they're looking for. Other than that, if you come to work smelling of alcohol or smoke, you'd be an idiot not to shower there and change into some clean scrubs first. Wait a minute, if you come to work smelling like you've just come from last call, that usually raises some red flags no matter what, right?
The purpose is to promote a healthier lifestyle. Lord knows this fat a** country could use it.
 

notinkansas

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So SERIOUSLY??

I had no idea. I have not encountered this. Hospitals are testing physicians for nicotine use???

I GET that they can (and probably should) ban smoking on premises, for health reasons for the patients.

What bad thing happens to a physician who tests positive for nicotine? For use of a LEGAL substance while off the job?

This is unbelievable. Just for the record, I'm a nonsmoker who things the practice is disgusting. But it's still legal and in a free society, how can we do this to people?
 

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I had to sign a no-nicotine policy at my program's interview. I'll be tested before starting in July.
 

Doctor Bob

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There is likely a financial aspect at work here. The hospital, which is probably picking up some part of your health insurance costs, wants to reduce their premiums; and having a workforce of non-smokers probably lets them negotiate for lower group premiums.
 

Dejavu

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There is likely a financial aspect at work here. The hospital, which is probably picking up some part of your health insurance costs, wants to reduce their premiums; and having a workforce of non-smokers probably lets them negotiate for lower group premiums.
This.
 

notinkansas

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I had to sign a no-nicotine policy at my program's interview. I'll be tested before starting in July.
*head explodes*

Egad. I totally understand (and would agree that the hospital/organization/health plan) has the right to charge smokers more for insurance, but to require you not smoke at all ever as a condition of employment...

what behavior will be banned next?

Was there anything at the programs web site to let you know this in advance, during the application process? Or were you surprised with it at the interview?
 

Slade

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I don't understand why you guys are all so incredulous. People are told before they interview there! It is their choice to interview for a position in the hospital (from janitor to head honcho). They can't complain later about the smoking policy since they knew what they were getting into when they started.

If you really want to be outraged, you should read up on hospitals that are not hiring people with BMIs greater than X (I don't remember the hospital or the particular BMI cutoff).
 

Bacchus

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*head explodes*

Egad. I totally understand (and would agree that the hospital/organization/health plan) has the right to charge smokers more for insurance, but to require you not smoke at all ever as a condition of employment...

what behavior will be banned next?

Was there anything at the programs web site to let you know this in advance, during the application process? Or were you surprised with it at the interview?
It was the first health system in my hometown area to do it. I was well aware even before medical school started, or maybe a year in. Oh well. I have no issues with it.
 

inspirationmd

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I don't understand why you guys are all so incredulous. People are told before they interview there! It is their choice to interview for a position in the hospital (from janitor to head honcho). They can't complain later about the smoking policy since they knew what they were getting into when they started.

If you really want to be outraged, you should read up on hospitals that are not hiring people with BMIs greater than X (I don't remember the hospital or the particular BMI cutoff).
http://www.texastribune.org/2012/03/26/victoria-hospital-wont-hire-very-obese-workers/
 

FutureInternist

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So next they won't hire people who have had speeding tickets because of MVAs --> disability ?
Poorly controlled HTN?
Poorly controlled DM? (don't necessarily have to be fat for this)

The ability to do a good job should be priority # 1 & if by choosing those people you get yourself a couple of fatties then that is the cost of doing business

There are better ways to save money (ex : how many nursing administrators, hospital administrators, patient relation liaisons are actually needed)
 

notinkansas

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I'm incredulous because it's yet another encroachment on freedom. Bottom line- human beings have an inherent liberty to do what they choose with their own bodies, as long as it doesn't interfere with anyone else's rights. In a society that claims to be free, human beings should be allowed to ingest a legal substance, that does not impair judgement skills, in their own home on their own time.

I realize there are some potentially more subtle issues. These hospitals listed as doing this are "private". But they take medicare/medicaid and are subject to numerous government rules as a result. This makes the issue as to whether this is Constitutional or not a bit muddy.

What further bothers me about this, is that in the hospitals named here it is NOT clear on their web sites for an applicant for residency programs that, if matched, one will be tested for nicotine and possibly have the matched spot withdrawn. I think revealing this at interview is too late, as it doesn't give the applicant an option not to apply to this program. So, if I decided to apply to 20 programs, and I find out at interview about this policy- which I completely oppose- then I pretty much wasted a portion of my application and interview travel on a program.

So the places that do this should have it listed on their page for residency applicants.

Again, for the record, I am a non smoker and find the smell of tobacco products disgusting.

However I will ALWAYS stand for an individual's fundamental freedom.
 
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My employer pre-screens for nicotine use (among other drugs). Potential new hires that use nicotine are disqualified from being employed. Current employees are grandfathered in. My guess is that they are trying to save money on insurance premiums, have a healthier staff overall, and not bring cigarette smell/smoke into the hospital.

America is half way on everything. You can't discriminate if someone is a certain gender, race, age, disabled, but you can judge them based on what they do and use in their personal life. We can't stand the notion of income redistribution, yet we pay taxes and have millions on Medicaid/food stamps/ housing assistance. The Medicare and social security programs also pay out more than they take in, so the tax payer is relied on to fund gov't controlled functions. You are free to use and abuse your body including lack of exercise, trans fat laden garbage for food, but don't you dare sin and use marijuana. Most legal sins have a special tax on them (some states have extra taxes on alcohol [California has an extra tax for alcohol above 40%], almost all continually raise taxes on smokes, states like Texas trying to add a tax to cover charges to get into strip clubs).
 
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I understand the arguement for personal freedom; however, I view it in the light of what the NBA does by mandating player dress code before and after games. Hospital employees represent the brand; having employees that smoke or are overweight is not consistent with a brand focused on promoting health. I'm an oncologist; what kind of message would I be sending by smoking; even it wasn't on hospital property, if I was out and about and seen by a patient, that hurts the brand. Sure there lots of activities that could fall under the same purview but I dont think its that big of a deal. If you dont want to do it, find another hospital. If a hosptial loses lots of employees because of rules like this and cant fill the positions, something tells me the rules will disappear.
I think that people who understand the pursuit of happiness is more important than the image of the company, who have physicians that care and can connect to patients on a human level, are more important than staff that do not represent the brand. Now, most people respond emotionally to things they experience as you have stated

Oncologist who is a drunk and smokes like a chimney
Bariatric specialist who is obese

Their knowledge may be extensive and their level of care provided unmatched, but you will still have patients who complain that the fat doctor told them to lose weight etc. We are better than this, but corporate America isn't. Always dumbed down for the consumer, what a pity.
 

Slade

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I understand the arguement for personal freedom; however, I view it in the light of what the NBA does by mandating player dress code before and after games. Hospital employees represent the brand; having employees that smoke or are overweight is not consistent with a brand focused on promoting health. I'm an oncologist; what kind of message would I be sending by smoking; even it wasn't on hospital property, if I was out and about and seen by a patient, that hurts the brand. Sure there lots of activities that could fall under the same purview but I dont think its that big of a deal. If you dont want to do it, find another hospital. If a hosptial loses lots of employees because of rules like this and cant fill the positions, something tells me the rules will disappear.
Well put.
 
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I don't think morbidly obese smokers should be employed as health care providers. There I said it #brave I know. Most hospitals agree with me and this is the trend of the future. Quit smoking and get in shape or don't make the big bucks simple as that.
 

kindasorta

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I've literally been walking into a county hospital in my white coat and been asked for a light. Carpe diem.

The reason these hospitals are doing this is for some BS self-interested branding, or, as someone mentioned above, insurance stuff. In other words, money money money. For people in this thread to think otherwise, such as something noble, I laugh in your general direction.
 

Slade

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I've literally been walking into a county hospital in my white coat and been asked for a light. Carpe diem.

The reason these hospitals are doing this is for some BS self-interested branding, or, as someone mentioned above, insurance stuff. In other words, money money money. For people in this thread to think otherwise, such as something noble, I laugh in your general direction.
I don't care why it's happening, I'm just glad it's happening.
 

dragonfly99

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Wow, I'm actually really surprised.
I was in residency from 2004-2007 and we had no alcohol or drug testing at all.
I don't think doctors should smoke...at all. But what if someone is using nicotine gum etc.
I think nobody should be allowed to smoke at work - I'm down with that. If you can't lay off cigarettes during work time, then you can't be a doc/nurse at a hospital if the hospital has a smoke-free campus. I honestly hate how smoke smells, etc. But what if someone was in a smoky bar the night before - will they test positive for nicotine? What if they quit a few months ago but using nicotine gum? Also, it is an imposition on people's personal freedom that they would make a highly trained progressional, who has no known h/o alcohol/drugs, pee into a cup for the residency program director. I actually think alcohol use is a lot more risk to patients, because most smokers (especially docs/nurses) know they should not be doing it and they try to minimize it and I don't know any who smoke at work. A lot of people who use alcohol don't think they have a problem and some of the ones who are problem drinkers don't think that they are. And some of the ones who are not "problem drinkers" are at risk for becoming that...binge drinking, etc. if they get depressed. Who is to say it doesn't affect people's work performance the next day? It is just that EtOH is socially acceptable among the educated class in the US but smoking is not (any longer). I had a friend in residency from Pakistan who still smoked to some degree - in some of these countries most of the men smoke or use other tobacco products. I'm not saying it is healthy but I am saying that not everyone is going to instantaneously stop doing it 100% of the time. If they don't smoke at work and don't come to work smelling like smoke I don't see what business it is of the residency program.
I really hate smoking too but I can totally see why civil libertarians would be up in arms.
I also think we should not have McDonald's or other unhealthy fast food joints in hospitals. It's just an example of the almighty dollar trumping all else.
 

Bacchus

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According to my program's policy online, they only test pre-employment for cotinine. If you fail the screening, then you get a LOA with payment for cessation program. At the end of the 90 day LOA you are tested again. If you pass, you work. If you fail, you are terminated.

It doesn't mention being tested during employment but I'm sure there is a provision in the official, contract version of the policy.

I was thinking the other day, what if someone goes out to the bar and for some reason has a cigarette? You will test positive. There's also the possibility for some reason you decide to go to a hookah bar. Bam... positive.

And it seems, from the policy, it doesn't matter if its because of passive smoke exposure. Cotinine can't differentiate between passive and active exposure.

http://en.wikipedia.org/wiki/Cotinine
 

aProgDirector

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I will join with those that think this is an unreasonable intrusion into employee's privacy.

I have no problem with hospitals tesing for illegal substances. They are illegal, and no one should be using them. We can have a debate about whether some (or all) of them should be legalized, but until they are I'm fine with that policy. THC aside, substance use has been shown to correlate with professionalism issues, etc.

I also have no problem with hospitals making their campuses smoke free. Mine is. There are NO smoking areas. You can't smoke anywhere. I believe that if visitors go outside and are far away enough from the door (which means quite far), no one will bother them. But technically the policy covers all of our property.

But I do have a problem with hospitals demanding that incoming employees be non smokers. I am a non smoker, so this doesn't affect me at all. But I agree that people have a right to engage in any activity that is legal in their own time, off campus.

The worry is where does this stop. Not hiring people because of their weight? What about based upon their hobbies -- what if a hospital demands that no one downhill ski, since that's dangerous and you might get hurt. Or what if an employee is an avid hunter, and the hospital thinks that injures their "brand".

I also have no problem if the hospital charges higher health premiums based upon lifestyle issues. Totally reasonable to charge someone who is a smoker more, or whose BMI is high more, or someone who engages in some "dangerous" activity. In fact, I like the idea of hiring people, testinging them for cotinine, if positive give them assistance in quitting, and if positive in 3-6 months, then increasing their health premiums. Same for high BMI. Seems like a good balance -- we try to help you improve your health, if you don't then you end up paying more for the increased financial risk.