Medical "clearance" for high intensity activities when working fast track or urgent care

[salud23]

Hello, when working fast track or urgent care, people come in with medical "clearance" pre-employment forms which state that the doctor says they are qualified to do high intensity activities such as run two miles, swim 500 meters, etc. Sometimes, it's the person who wants to enter the police academy, or it may be somebody who wants to do an endurance sporting event. This is an activity level far beyond the person who just needs a basic exam so they can go be a teacher or enroll in pharmacy school. They are coming to see you because they, of course, "don't have a primary care doctor and I have to turn this in today." The patient care satisfaction people always have a problem with redirecting these persons to a primary care setting, because they see it as lost revenue. Does anyone have thoughts on how to safely evaluate whether a person's health is good enough that they can safely participate in this kind of high intensity activity? It's not like there's a swimming pool in front of me where I can even confirm the person knows how to swim, and I don't have a room inside where I can see if they can run a couple of miles in front of me without experiencing syncope or an asthma flare. Any input would be appreciated. Thanks.

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[RuralEDDoc]

Can I answer in haiku form?

No helpful thoughts here
Still not an emergency
Sorry admin guy

 

[RuralEDDoc]

Meaning I don’t sign these forms and have no sympathy for those who ask me to do so

 

[greatnt249]

Not your problem they waited until the last minute to have their physical fitness form filled out an urgent care or fast track. Would your admin's answer be the same if you were turning away people wanting disability forms filled out?

 

[Dr Mantis Toboggan]

 

[southerndoc]

I would only sign one of these if I witnessed them run 2 miles, swim 500 meters, etc.

It's a no win situation for you. You sign it and they crump, you're liable for not detecting their undiagnosed asthma, heart murmur, HOCM, etc. These people are already high risk because they don't see a physician regularly.

 

[BoardingDoc]

They are coming to see you because they, of course, "don't have a primary care doctor and I have to turn this in today."

Their failure to plan does not constitute your emergency. I tell these patients that "we don't do that here" and refer them to a PCP if they don't already have one.

 

[Vandalia]

As alluded to, if it is the standard form for a student at a university that they have a pulse, sure.

However, for what is mentioned, that sounds like occupational health. I am not even sure if their primary care physician (if such an individual existed) would touch those specific statements.

The passive-aggressive in me would say that I would sign after an echo, stress test, pulmonary function test and lets throw in a bone scan for good measure. Retirement is fun.

The way to deal with administrators is to always emphasize the liability.

Rule #7 for dealing with hospital administrators: Always make it about their money.

 

[Arcan57]

I wrote one for someone when I was early in my career in a outside the ED capacity. Turned out the guy lied to me about no PMHx and was actually a type I diabetic. Never came back to bite me but was definitely a lesson learned.

 

[WilcoWorld]

My sister asked me to fill one out for my niece last week. I stated going through the questions,
-Do you get chest pain when you run? Yes.
-Do you get excessive shortness of breath with exercise? Yes.

Sorry sis, you're going to need to see a pediatrician. I'm not signing off on this.

 

[EctopicFetus]

I would only sign one of these if I witnessed them run 2 miles, swim 500 meters, etc.

It's a no win situation for you. You sign it and they crump, you're liable for not detecting their undiagnosed asthma, heart murmur, HOCM, etc. These people are already high risk because they don't see a physician regularly.

I get your point but depending on age seeing a physician regularly might be nothing but a waste of time.

 

[WilcoWorld]

I get your point but depending on age seeing a physician regularly might be nothing but a waste of time.

I got a new PCP this year. After everything checked out fine she said "I'm supposed to tell you to come back in a year, but if you're feeling fine that's probably not necessary".

Decided I like her very much.

 

[RuralEDDoc]

For the newbies here, you may be wondering why the old timers keep mentioning liability. It’s hard to explain to someone who’s never been involved in a suit. But here goes: the entire reason these “medical clearance” forms exist is because someone at some point dropped dead during 1. Police academy 2. Fire academy 3. Tuff Mudder 4. Guitar Center Sing Along 5. Whatever. The sponsoring entity paid out on a lawsuit and so decided they would require “medical Screening” as an entry requirement. It is literally no skin of their back to do so. As the physician asked to sign off on this clearance, you are accepting a portion of the liability for however extreme the event is that you signed off for. Unless you routinely do pre-employement screening (or Tuff Mudder screening), as an emergency physician, you are stepping out of your lane by signing these forms. Generally this is low risk but not zero risk, and when a bad outcome occurs, everyone else can wash their hands of the outcome, but the physician will be hung out to dry.

Stay in your lane.

 

[betamale]

Widow of Atlanta cop who died during three-way sex is awarded $3 million

www.nbcnews.com

 

[PikminOC]

Widow of Atlanta cop who died during three-way sex is awarded $3 million

www.nbcnews.com

That's why I get rid of noncompliant patients

 

[VA Hopeful Dr]

I got a new PCP this year. After everything checked out fine she said "I'm supposed to tell you to come back in a year, but if you're feeling fine that's probably not necessary".

Decided I like her very much.

I basically say that they need to see me at least every 3 years to stay an active patient.

 

[BoardingDoc]

Widow of Atlanta cop who died during three-way sex is awarded $3 million

www.nbcnews.com

Our medicolegal system is profoundly stupid.

 

[Saddleshoes]

Would referring to a cardiac stress test work?

 

[Arcan57]

Would referring to a cardiac stress test work?

Would be overkill for most people. And if they have critical aortic stenosis or some genetic abnormality?

It's a difference in mindset. "I want to make sure I'm healthy enough to do this exercise regimen" vs. "I need this form signed". Almost everyone is after the latter, and they forget stuff, minimize symptoms, and don't treat it like it's a real medical evaluation. It's not that we can't be trained to do it well (there's a ton of EM docs that volunteer doing sports physicals for high school) but it's not in our wheelhouse and I personally don't know that I can tell based on a 5 min H&P whether someone's dyspneic on exertion because they're 5'1" 240 lbs or because they have early atherosclerotic disease due to systemic inflammation from hyperglycemia and morbid obesity that have been present since puberty.

 

[Vandalia]

For the newbies here, you may be wondering why the old timers keep mentioning liability. It’s hard to explain to someone who’s never been involved in a suit. But here goes: the entire reason these “medical clearance” forms exist is because someone at some point dropped dead during 1. Police academy 2. Fire academy 3. Tuff Mudder 4. Guitar Center Sing Along 5. Whatever. The sponsoring entity paid out on a lawsuit and so decided they would require “medical Screening” as an entry requirement. It is literally no skin of their back to do so. As the physician asked to sign off on this clearance, you are accepting a portion of the liability for however extreme the event is that you signed off for. Unless you routinely do pre-employement screening (or Tuff Mudder screening), as an emergency physician, you are stepping out of your lane by signing these forms. Generally this is low risk but not zero risk, and when a bad outcome occurs, everyone else can wash their hands of the outcome, but the physician will be hung out to dry.

Stay in your lane.

I would elaborate on a couple of point:

The key component in liability is potential damages. You can have horrible malpractice with a 95 year old with dementia, but the damages would be minimal. To be blunt, you almost certainly saved their estate money. Or, if you miss a glioblastoma, the outcome is going to be pretty much the same. This is critical in the places that have a cap on non-economic damages.

The problem with this specific scenario is that you are dealing with young people with a whole career of potential earnings in front of them. In other words, a lot of uncapped economic damages: "He was going to make it all the way to Captain in the police department, be hired by a couple of large metro areas, be named chief of the NY Police Department, and spend 20 years as a legal analyst on CNN ..." There is a lot of room for expensive hypotheticals in young people.

The other issue is the specific statements in the original post. It is one thing to say, "Based on the provided history and the limited physical exam, there is no evidence of cardiac disease ..." That is very different from the yes/no question of "Can this individual run 2 miles with 100 pounds of equipment ..." Particularly in young men and women, it is tough to tell the difference in a 20 year old between the one who is currently very physically active and the one who played sports year round but spent the last six months all day on the couch drinking soft drinks and eating candy. That difference will show up, but perhaps not be all that obvious that early.

 

[HemeOncHopeful19]

Widow of Atlanta cop who died during three-way sex is awarded $3 million

www.nbcnews.com

Interesting, I could’ve sworn Georgia was supposed to be a good medicolegal state according to some threads in this forum. Maybe you guys were specifically talking about for EM or maybe things have changed.

Edit: looking into it more, the original verdict was $5 million but they found that the patient was 40% responsible so the wife only got 3 million! Good grief

 

[Kryptocoin]

Widow of Atlanta cop who died during three-way sex is awarded $3 million

www.nbcnews.com

Strange case. 31 yo male, police officer, dies of MI during sex . I have discharged hundreds of males in their 30s with chest pain....I've never considered sex a " strenuous activity" to be avoided. Definitely not considered "standard of care" discharge planning advice. Which means " standard of care" is arbitrary and hence, a misnomer and should be stripped from medical lingo.

 

[Apollyon]

Strange case. 31 yo male, police officer, dies of MI during sex . I have discharged hundreds of males in their 30s with chest pain....I've never considered sex a " strenuous activity" to be avoided. Definitely not considered "standard of care" discharge planning advice. Which means " standard of care" is arbitrary and hence, a misnomer and should be stripped from medical lingo.

It may be before your time, but, when Viagra came out, there was a wave of warning guys on nitrates that they could have profound hypotension if they took the boner pills. Even with a 1 in 3 chance of dying, guys still took the opportunity for a screw.

And my PD in residency told us of a pt she saw, who was getting railed from behind, and suffered a liver lac.

And, isn't there a TV show called "Sex Sent Me To The ER"?

 

[Apollyon]

Oh, and, look up Nelson Rockefeller and Megan Marshack.

 

[GassYous]

Strange case. 31 yo male, police officer, dies of MI during sex . I have discharged hundreds of males in their 30s with chest pain....I've never considered sex a " strenuous activity" to be avoided. Definitely not considered "standard of care" discharge planning advice. Which means " standard of care" is arbitrary and hence, a misnomer and should be stripped from medical lingo.

In residency I've had two young relatively healthy patients who burst an aneurysm during sex and ended up in the icu tubed with sah

 

[RustedFox]

In residency I've had two young relatively healthy patients who burst an aneurysm during sex and ended up in the icu tubed with sah

My gym buddy had a buddy who died of a TAD at 29 during heavy lifting.

 

[southerndoc]

My gym buddy had a buddy who died of a TAD at 29 during heavy lifting.

One of the cardiovascular surgeons specializing in TAD repair put A-lines in powerlifters and found that their BPs were in the 300-500 range during squats and deadlifts.

 

[Apollyon]

In residency I've had two young relatively healthy patients who burst an aneurysm during sex and ended up in the icu tubed with sah

I was just reminded of that today. 32F SAH brain dead during sex. 20+ years ago NYC. I recall the senior resident saying, far away from the pt and family, "I know he doesn't think he was THAT good!"

 

[Kryptocoin]

It may be before your time, but, when Viagra came out, there was a wave of warning guys on nitrates that they could have profound hypotension if they took the boner pills. Even with a 1 in 3 chance of dying, guys still took the opportunity for a screw.

And my PD in residency told us of a pt she saw, who was getting railed from behind, and suffered a liver lac.

And, isn't there a TV show called "Sex Sent Me To The ER"?

Yeah , I wondered if something else was on board. The article seems to indicate it was 2 guys + 1 woman. Looks like homie MI'ed doing half the work (no pun intended).

 

[wook]

For the newbies here, you may be wondering why the old timers keep mentioning liability. It’s hard to explain to someone who’s never been involved in a suit. But here goes: the entire reason these “medical clearance” forms exist is because someone at some point dropped dead during 1. Police academy 2. Fire academy 3. Tuff Mudder 4. Guitar Center Sing Along 5. Whatever. The sponsoring entity paid out on a lawsuit and so decided they would require “medical Screening” as an entry requirement. It is literally no skin of their back to do so. As the physician asked to sign off on this clearance, you are accepting a portion of the liability for however extreme the event is that you signed off for. Unless you routinely do pre-employement screening (or Tuff Mudder screening), as an emergency physician, you are stepping out of your lane by signing these forms. Generally this is low risk but not zero risk, and when a bad outcome occurs, everyone else can wash their hands of the outcome, but the physician will be hung out to dry.

Stay in your lane.

Agreed!

I would caution anyone thinking of doing this to re-consider.

I have been present at the first day of multiple law enforcement academies. There is a very large potential liability here. I have seen the following who then ended up having to go the Emergency Department on the first day:
1) 8-10 cases of rhabdo
2) 4 cases of undisclosed (two cases where the recruit did not follow up even after being told to do so) underlying cardiac issues, including one who had just had a cardiac cath 1-2 weeks prior to the academy (and was told they could start the academy).
3) 4 cases of disclosed underlying medical conditions (e.g. pulmonary, rheumatological, endocrine, etc)
4) 1 case of compartment syndrome

I would concur with those who suggested that this go to occupational health. In some of the above cases, I was asked whether the physicians who signed the paperwork should be reported to the state licensure board. Thankfully, no one died, but several required multiple day stays at their lovely local hospital. The civil liability for any injuries or death is not small to the signing physician. If you do this activity you are potentially incurring risk with your state licensure board and civil liability if you are not doing it well.


Thanks.


Wook

 

[RustedFox]

Holy smoke.
Wook?

If I'm not thinking of someone else; I haven't seen a post from you in YEARS.

 

[wook]

Holy smoke.
Wook?

If I'm not thinking of someone else; I haven't seen a post from you in YEARS.

Dude!

Been mostly lurking. How the heck you been?

 

[nimbus]

Agreed!

I would caution anyone thinking of doing this to re-consider.

I have been present at the first day of multiple law enforcement academies. There is a very large potential liability here. I have seen the following who then ended up having to go the Emergency Department on the first day:
1) 8-10 cases of rhabdo
2) 4 cases of undisclosed (two cases where the recruit did not follow up even after being told to do so) underlying cardiac issues, including one who had just had a cardiac cath 1-2 weeks prior to the academy (and was told they could start the academy).
3) 4 cases of disclosed underlying medical conditions (e.g. pulmonary, rheumatological, endocrine, etc)
4) 1 case of compartment syndrome

I would concur with those who suggested that this go to occupational health. In some of the above cases, I was asked whether the physicians who signed the paperwork should be reported to the state licensure board. Thankfully, no one died, but several required multiple day stays at their lovely local hospital. The civil liability for any injuries or death is not small to the signing physician. If you do this activity you are potentially incurring risk with your state licensure board and civil liability if you are not doing it well.


Thanks.


Wook

When you test peoples’ limits, sometimes you hit their limit.

SEAL candidate dies after Hell Week test; a second is in the hospital

The Navy said neither SEAL candidate had experienced an accident or unusual incident during the five-and-a-half-day Hell Week.

www.navytimes.com

Family of Navy SEAL trainee who died during pool exercise plans to take legal action

The Navy said no one would face criminal charges related to the trainee's death.

abcnews.go.com

 

[WilcoWorld]

Yeah , I wondered if something else was on board. The article seems to indicate it was 2 guys + 1 woman. Looks like homie MI'ed doing half the work (no pun intended).

I recall cocaine being mentioned when this story first broke a few years ago, but I can't say if that's been confirmed.

 

[DoctwoB]

Uro here.

Screening test for viagra: “Can you walk up 2 flights of stairs”. Yes = boner pills.

 

[VA Hopeful Dr]

Uro here.

Screening test for viagra: “Can you walk up 2 flights of stairs”. Yes = boner pills.

FP here, if I tried that (and my patients were honest), no one would ever get boner pills.

 

[GassYous]

Uro here.

Screening test for viagra: “Can you walk up 2 flights of stairs”. Yes = boner pills.

Just get an office on the third floor with no elevator
Have a box of pills and a sign congratulating them

 

[namethatsmell]

Hello, when working fast track or urgent care, people come in with medical "clearance" pre-employment forms which state that the doctor says they are qualified to do high intensity activities such as run two miles, swim 500 meters, etc. Sometimes, it's the person who wants to enter the police academy, or it may be somebody who wants to do an endurance sporting event. This is an activity level far beyond the person who just needs a basic exam so they can go be a teacher or enroll in pharmacy school. They are coming to see you because they, of course, "don't have a primary care doctor and I have to turn this in today." The patient care satisfaction people always have a problem with redirecting these persons to a primary care setting, because they see it as lost revenue. Does anyone have thoughts on how to safely evaluate whether a person's health is good enough that they can safely participate in this kind of high intensity activity? It's not like there's a swimming pool in front of me where I can even confirm the person knows how to swim, and I don't have a room inside where I can see if they can run a couple of miles in front of me without experiencing syncope or an asthma flare. Any input would be appreciated. Thanks.

I frequently get requests to complete disability forms, forms for handicap parking tags, physicals for police/fire academy recruits etc.

The solution is simple: "no."

If your employer is truly pressuring you to do these, your job is terrible and should be vacated.

 

[nimbus]

Uro here.

Screening test for viagra: “Can you walk up 2 flights of stairs”. Yes = boner pills.

Anesthesia preop clinic located up 2 flights of stairs with no elevator. If the patient can show up to Clinic, they’re cleared for surgery.

 

[NITRAS]

FP here, if I tried that (and my patients were honest), no one would ever get boner pills.

It always amazes me how many people just stop going up stairs. You ask them and they look at you crazy. How did our society tolerate such abundant sloth?

 

[d2305]

Recruits die on occasion. Most don't get an ekg.

 

[VA Hopeful Dr]

It always amazes me how many people just stop going up stairs. You ask them and they look at you crazy. How did our society tolerate such abundant sloth?

No kidding. That's the question I use for pre-op clearance and it's the very rare person who has gone up even one flight of stairs in the last 6 months.

 

[nimbus]

Recruits die on occasion. Most don't get an ekg.

Recruits die on occasion. Most don't get an ekg.

I understand there’s a low pretest probability of finding anything. But what about smaller populations like the NBA? Do they do screening ekg and echo before the draft?

 

[Vandalia]

I understand there’s a low protest probability of finding anything. But what about smaller populations like the NBA? Do they do screening ekg and echo before the draft?

They certainly do for the NFL, and I would be absolutely shocked if they didn't for the NBA. In fact, I believe such screening is mandatory for college athletes.

Every year it comes out at the NFL combine that some player has a potential cardiac issue, they drop in the draft, then they determine it is not significant.

Montez Sweat possibly misdiagnosed with heart issue

Big news regarding Montez Sweat on draft day. Teams believe the Mississippi State pass rusher was misdiagnosed with a heart condition at the scouting combine, Ian Rapoport reported.

www.nfl.com

If I remember correctly, NBA coach Monty Williams had to sit out at least a year at Notre Dame while they evaluated him for hypertrophic cardiomyopathy.

Monty Williams, Suns' New Coach: 5 Fast Facts You Need to Know

The Phoenix Suns have hired Monty Williams, currently an assistant coach with the Philadelphia 76ers, to be the 20th head coach in the history of the franchise.

heavy.com