While less focused and less intensive than fit for work testing, pre-employment medical exams are still important for a company and can reduce costs of hiring employees with serious medical issues that can affect job performance and safety. While in fit for work testing, the emphasis is on the individual’s functional capacity in relation to the tasks and the risks of the particular job rather than the absence or presence of specific medical conditions, a pre-employment medical exam looks at general health and can also identify pre-existing injuries.
Some of the tests done during the pre-employment examination also serve as a foundation for ongoing medical surveillance and may be regulatory requirements for high-risk occupations. They provide a baseline against which to compare future changes in the individual’s health status which could be due to occupational exposure on the job.
Pre-employment medical exams (used interchangeably with pre-placement fit for work testing in many parts of the world but a separate process in the US and Canada) is done after a conditional job offer has been made. Using a health questionnaire or medical examination as part of the job application process holds many pitfalls in relation to the violation of human rights and discriminatory practices and is therefore increasingly subject to strict regulation.
Who Performs Pre-Placement Medical Exams and Fit-For-Work Testing?
White fit-for-work testing may involve a specialized occupational medical practitioner or even physical therapists, audiologists, chiropractors and kinesiologists, a pre-employment medical exam can often be completed by a general practitioner or family doctor.
Besides medical knowledge, occupational medical practitioners involved in fit-for-work testing have in-depth knowledge of the working conditions and risks for specific occupations as well as the legislation relevant to employee medical assessments. This includes regulations dealing with minimum standards of fitness for high risk occupations, the various required examinations, as well as law concerning employee rights (for example in relation to which examinations are permitted) and protection against discrimination. This knowledge, combined with the risk exposures and hazards of the particular workplace, enable to examiner to determine which examinations are necessary and advise whether a worker is fit for a specific job. Knowledge of discrimination regulations is especially helpful for both fit-for-work testing and pre-employment medical exams as these exams are often brought up in ADA lawsuits, especially with regards to uneven guidelines and testing of women, older adults, and minorities.
Who Gets the Employee Medical Data?
Employers should accept that the medical practitioner who conducts examinations on behalf of an organization is still bound by professional ethical considerations and laws regarding health data (such as HIPAA) and personally identifiable information. An individual’s medical history and the results of both pre-employment examinations and fit-for-work testing are confidential and can only be shared with the employer with the person’s permission and shared information is limited to information directly related to the intended job. Furthermore, the person has the right to be fully informed about the medical findings and the reasons for any restrictions. There should also be a process allowing for appeal against the medical practitioner's findings in cases of disagreement.
What is Included in a Pre-Placement Medical Evaluation?
A full medical history, generally using a standardized form, identifies pre-existing medical conditions and disabilities. The answers on the form could lead to further questioning and examinations.
Conditions which could exclude the person from specific categories of risk work include diabetes, epilepsy, and certain mental disorders. Physical disabilities which reduce functional capacity might exclude the person from certain occupations. For example, a person with chronic lower back pain or a back injury could not function effectively in a job requiring heavy lifting. (Learn more in "A Look at Lower Back Pain in the Workplace".)
The medical history also includes questions relating to the person’s previous injuries, whether work-related or not. This is important baseline information to protect the employer against compensation claims for injuries, or aggravation of injuries, which were in fact not the employer’s responsibility. The same applies to the presence of occupational diseases. (Learn more in "The Importance of Determining an Employee's Pre-Existing Injuries".)
A physical examination should include vitals, height and weight, and other objective measurements that could have an impact on job performance. For example, a worker who is severely obese or severely underweight may not have the physical capacity for the job while in some jobs it might be a safety risk. While some parts of the exam are fairly standard, an exam may include more or less focus areas depending on the job the person is being evaluated for and the person's prior health history. This would be similar to your annual physical with a doctor and may vary from practitioner to practitioner. More in-depth testing is usually restricted to fit-for-work exams and targeted based on the specific job in question. Common items checked may include:
- Blood Pressure
- General Flexibility and Range of Motion
- Basic Lung Function (not spirometry)
- Blood Draw - Checking for things such as indications of heart disease, diabetes, or cancer
- Eyesight - Very basic and usually restricted to little more than pupil reactivity
Drug testing, and the particular tests used, will depend on the policy of the specific employer. A potential employee who tests positive for prohibited substances could be excluded from the job.
However, a positive test result may be due to legally prescribed medication. (Learn more in "Managing Opioids in the Workplace".) The examiner needs to consider the results of drug tests against the individual’s health history and the safety implications of a particular job. (Learn more in "Drug Test Types: 5, 7, and 12 Panel Urine Screening Differences and Reasons to Use".)
What is Included in a Fit-For-Work Evaluation?
While there are many possibilities of what can be checked in a fit-for-work evaluation, it is important to remember that what can be checked in each exam must be dependent on the specific job that an applicant is being tested for suitability for. For example, testing whether or not someone could run 5 miles would be inappropriate for an applicant for an office job.
- Body parts - Adequate functioning of all body parts, as required for the particular job. Disabilities and scars from previous injuries and surgeries are also noted.
- Auscultation of the heart and lungs - Abnormalities may indicate the presence of a chronic condition such as asthma or COPD, which could affect physical strength and ability or be a contraindication for exposure to certain hazardous substances.
- Ear examination - A perforated eardrum makes the person more susceptible to noise-induced hearing loss and the worker should likely be excluded from working in noise. In the presence of a chronic ear infection, hearing protection devices are contraindicated and the condition should be treated and healed before the person is exposed to noise. A common wax impaction requires referral for treatment as it affects hearing ability, which could pose a safety risk.
- Skin - A rash or eczema may point to existing or potential occupational dermatitis after exposure to hazardous substances. Abnormal coloring could also indicate specific diseases and conditions.
- Other physical signs of disease - The medical practitioner observes and examines for any other physical signs of disease which could impact on the worker’s job performance.
A simple urine stick test can point to possible diabetes, kidney disease, or an infection, all of which could require further investigation before a final decision on fitness for the job can be made.
Severe and uncontrolled hypertension can exclude the potential employee from most high risk work because of the potential for a stroke or myocardial infarction. This applies mostly where the worker operates vehicles and heavy equipment, such as cranes and forklifts, as well as some dangerous industrial processes.
Where moderate hypertension is diagnosed the person can be referred for treatment and assessed regularly to ensure that his or her blood pressure is adequately controlled.
A number of occupations require minimum levels of visual acuity, depth vision, lateral vision, and/or color vision. This could either be a functional or a safety requirement, the latter often being prescribed by legislation. The nature of vision screening conducted during a pre-employment examination will be determined by the intended occupation.
Good visual acuity is necessary for drivers and those operating heavy moving machinery. Workers may need to meet further visual requirements. For example, at least 70 degrees of lateral vision on each side is the usual standard for forklift operators who usually operate in a crowded environment with a blocked forward view. In the interests of safety, a person who has reduced lateral vision due to being completely blind in one eye should be restricted from working in an environment where there is heavy moving equipment.
Some occupations require normal color vision, as in the case of electricians. A high level of fine color discrimination is needed for color mixing, for example in the textile industry.
Pre-placement audiometric screening for persons who will be exposed to noise serves mainly as a baseline against which future hearing loss can be compared, and is a legal requirement in most countries. (Learn more in "Understanding Audiometric Screening".)
However, where there is existing hearing loss, additional hearing protection may be indicated and in the presence of extensive hearing loss further noise exposure should be avoided.
Spirometry is a common test to determine lung function by measuring the maximum exhaled volume of the lungs after a forced inspiration and the speed achieved during a forced exhalation. At the pre-placement examination this test mostly serves as a baseline for early detection of deteriorating lung function in workers who are exposed to respiratory hazards. Spirometry is usually a regulated requirement where there is exposure to dust from for example silica, asbestos, and from cotton; coke oven emissions; and hazardous chemicals such as benzene and formaldehyde.
Reduced lung function found during the fit for work assessment may be an indication for medical referral and could preclude the worker from the intended job, for example where there are respiratory hazards or where a high level of fitness is required.
A chest x-ray is often required as part of the pre-placement examination. Again this serves as a benchmark against which to determine the development of lung disease after exposure to hazards. However, it is also useful as an indicator of existing occupational lung disease and for early diagnosis of health issues such as tuberculosis, cancer and heart disease.
Functional Capacity Evaluation
This evaluation, usually done by a physical therapist or kinesiologist, goes further than basic flexibility and mobility assessment by a doctor and provides a quantitative assessment of the workers’ physical strength or limitations. Assessments can include range of motion, limb strength, lift strength, flexibility and cardiovascular fitness. Once again, the tasks required in a particular job will decide which tests are conducted. Functional capacity evaluation assists in reducing the risk of injury and could be particularly useful where the worker might have a limitation due to a prior injury.
The Employer and Medical Examinations
Pre-placement medical examinations help to ensure that the new employee is healthy enough to work and can thereby reducing potential safety risks and unnecessary legal and compensation pitfalls. However, because of the dynamic relationship between the individual’s health status and the demands of a particular job, decisions relating to the assessments to be conducted and fitness to work for a specific job would fall under fit-for-work testing. A medical condition found during the examination may be completely irrelevant for effective and safe performance of the work and not pose any risk to others.
There are many benefits for employers in setting up a fit for work testing program. (Learn more in "How to Set Up a Fit-for-Work Testing Program".) Fitness for work is not static and should be followed by periodical fit for work assessments. This is especially indicated, and often legally required, where there are health hazards in the workplace, for safety-sensitive jobs, and when employees are transferred to a significantly different position. A re-evaluation of an employees’ fitness for work may also be necessary after a change in the employee’s health status such as the diagnosis of a chronic medical condition or after recovery from serious injury or disease.