Supervision of Occupational Fitness Assessments

Occupational Fitness Assessments • 225

Supervision of Occupational Fitness Assessments

Roy J. Shephard and the late Jean Bonneau

Catalogue DataShephard, R.J.; and Bonneau, J. (2003). Supervision of occupational fitness assessments.Can. J. Appl. Physiol. 28(2): 225-239. © 2003 Canadian Society for Exercise Physiology.

Key words: cardiac catastrophe, professional fitness and lifestyle consultant, medical del-egation, medical supervision, sudden death

Mots clés: crise cardiaque, conseiller (ère) en condition physique et habitudes de vie–niveauII, actes médicaux délégués, supervision médicale, mort subite

Abstract/Resumé

Controversy continues regarding an appropriate level of supervision for occupational fit-ness assessments. A bout of vigorous physical activity can augment the immediate risk of acardiac catastrophe by a factor of 5–100 depending on age, cardiac risk factors, and thephysical and emotional circumstances of the participant. However, if a person engagesregularly in such activity, the immediate risk is more than offset by an improvement inprognosis during intervening periods of rest. During demanding physical work, there is asmall but measurable risk of sudden death (3 to 7 episodes per 100,000 personnel peryear). The risk associated with a brief (<15 min) but vigorous occupational fitness assess-ment is so low as to preclude attempts to reduce it still further by direct medical supervi-sion. If testing encourages an increase in personal fitness, any immediate increase in risk isenormously offset by a reduction in the number of cardiac deaths while resting. Further-more, evidence is unconvincing that the average medical practitioner can prevent or treatany emergencies that may arise better than a well-trained professional fitness and lifestyleconsultant (PFLC), a person certified by the Canadian Society for Exercise Physiologywho has had frequent opportunities to practice the necessary skills. Since occupationalfitness assessments are not diagnostic procedures, they appear to fall outside the jurisdic-tion of medical licensing bodies. In the absence of a history of cardiovascular disease,

225

R.J. Shephard is professor emeritus of the Faculty of Physical Education & Health,and Dept. of Public Health Sciences, Faculty of Medicine, Univ. of Toronto; the late J.Bonneau served with the Royal Canadian Mounted Police, Ottawa, Ontario.

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226 • Shephard and Bonneau

supervision of such assessments is safely and appropriately undertaken by the PFLC. Un-necessary insistence on medical supervision could preclude annual evaluation of occupa-tional fitness and a resulting enhancement of physical condition, thus increasing ratherthan diminishing the risk to the worker.

Le contenu du dépistage pré-test ainsi que la supervision appropriée des évaluationsd’aptitudes physiques en milieu de travail demeurent des sujets controversés. Le facteur derisque immédiat d’une crise cardiaque s’augmente de 5 à 100 fois lors d’une périoded’activité physique vigoureuse en raison de l’âge, des facteurs de risques cardiaques, et descirconstances physiques et affectives du participant. Cependant, si la personne pratiquedéjà à un régime d’exercices de façon régulière, le risque immédiat est de beaucoup compensépar l’amélioration du pronostic au cours des périodes de repos interimaires. Lors d’untravail physiquement exigeant, le risque de mort subite est modeste mais mesurable (3 à 7cas par 100,000 personnes par an). Le risque associé à une brève (<15 minutes) maisvigoureuse évaluation de l’aptitude physique en milieu de travail est suffisamment bas qu’ilserait inutile d’essayer de le réduire davantage par une surveillance médicale. Tout risqueimmédiat est largement compensé par une diminution de la mortalité cardiaque lorsquel’individu est au repos, car le test encourage le travailleur de se maintenir en forme. Deplus, lors d’une évaluation des capacités physiques, l’évidence n’est pas convaincant qu’unmédecin peut prévenir ou traiter les urgences mieux qu’un(e) conseiller (ère) en conditionphysique et habitudes de vie (niveau II) (CPHV-II) certifié(e) par SCPE. Les évaluationsd’aptitudes physiques en milieu de travail se sont avérées très sécuritaires. Puisque cesévaluations ne sont pas des procédures diagnostiques, elles ne sont pas sous la juridictiondes organismes qui réglementent la profession médicale, et si il n’y a pas evidence d’unemaladie cardiovasculaire, elles peuvent être surveillées par les CPHV-II. Le fait d’insistersur une supervision médicale peut empêcher les évaluations d’aptitudes physiques annuelles,et l’amélioration de la forme physique qui en résulte. Par conséquent, une telle politiquepeut augmenter plus que diminuer les risques cardiaques.

Introduction

Occupational fitness assessments are commonly applied in deciding on the re-cruitment and retention of employees in physically demanding jobs such as publicsafety officers (Shephard, 1991b). The typical procedure requires several minutesof vigorous or even maximal physical activity and, particularly when the assess-ment is applied to middle-aged and older incumbents, questions are raised con-cerning the risks of the evaluation and the medical supervision needed during ap-praisals. Specific issues have included the following:

• The risk of a cardiac emergency during vigorous exercise;• The influence of age and other risk factors upon this risk;

• The prevalence of cardiac events and death in physically demanding occu-pations such as the armed forces and the police;

• The influence of physician presence on the likelihood of an emergency andon success in resuscitation of the victim;

• The frequency of adverse consequences during assessments;• The appropriate level of supervision of assessments.

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Risk of a Cardiac Emergency During Vigorous Physical Activity

It has been recognized for many years that a bout of vigorous physical activityincreases the immediate risk of a cardiac emergency relative to resting conditions(Shephard, 1974). However, the extent of the increase in risk is less clearly estab-lished, in part because we are seeking statistics on a very rare event, and in partbecause the low likelihood of a cardiac emergency is modulated by many factorsincluding the intensity and duration of the activity, the fitness and general health ofthe employee, the time of day when the assessment is made, and other incidentalphysical and psychosocial circumstances (Shephard, 1995).

A two- to 100-fold increase in the risk of a cardiac emergency has beenestimated during and immediately following a sustained bout of physical activity,whether this is performed in the community or in the laboratory (Cobb and Weaver,1986; Mittleman et al., 1993; Shephard, 1995; Siscovick et al., 1984; Vuori, 1995;Willich et al., 1993). Moreover, risks are two to four times greater for strenuousthan for nonstrenuous activity (Vuori, 1995). In the occupational setting, the esti-mate of increased risk is tempered by several considerations:

1. If a good standard of physical fitness is demanded as a condition of re-cruitment and/or continuing employment, the individual’s overall risk of eithermyocardial infarction or cardiac death will be only 33–50% of that if the employeewere to remain sedentary (Powell et al., 1997; Shephard, 1995; Siscovick et al.,1984). If (as is likely) regular occupational fitness assessment encourages an em-ployee to maintain his or her physical fitness, this will counter any immediate risksof appraisal, and the overall prognosis will be further improved rather than wors-ened as a consequence of such assessment.

2. The risk of a myocardial infarction or cardiac death during the few min-utes required to complete an occupational fitness assessment is extremely low.Much of the available scientific information has been derived from the experienceof exercise testing in cardiac rehabilitation programmes. Here, risk has been as-sessed quite conservatively, so that deaths, myocardial infarctions, cardiac arrests,and arrythmias occurring as long as 6 hours after testing have been attributed tothe test. In this particularly vulnerable segment of the community (Table 1), thenormal (resting) risk of a fatal incident is currently 1–2% per year among middle-aged patients (40–50 years). Since there are 8,760 hours in a typical year, thecorresponding risk of a fatality over a 6-hr period is about 1 in 100,000.

On the conservative assumption that exercise causes a tenfold increase inrisk throughout this 6-hr period, the likelihood of such an incident following a 12-min laboratory bout of peak exercise would be 1 in 10,000. Given that the assess-ment is supervised by a person with expertise in cardiopulmonary resuscitation,there is often recovery from an event that would be fatal at home. Nevertheless,the estimate of one serious incident in 10,000 tests seems in keeping with empiricalreports of 1.59 life-threatening complications per 10,000 clinically-indicated exercisetests (Myers et al., 2000) and 1.06 per 10,000 cardiac screening tests (Gibbons et al.,1989). A recent review of postcoronary programmes suggested an average of 5complications per 10,000 tests, with a death rate of around 0.5 per 10,000 tests(Gibbons et al., 1994). A second, more optimistic report in the same journal foundless than 1 complication in 10,000 tests (Fowler et al., 1997). Many postcoronaryprogrammes have experienced no fatalities over many years of exercise testing.

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Reports bringing to light cardiac fatalities have included two widespreadsurveys covering information from the early days of cardiac rehabilitation (Atterhoget al., 1979; Hamm et al., 1989). One study analyzed questionnaire responses froma large number of cardiac rehabilitation centres (151,949 tests at 570 institutions).It found a fatality rate of 3 per 10,000, with failure to resuscitate a quarter of majorcardiac events. However, given the number of programmes evaluated, and the factthat reports dated back to the early days of cardiac rehabilitation, skill in cardiacresuscitation may initially have been less than optimal at some centres. In at leastone major study, the safety of testing appears to have increased as experience incardiac resuscitation increased, paramedical staff became well trained and wellprepared, and a well-rehearsed emergency procedure was established. Thus, whenthe Cooper Clinic performed 71,914 maximal tests on a mixed adult populationwith a low prevalence of diagnosed coronary vascular disease, a total of six majorcardiac complications with one death was experienced (Gibbons et al., 1989); how-ever, no complications were seen in the last 45,000 tests from this series. A sub-stantial proportion of clinical exercise testing is submaximal. One author also notedthat an increase in the intensity of effort led to a 1.9-fold increase in the risk ofmajor complications relative to a low level procedure (Hamm et al., 1989).

In healthy adults ages 35–54 years, the risk of a fatality from ischaemicheart disease (International Classification of Diseases #9, diagnostic categories410–414) is much smaller than in the typical cardiac patient. In 1997, figures forthe male Canadian population ages 35–54 years averaged 48.5 per 100,000 per-son-years (Health Protection Branch, 1997); in women ages 35–54 years, the riskwas about one quarter of this, at 11.5 per 100,000 person-years (Health ProtectionBranch, 1997). Again making the very conservative assumption that there is a

Table 1 Previously Reported Estimates of the Safety of Exercise Testingin Cardiac Patients

Number of major eventsSample Cardiac In- Arrhyth-

Year Authors size arrest farct mia Deaths Comment

1979 Atterhog et al. 50,000 ---------92------------ 2 Prospective questionnaire1984 Young et al. 1,377 ---------32------------ 0 High-risk ventric. arrhythm.1987 Tristani et al. 607 0 0 10 0 CHF patients1989 Gibbons et al. 71,914 ----------6------------ 1 Maximal tests1989 Hamm et al. 151,949 -------141------------ 41 Questionnaire1995 Simicek et al. 37,250 1 4 0 0 98.7% symptom-limited1997 Ilia & Gueron. 38,970 0 2 5 0 Community clinic1999 Olivotto et al. 243 0 0 0 0 Hypertrophic cardiomyop.1999 Squires et al. 289 1 0 0 0 Tech. supervised, CHF2000 Myers et al. 75,828 0 3 1 0 Questionnaire survey

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tenfold increase over the resting risk throughout the 6 hours following a bout ofexercise such as a laboratory evaluation, we might anticipate 485 3 6 / 8760, or0.33 life-threatening cardiac episodes per 100,000 assessments in men ages 35–54years; in women of similar age the risk would be 0.08 per 100,000 assessments. Itis likely that the true incidence of both events and fatalities would be lower thanthis during most worksite assessments, given (a) the absence of many stressesassociated with a diagnostic evaluation; (b) a shorter test duration (e.g., 4 ratherthan 12 minutes in the RCMP fitness assessment; Gaul and Wenger, 1992); (c) theselective recruitment of fit employees to physically demanding work; and (d) themaintenance of fitness by such employment.

Influence of Age and Other Cardiac Risk Factors

Under resting conditions, an increase in age leads to an exponential increase in therisks of both myocardial infarction and cardiac death (Health Protection Branch,1997). According to McHenry et al. (1972), the risk of an ischaemic episode inpolice officers doubles for each decade of service. Their survey reported “definiteor suspect” cardiovascular disease in 5% of policemen ages 25 to 34 years, 13% ofthose ages 35 to 44, and 21% of those ages 45 to 54, similar to the figures encoun-tered in the general population. However, some early reports suggested that theincidence of cardiac risk factors was greater than average in middle-aged officers(Johnston and Hope, 1981; Pollock et al., 1978) and, probably in part for thisreason, the cardiac death rate of older police officers during the early 1960s wasabove the population average (Guralnik, 1963).

The effects of advancing age and of cardiac risk factors on the likelihood ofan exercise-induced cardiac catastrophe are not clear-cut. The incidence of exer-cise-related sudden death increases sharply between 30 and 40 years of age, due inpart to an increasing prevalence of coronary artery disease, and in part becausehigh-risk individuals who have become unfit decide to initiate a bout of vigorousphysical activity without adequate preparation. Nevertheless, the risk that cardiacdeath will be associated with exercise rather than resting conditions is similar inpersons ages 20–38 and 40–49 years, and decreases substantially in persons ages50–69 years (Vuori, 1995). This is in part because the oldest group takes less exer-cise, and in part because they are less likely to exercise imprudently relative tosomeone who is younger.

Prevalence of Exercise-Induced Cardiac Events and Deathin Physically Demanding Occupations

MILITARY SERVICE

A small but measurable risk of exercise-induced death is inherent in normal mili-tary service, and there seems little possibility of averting this risk by preliminaryscreening (Shephard, 2000a). Of 1,000 cases of sudden death in apparently healthyU.S. soldiers, 350 apparently had a cardiac cause, and some 300 of these incidentsarose in older individuals with coronary atherosclerosis (Moritz and Zamcheck,1947). During a 10-year period, male soldiers in the British Army sustained 56

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cases of sudden death after engaging in sport or strenuous exertion, an incidenceof 3.5 sudden deaths per 100,000 man-years of service (Lynch, 1980), or, assum-ing 5 hours of exercise per week and 260 hours per year, one sudden death per 7.43million hours of exercise.

A 25-year review of Finnish male conscripts noted somewhat comparablefigures of 6.8 deaths per 100,000 man-years, or, again assuming 5 hours of vigor-ous exertion per week, one death per 3.82 million hours of exercise (Koskenvuo,1976). A 20-year study of U.S. Air Force recruits found 19 instances of suddendeath among ostensibly healthy, medically-screened recruits (Phillips et al., 1986);the risk for this population was estimated at one sudden death per 2.94 millionhours of exercise. Finally, the Israeli Armed Forces experienced 20 sudden deathsover 13 years, although in this instance the available information does not allowan estimation of the risk associated with exercise (Drory et al., 1991). AveragingBritish, U.S., and Finnish data, the risk to military personnel is one death per 4.7million hours of sustained, vigorous exercise.

None of the military reports have considered the risk of death in the absenceof exercise, and it is not easy to make such a calculation in retrospect, given strongsecular trends to a decreasing cardiovascular mortality and the major influence ofsample age. If vigorous exercise occupied some 3% of the soldier’s week (5 of 168hrs), and a third of the exercise-related deaths had a cardiovascular basis, a rate of2 cardiac deaths per 100,000 man-years of service while exercising would corre-spond to a total annual cardiac death rate of some 67 per 100,000 soldiers, prob-ably not much in excess of the normal resting rate for a population of young andmiddle-aged men during the 1970s. If the two exercise-related deaths were accu-mulated during 10 rather than 5 hours of vigorous physical activity per week, thecardiac death rate while exercising would correspond to a still lower total annualrate of 33 per 100,000 men.

The cardiac risk is likely to rise exponentially with the duration of exercise.However, prorating one death per 4.7 million hours of exercise to a 4-min occupa-tional appraisal, and ignoring the issue of how far this apparent risk exceeds thenormal rate for resting conditions, there would be one cardiac death during 70million occupational fitness assessments.

POLICE OFFICERS

Police duties also carry a small inherent risk of death from various causes. Again,there is a need to distinguish cardiac fatalities caused by a specific bout of exercisefrom those that would have occurred under normal resting conditions. Taking the1997 statistics for Canadians ages 35–54 years, ischemic heart disease deaths av-eraged 48.5 per 100,000 person-years in males, and in females ages 35–54 yearsthe risk was about one quarter of this (Health Protection Branch, 1997). For thoseunder 35 years of age, the risk was extremely low in both sexes. Assuming a malepolice officer over the age of 35 years works 37 hours per week during 46 weeksof the year, the inherent risk of incurring a fatal ischemic episode while on dutywould be 1702 / 8760 3 48.5, or 9.4 episodes per 100,000 person-years of work,18.1 million hours of work per episode.

Older police officers are rarely required to undertake very vigorous physicalactivity. All-out effort is needed only once every 6–12 months. Exercise bouts are

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also short, the median total time for a critical incident being around 15 minutes(Anderson and Plecas, 1999). Assuming 15 minutes of exercise per incident, theinherent risk of a cardiac fatality for male officers age >35 years during such anincident would be one in 72.4 million. Making the conservative assumption thatthere is a tenfold increase of risk during vigorous physical activity, the exercise-induced risk of sustaining a heart attack due to a critical incident would then benine times the resting level for the same period of time, or one cardiac death in 8million critical incidents for male officers >35 years, and one cardiac death in 32million critical incidents for females >35 years. On the much more conservativeassumption that the risk remains elevated for 6 hours, there would then be onedeath in 333,000 men and one death in 1,333,000 women age >35 years.

How do these figures relate to the risk incurred during a brief occupationalassessment? Prescreening, test monitoring, and posttest observation all reduce thedanger of an appraisal relative to normal active duty. Further, a warm-up and cool-down are possible, the speed of performance is generally self-determined and isnot necessarily maximal, and candidates can be instructed to stop the assessment ifuntoward symptoms develop. Finally, the risk of a cardiac incident is lower be-cause the duration of activity is shorter. But making the conservative assumptionsthat maximal effort is expended during the appraisal, that screening and monitor-ing confer little benefit, and that there is no more than a prorated decrease in riskbecause the exercise is brief, the hazard of a single 4-min all-out occupationalassessment would be 4/15ths of that for a critical incident (that is, for persons ages35–54 years, one cardiac death in 30 million male assessments and one in 120million female assessments during the assessment).

On the very conservative assumption of a 6-hr persistence of risk, there wouldbe at most one cardiac death in 1.25 million men and one in 5 million women forthe 6 hours following appraisal. Even if there were to be no compensating increasein survival during the remainder of the year from an enhanced interest on the partof the employee in his or her fitness, insistence on medical supervision in an at-tempt to reduce the immediate risk of one in 30–120 million seems highly inap-propriate. At a fee of $200 per test, and making the generous assumption of 100%success in resuscitation, the cost of such a resuscitation would be $6 billion formen and $24 billion for women, or, with 20 years of survival postresuscitation,$300 million per year for men and $1.2 billion for women. Health economistswould regard such a procedure as cost-effective if the cost of a successful resusci-tation fell in the range $20,000–$100,000 per year of survival. Medical supervi-sion of a 4-min occupational assessment is thus cost-ineffective by three to fourorders of magnitude (Shephard, 1986).

If we assume that ready access to an occupational fitness assessment en-courages an active lifestyle, with a resultant halving of the normal risk of coronarydisease, the overall cardiac death rate for 35- to 54-year-old employees would bereduced from 48 to 24 males and 12 to 6 females per 100,000 person-years at theexpense of a risk of .0033 deaths per 100,000 males and 0.0008 deaths per 100,000females during the fitness assessment, with possible additional risks of 0.08 and0.02 per 100,000 for the 6 hours following appraisal. The corresponding cost/benefit ratios would be more than 7,000 to one, and 29 to one, even in the absenceof attempts to resuscitate any individuals who develop a cardiac emergency.

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Influence of Physician Presence on the Likelihoodof an Emergency and on Success in Resuscitation

Although at first the attendance of a physician might seem likely to increase thesafety of an occupational fitness assessment, this assumption should not beaccepted uncritically. The presence of a doctor may suggest to an employeethat the assessment is a dangerous procedure. The resulting anxiety could thusprecipitate the heart attack which it is hoped to avoid. One reason why exerciseincreases the risk of a cardiac catastrophe is the associated rise in systemic bloodpressure, and thus the work of the heart relative to the available oxygen supply.The adverse influence of the presence of a physician upon blood pressure(“white coat hypertension”) is now well documented (Young et al., 1983) andis an important concern when seeking to optimize the conditions of anyworksite assessment.

Do physicians have a greater ability than paramedical professionals to fore-see and treat any complications that may arise during an occupational fitness as-sessment? Highly trained specialists can legitimately make such a claim, but manyphysicians are handicapped by a limited educational background in exercise sci-ence and lack the regular exposure to fitness testing that is important to maintain-ing high standards of practice in this domain (Schlant et al., 1990). One trial foundthat the rate of exclusion of apparently healthy people from a fitness test rangedfrom 0.9% to 15% among physicians (Chisholm et al., 1975; Shephard et al., 1981).Further, there was no evidence that the vagaries of medical opinion concerningability to perform a simple exercise test bore any relationship to the likelihood ofdeveloping symptoms and/or electrocardiographic abnormalities during the evalu-ation (Shephard, 2000b).

In contrast to the varying interpretations of medical practitioners, suitablytrained health professionals are likely to adhere closely to published end-pointsand contraindications, showing commendable caution and making a minimum ofunwarranted personal judgments (Franklin et al., 1997; Shephard, 1991a). Thelikely result is that the incidence of cardiovascular complications during a fitnessassessment will be no higher when supervised by experienced and well-qualifiedpersonnel such as professional fitness and lifestyle consultants (PFLC) certifiedby the Canadian Society for Exercise Physiology than when there is direct physi-cian supervision (Franklin et al., 1997; Shephard, 1991a). Likewise, appropriatelytrained paramedical professionals and even lay people are often very effective inadministering standardized cardiac resuscitation if this is required (Cobb et al.,1990; Liberthson et al., 1974).

A broader but equally important issue is that if the regular fitness testing isrestricted or abolished because of insistence upon costly medical supervision,employees are likely to become physically less fit and therefore more vulnerableto heart attacks (Shephard, 2000b). The current incidence of cardiac risk factorsamong the general population points strongly to the need for motivation to ahealthier lifestyle, and there is good evidence that an occupational fitnessassessment contributes to the necessary change in attitudes and behaviour (Gaulet al., 1992).

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Frequency of Adverse Consequences During Administrationof Occupational Fitness Assessments

There is little empirical information on the frequency of adverse events duringoccupational fitness assessment, mainly because problems are extremely rare.Unwarranted fears about the safety of a proposed assessment of officers in theRoyal Canadian Mounted Police led as many as 25% of personal physicians torefuse permission for incumbents to participate in appraisals (Gaul et al., 1992).Reasons advanced for exclusion included high blood pressure, a previous heartattack, an old musculoskeletal injury which might have been exacerbated, and, insome instances, capitulation to demands of officers who were unwilling to take theassessment (Gaul et al., 1992). The reality, as predicted above, has been a remark-ably low incidence of problems among those who were allowed to undergo evalu-ation. In the first 2,100 serving officers, there were 5 episodes of minor nausea orvomiting and 8 minor ankle, knee, and back injuries (Gaul et al., 1992). The RCMPhas seen no evidence of cardiac complications in over 30,000 assessments to date.

Policy of Professional Bodies

CANADIAN MEDICAL ASSOCIATION

Under “General Responsibilities,” the Code of Ethics of the Canadian MedicalAssociation emphasizes that the first duty of the physician is to the well-being ofthe patient. This indicates a welcome commitment to long-term health rather thanto avoidance of short-term risk by a supervising physician. A second relevant ethi-cal requirement (#32) is the prudent use of health care resources, a requirementwhich in the present context is best satisfied by avoiding unnecessary and cost-ineffective physician supervision of occupational fitness assessments.

Dr. Scully, past-president of the Canadian Medical Association, has statedthat the solution to human resource issues in the health sector in Canada lies in“the coordinated delivery of services by a variety of health occupations” (HumanResources Development Canada, Sept. 20th, 2001).

COLLEGE OF FAMILY PHYSICIANS OF CANADA

High in the mission statement of the College of Family Physicians of Canada is theneed to improve the health of Canadians by contributing to public understandingof healthful living. Encouragement of regular occupational fitness assessmentplainly makes an important contribution to this objective.

COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO

Policy 1-99 provides specific guidelines on the delegation of controlled acts. TheRegulated Health Professions Act indicates that there are 13 controlled acts. Theonly one at all relevant to the present discussion is #1—communicating to theindividual a diagnosis identifying a disease or disorder as the cause of symptoms.However, for the act to be controlled by the College, there must be symptoms, and

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there must be an attempt to make a diagnosis from this. It would appear that nei-ther of these conditions applies during an occupational fitness assessment, so thatsupervision of such an assessment by an exercise professional does not in factconstitute delegation of a controlled act.

Scope of Practice for Exercise Professionalsand Resulting Physician Liability

Despite strong arguments for why physician supervision of occupational fitnessassessment is unwarranted, there is still considerable controversy as to the super-vision of exercise testing. The American College of Sports Medicine [ACSM](2000) has shifted progressively toward a more liberal position on this issue. Cur-rently it recommends that during maximal diagnostic testing (typically an exercisebout of 10–15 min duration), a physician should be present only for older candi-dates (men >45 yrs, women >55 yrs ) and for those with two or more major cardiacrisk factors. No specific opinion is expressed concerning a brief 4-min nondiagnostictest, although the ACSM guidelines (2000) acknowledge that “There is disagree-ment as to whether direct physician supervision of exercise tests in persons withknown cardiovascular disease is routinely needed” (p. 112, author’s italics); thesame page cites references endorsing non-physician supervision for apparentlyhealthy adults and low- to moderate-risk coronary patients (American Associationof Cardiovascular and Pulmonary Rehabilitation, 1999; Fletcher et al., 1995; Gib-bons et al., 1997; Pina et al., 1995; Schlant et al., 1990).

Many hospitals and medical centres are recognizing that specialized healthprofessionals with appropriate training in exercise science, fitness testing, and car-diopulmonary resuscitation offer a safe and cost-effective alternative to directmedical supervision of exercise tests (Ellestad et al., 1979; Knight et al., 1995).Critics of earlier restrictive policies argue that there is good evidence that a healthprofessional with appropriate training can (a) appropriately screen patients fromthe medical history and resting ECG, (b) make a timely and accurate interpretationof ancillary signs and symptoms, and c) terminate an exercise test in accordancewith current best practice (Shephard, 1991a). Suitably trained health professionalsadhere to published end-points and contraindications with a commendablecaution and minimum of personal interpretation, so that the incidence of cardio-vascular complications is no different whether an exercise test is supervised byexperienced paramedical personnel or a physician (Franklin et al., 1997; Shephard,1991a).

The key to safety and appropriate interpretation of results is in fact experi-ence and expertise rather than a formal medical qualification (Ellestad, 1993). Onemust perform a minimum of 25 exercise tests per year to maintain a reasonablecompetency in the relevant procedures, and physicians who only occasionally as-sume responsibility for exercise test supervision may lack adequate opportunity toconserve the necessary skills (Schlant et al., 1990). Furthermore, if resuscitation isrequired, the abilities of trained paramedical and lay personnel are amply docu-mented (Cobb et al., 1990; Liberthson et al., 1974).

Despite growing recognition of the role of the American College of SportsMedicine/Canadian Society for Exercise Physiology certified exercise specialist

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in diagnostic exercise testing, the consensus remains that a physician should bepresent if a maximal diagnostic exercise test is to be performed on an individualwho has two or more major risk factors for cardiac disease, or who exceeds aspecific age standard (age 45 for men and 55 for women) (American Association,1995; ACSM, 2000; Fletcher et al., 1995; Pina et al., 1995). Physicians might thusbe open to action for negligence if they were to delegate duties to such an exercisespecialist during maximal diagnostic testing of an older patient.

However, the above requirements apply specifically to clinical, diagnostictesting. The Oxford English Dictionary is characteristically clear in its definitionof the word diagnostic. It means “Of or pertaining to diagnosis.” Further, the dic-tionary specifies that diagnosis is “determination of the nature of a diseased condi-tion; identification of a disease by investigation of its symptoms.” The ACSMGuidelines (2000) distinguish between “physical fitness testing” for such purposesas health education, exercise prescription, and motivation (chapter 4) and “clinicalexercise testing” (chapter 5) used for diagnostic, prognostic, and therapeutic ap-plications, although they do not distinguish the level of supervision required forthe two types of activity. Nevertheless, the current consensus requirements on di-agnostic testing are not necessarily appropriate for either nondiagnostic assess-ments of fitness for work or the use of exercise testing to encourage an activelifestyle in a symptom-free, healthy employee who during a periodic medical ex-amination has already been found capable of vigorous employment. In such situa-tions there is no doctor-patient relationship, although issues of medical delegationcould still arise if the person performing the worksite test was required by corpo-rate structure to report to the company physician.

Appropriate Supervision of Occupational Fitness Assessment

Given that physician supervision of occupational assessments is not cost-effec-tive, what is an appropriate level of qualification for those conducting such tests?The CSEP–ACSM exercise specialist (ACSM, 2000) would clearly be capable ofthe task, but the requirement of 600 hours of practical experience in a clinicalexercise programme appears unnecessary, given that occupational assessments aremade on healthy individuals. The National Council of the Health and Fitness Pro-gram of CSEP has implemented certification as a PFLC as of the fall of 2002.These individuals must attain their PFLC qualification before they can become anexercise therapist. Again, such individuals would be well qualified to undertakeoccupational assessments, but their minimum of 1,000 verified hours of experi-ence working with persons who have impairments, functional limitations, or dis-abilities is not needed for conducting a brief occupational fitness assessment orother nondiagnostic maximal testing on a healthy person.

It seems that the most appropriate type of person to supervise occupationalappraisals is the CSEP-certified PFLC. Such an individual is capable of competentand autonomous appraisals, utilizing a variety of assessment protocols, and he orshe can also interpret the results and develop an appropriate personalized fitnessprogramme. Minimum qualifications include a university degree in Exercise Sci-ence, a PFLC workshop/apprenticeship of at least 120 contact hours, the passingof comprehensive practical and written examinations, and current certification in

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cardiopulmonary resuscitation. Two restrictions imposed by CSEP on such indi-viduals are relevant to occupational assessments: appraisals may not proceed onan individual with a history of cardiovascular disease unless he or she has beencleared for unrestricted physical activity by a physician, and appraisals may not bemade if these fall within a physician’s written restrictions on physical activity.

Conclusions

If the purpose of testing is the diagnosis of some medical condition such as myo-cardial ischaemia in a man over 45 years of age, a woman over 55 years, or anindividual with two or more cardiac risk factors, medical supervision of a maximaltest is still “recommended” by professional groups such as the American Collegeof Sports Medicine (2000), the implication being that “the physician should be inclose proximity and readily available should there be an emergent need.” In suchcircumstances, a physician could be criticized for delegating testing to an exerciseprofessional, even if that person was trained to the standards of the Canadian Soci-ety of Exercise Physiology’s PFLC.

However, the purpose of a typical occupational fitness assessment is notdiagnostic. The employees concerned are symptom-free, and their fitness to per-form vigorous physical work has generally been determined by a physician andconfirmed by their employment record. Rather, such an assessment is intended todefine the individual’s continuing fitness for work, and it provides strong motiva-tion to enhance personal fitness both prior to and subsequent to testing. Further,the employee is performing a normal job requirement when undergoing such anassessment. Any risk of a heart attack is so low that it is impossible to determineby empirical analysis, and attempts to modify such a low risk by insisting on su-pervision by a physician fail to meet current standards of cost-effective medicineby several orders of magnitude.

There is now strong evidence on (a) the multiple health benefits of encour-aging a high level of personal fitness (Bouchard et al., 1994; U.S. Surgeon Gen-eral, 1996), and (b) the responsibility on the part of physicians to encourage thedevelopment of such fitness through their contacts with individual patients and thegeneral public (Godin and Shephard, 1990; Valente et al., 1986; Wallace et al.,1987; Wechsler et al., 1983). If fitness assessment encourages an active lifestyleboth before and after testing, this would save some 24 cardiac deaths per 100,000person-years in a male population ages 35–54 years, at a cost perhaps as low as0.0033 cardiac fatalities per 100,000 person-years. This is a highly effective rateof return. There would thus seem little justification for limiting the benefits ofregular nondiagnostic appraisals by insisting on direct medical supervision. CSEP-certified PFLCs have the necessary training to undertake such assessments safely,and they can complete this task in a much more cost-effective manner.

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Documents

Supervision of Occupational Fitness Assessments