As of 2019, medical schools do not offer much teaching on medical selection. This partly is the reason why many clinicians have an unclear understanding of why and how medical selection differs from the usual diagnostic, therapeutic and preventive practices most doctors know so well.
Research in the field is at best sparse. The end-points in today’s research studies do not give us much evidence for a better understanding of the selection process and its basis. Screening tests are widely used in enhanced PEME schemes, often without a justification and with a dubious evidence basis using cut-off points for therapeutic intervention as cut-off points for prediction of working ability at sea.
The literature is not abundant. There is some literature regarding medical selection for insurance purposes[1], on rehabilitation[2], on fitness to drive a car[3]. The ‘Handbook for seafarer medical examiners’[4] by professor Tim Carter is a practical handbook for the daily work as an approved doctor. It is based on the ILO/IMO Guidelines[5] and the author’s long experience as senior medical adviser to the UK Department of Transport, the UK Maritime and Coastguard Agency and as secretary to the ILO on producing the guidelines. Specific guidance documents are developed by some authorities[6] on how to make decisions in accordance with their respective statutory requirements.
We would very much like to know something of the likelihood for those medical incidents that could threaten safety for crew, ship and self for a period of maximum two years ahead, corresponding to the maximum validity period of a medical certificate. Published scientific articles only rarely offer such data.
At present, the heuristic way of decision-making is the regular one: Experience of what have worked in the past, and the doctor’s subjective assessment. We certainly hope that the future will provide us with scientific data that that enable us to reach decisions that are based more on evidence than on gut-feelings.
[1] Brackenride RDC, Croxson R, Mackenzie R. Brackenridge’s Medical Selection of Life Risks. Palgrave Macmillan. ISBN 978-1-349-72324-9
[2] Hobson J, Smedley J. Fitness for work. Sixth Edition 2019. The Medical Aspects. Faculty of Occupational Medicine (UK). Oxford University Press. ISBN: 9780198808657
[3] Carter T. Fitness to Drive. A guide for health professionals. Royal Society of Medicine Presss Ltd, 2006. ISBN 1-85315-651-5
From time to time maritime authorities receive concerns regarding the reliability of the assessments of approved doctors. Such concerns have been based on cases where either the ship-owner or the insurer for some reason finds it peculiar that the conditions which led to diversion, hospitalisation and repatriation in a seafarer, was not revealed during the latest PEME before commencement of work on board. Sometimes seafarers ask how the doctor could possibly have done his job, when he used just a few minutes on the consultation.
During the latest decades, public and professional attention has increased regarding quality, safety and efficiency of health services. Today quality systems at different levels are necessary for clinics and single-handed practitioners that want to present themselves as running a safe and reliable service.
Audits of approved doctors have been in place in several countries having approved doctors abroad. Examples are the UK, Germany and the Netherlands.
The country having most approved doctors outside own borders, namely Norway, got this in place as mandatory after the new regulations[1] entered into force from 2014. The requirements for a quality system is described in a circular dated October 2014[2]. In this circular it is required that “the seafarer’s doctor shall have a quality system in accordance with an internationally recognised standard. This could for instance be a system based on ISO 9001[3] or IMHA Quality[4]. The Circular RSV 12-2014 from the NMA describes the minimum content of the quality system, also included in the ‘Guidance’ to the regulations[5].
The ISO Standards
The focus of the ISO 9000 family of quality management systems is to help organisations ensure that they meet the needs of customers and other stakeholders while meeting statutory and regulatory requirements related to a product or service[6].
The ISO 9001:2015 Quality Management Systems – Requirements is a document that encompasses the following sections:
Section 1: Scope
Section 2: Normative references
Section 3: Terms and definitions
Section 4: Context of the organization
Section 5: Leadership
Section 6: Planning
Section 7: Support
Section 8: Operation
Section 9: Performance evaluation
Section 10: Continual Improvement
It is obvious that the designers of ISO 9001:2015 did not think about medical service providers when they designed the system. The system does not include aspects of sound practice assessment, and it does not check the quality of the product (e.g. medical certificates). A proper quality system for health service providers dealing with medical selection should cover all these aspects.
The IMHA Quality standards
The abstract of the article by Carter, Bell, Horneland and Idnani (2017) gives a good overview of the background for the IMHA Quality standards and is quoted below.
Standards to assess the quality of doctors and clinics performing pre-employment medical examinations (PEMEs) were developed for International Maritime Health Association (IMHA) Quality, a not for profit organisation, created to provide an ethically sound and professional accepted accreditation system that would benefit seafarers having PEMEs and employers, insurers and national maritime authorities seeking valid assessments of seafarers’ fitness for duty. Thesestandards followed a format widely used in other healthcare settings, where assessment of clinical performance is desirable.
Uptake of these standards by doctors and clinics was not as expected, as they did not see sufficient business benefits coming from accreditation to justify the costs. This was, at least in part, because there was some antagonism to a professionally based accreditation system from commercial interest groups such as insurers, while national maritime authorities did not come forward to use the system as a recommendation or requirement for approval of doctors.
The IMHA Quality accreditation system has now been closed and for this reason and the standards are made publicly available. They are now free to use by anyone who wants, as a means of improving quality of practice when performing PEME[7].
The standards encompasses the following sections:
1. Clinic management
2. Policies and procedures
3. Staff
4. Complaints
5. Clinic facilities
6. Health and safety
7. Infection control
8. Information technology
9. Finance
10. Clinical practice
11. Health records
12. Laboratory services
13. X-ray services
14. Immunisation service
15. Pharmacy service
16. Audit and quality improvement
From our point of view, the IMHA Quality Standards are a tailored quality system for clinics and single-handed practitioners dealing with medical selection. The complete standards and criteria are available free on the ViaMedica website[8].
Audits of doctors
A quality improvement system could be an internal system, where the well-known quality circle[9][10] is running under the management’s supervision.
It could, however, brought to a higher level including verification and validation. These independent procedures are used together for checking that the product, service or system meets the requirements and specifications and fulfils the intended purpose. Usually external auditors carry this out.
The Norwegian Maritime Authority introduced an audit system for approved doctors in their circular RSV 12-2014[11]. The inspection mainly focuses on the mentioned circular, as well as compliance with the requirements of the Public Administration Act[12] and the Health Regulations[13]. The NMA audit the administrative procedures, as well as the medical content of the assessment. The inspections commenced in 2017 and for doctors both inside Norway and abroad.
Similar arrangements have been in place for years in UK, Germany and the Netherlands.
[1] Regulations of 5 June 2014 No. 805 on medical examination of employees on Norwegian ships and mobile offshore units
[2] Norwegian Maritime Authority. RSV 12-2014 of 22 October 2014, Journal No 2014/6628. Quality System for seafarer’s doctors
[3] ISO 9001:2015 Quality management systems — Requirements. Organisation Internationale de Normalisation (ISO).
[4] Carter T, Bell SR, Horneland AM, Idnani S. Standards for quality assurance of pre-employment medical examinations of seafarers: the IMHA Quality experience. Int Marit Health. 2017;68(2):99-101.
[5] Guidance to the regulations on the medical examination of employees on Norwegian ships and mobile offshore units. Ver 2.3 of 8th June 2018, pp 18-22. Available at the NMA website: www.sdir.no.
[6] Poksinska, Bozena; Dahlgaard, Jens Jörn; Antoni, Marc (2002). "The state of ISO 9000 certification: A study of Swedish organisations". The TQM Magazine. 14 (5): 297
[7] Carter T, Bell SR, Horneland AM, Idnani S. Standards for quality assurance of pre-employment medical examinations of seafarers: the IMHA Quality experience. Int Marit Health. 2017;68(2):99-101.
[9] Rohrbasser A, Mickan S, Harris J. Exploring why quality circles work in primary health care: a realist review protocol. Syst Rev. 2013;2:110. PMCID: PMC4029275. PMID: 24321626.
[10] Rohrbasser A, Harris J, Mickan S, Tal K, Wong G. Quality circles for quality improvement in primary health care: Their origins, spread, effectiveness and lacunae– A scoping review. PLOS ONE https://doi.org/10.1371/journal.pone.0202616 December 17, 2018
[11] Norwegian Maritime Authority. RSV 12-2014 of 22 October 2014, Journal No 2014/6628. Quality System for seafarer’s doctors
[12] Act of 10 February 1967 relating to procedure in cases concerning the public administration (Public Administration Act) with later amendments, latest by Act of 16th June 2017 No 63, in force from 1st January 2018.
[13] Regulations of 5 June 2014 No. 805 on medical examination of employees on Norwegian ships and mobile offshore units
C.8.13 The doctor's role in medical selection
Details
ALF MAGNE HORNELAND
The doctor’s role in medical selection is different from the role in the usual way doctors handle their customers. The below table gives an impression on how different such work is.
Comparison of doctors’ different roles
Seafarer’s doctor
Company doctor
General practitioner
Role
Compliance check
Prevention
Treatment
Focus
Fitness for work / absence of disease
Working environment / Occupational injuries and diseases
Individual’s health
Perspective
Maximum two years ahead
Past, present and future
(Past), present and future
Tools
Medical selection in relation to requirements
Environmental factors affecting the worker
Medical treatment of illness and injuries
Aim
Contribution to the safety of the working environment
Prevent occupational injuries and diseases
Prevent and treat disease regardless of cause
Acts
Ship Safety and Security Act
Working Environment Act
Health and Care Act
The individual
A Candidate
An employee/worker
A Patient
Table 8: The roles of the medical examiner in medical selection, compared to other roles a doctor can have (Horneland AM).
Medical examiners approved by the NMA act as civil servants when carrying out their work as NMA seafarers’ doctors. They are checking whether the seafarer – today – meets the requirements, and assessing whether this is likely to be so for a maximum period of two years ahead. If not, they will limit the time of the medical certificate. The seafarer is a candidate showing up for his compliance check, and the result could be ‘pass’, ‘fail’ or ‘pass with restriction and/or limitation’. This is quite different from the role of a company doctor whose real ‘patient’ is the working environment or a general practitioner who is focusing on the patient’s individual health issues.
To give an example – an individual with a hearing loss, coming to three different doctors.
Seafarer’s doctor:
Company doctor:
General practitioner:
The AD will
· Check the hearing capacity against the requirements
Decision
· Issue a medical certificate if compliant
· Issue a declaration of unfitness if non-compliant
The company doctor will
· Check the medical record, to see if there is a trend in hearing loss
· Ask if the worker is using hearing protection
· Ask if there is much noise at the working place
· Ask if there are colleagues that are suffering from hearing loss
Decision
· Inform about the use of hearing protection
· Carry out a noise level measurement at the working place
· Call the colleagues for a hearing measurement
The General practitioner will
· Check if there is cerumen in the auditory canal
· Ask if the patient needs hearing aid
· Ask if he want to be referred to a specialist
Decision
· Refer to specialist if patients want so
· Ask the patient to come back if he think the hearing deteriorates
It is obvious that the approach is very different. However, why is this important?
Sometimes there are legal barriers between what a general practitioner can reveal of information towards others, especially towards people outside the regular health service. This would apply in dealing with civil servants who is carrying out a lawful differential treatment or medical selection of workers. Having both roles, sometimes leads the doctor to trouble. He may not be entitled to know in another role what he knows in one role. Having also a company doctor role for the worker’s company, could lead to double trouble.
C.8.14 Approval and training of Doctors
Details
ALF MAGNE HORNELAND
Some countries have specific requirements for first time approval as a medical examiner. They may also have specific requirements for in-service approved doctors, like regular attendance at meetings, or individual audits from the maritime authority. Only a few national maritime authorities approved doctors outside their own borders. The best known are the UK, Germany, Netherlands and Norway.
The requirements for approval varies between countries. In Northern Europe, a growing, informal cooperation between seafaring countries has grown, which leads us to the NEMAM[1] Group mentioned below.
Medical examiners have the right and duty to carry out an assessment against standards and criteria, which means that they are allowed a certain amount of discretion. How do we ensure that this is carried out properly? When individual doctors mostly are following their gut feeling, the need for harmonisation of their assessments is obvious.
How do we harmonise doctors’ assessment and decisions against a given set of standards and criteria? The answer is basic training and refresher training, exercises, discussions, quality circles, quality assurance and audits. We will have a look at these aspects below.
NEMAM Group curriculum
The NEMAM Group got its name in November 2018, after having existed as an informal cooperation between the medical advisers of the maritime authorities in several Northern European countries.
The ‘NEMAM Group’ stands for Northern European Maritime Authorities Medical Group. It is an informal group that is open to attendance by more countries than the present 10. Per 2019, the group consists of Belgium, Denmark, Faroe Islands, Finland, Germany, Luxembourg, Netherlands, Norway, Sweden and the UK. The initiative came from Norway, and the first meeting was between Norway, UK, Netherlands, Germany and Denmark. Both Germany and Denmark left the group, but joined again later. The first agreement between the countries Norway, Netherlands and UK, was a curriculum for basic training of approved doctors, including a description of skills and knowledge necessary for approval by the maritime authorities in the different countries.
Some countries require this training prior to approval, others within the first year after approval, but the curriculum of the “Basic Course for Medical Examiners, On behalf of the Maritime Administrations of Denmark, Germany, Netherlands, Norway and UK” is a description of the expected skills and knowledge of the approved doctors, regardless of how their competencies are achieved.
On completion of this course, the participants shall
be able to conduct medical examinations of seafarers in accordance with laws, regulations and guidelines, which set the requirements for such examinations on behalf of the British, Dutch, German and Norwegian flags.
be able to assess the safety risk that relates to the seafarer’s medical condition in general, to his or her regular and emergency duties, within a time perspective corresponding to the validity period of the medical certificate.
be able to individualize the safety risk assessment relating to workers with medical conditions, and the consequences this may have for the individual him/herself, the safe operation of the ship and to other crewmembers.
understand the limitations and challenges regarding medical treatment of ill and injured seafarers whilst at sea.
understand the possibilities and limitations for medical care for workers on board ships whilst at sea, including knowledge of available on board medical resources.
understand the possibilities and limitations for medical assistance to workers on board ships, including medical evacuation and evaluation of the specific dangers related to medical evacuation
understand the characteristics of working places on board ships, and the different physical and mental demands which relate to different types of work on board ships
be able to conduct medical examination in accordance with statutory requirements, medical best practice, and proper case consideration
understand the different roles of doctors in different positions, and be aware of his/her own role whilst conducting medical examination of seafarers
be able to conduct medical examinations with a clear understanding of confidentiality, gathering of information and communication
understand the consequences of a declaration of unfitness in relation to the statutory regulations, and the “loss of licence insurance”
be able to assist the seafarer in cases of complaints and applications for exemption, and prepare a proper case for the appellate bodies
The Norwegian basic course for seafarers’ doctors
In Norway, this is organised as a 3-day course of attendance, preceded by preparatory homework and a pre-course test. Refresher training is due every 5 years and is organised as a course of 2 days attendance, also preceded by some preparatory homework and a pre-course test. Both the basic and the refresher courses concludes with a course test where the participant has to answer 80 % of the questions correctly to pass.
[1] Northern European Maritime Authorities Medical Group, an informal group of medical advisers of the European maritime authorities.
[2] Basic Course for Medical Examiners On behalf of the Maritime Administrations of Denmark, Germany, Netherlands, Norway and UK, unpublished
C.8.12 Medical selection in specific sectors of the maritime industry
Details
ALF MAGNE HORNELAND
Military navy
Working on naval vessels differs a lot from working on merchant ships. Naval ships cannot change flag like a merchant ship, unless they are decommissioned and sold to another country. The crew is composed of seafarers from one country - the country of the flag the vessels fly.
Crewmembers usually are young, and they are selected on stricter criteria than for merchant ships, usually including positive selection. The crew is much larger than on a merchant ship. The positions and job tasks are focused on warfare. Exposure hazards in the working environment encompasses hazards that are unusual on merchant ships.
The standards and criteria are strictly national, although some similarities can be found, especially between countries belonging to the same military alliance. Medical selection is carried out by naval doctors only.
It falls beyond the scope of this chapter to discuss naval medical selection in more detail.
Fisheries
Medical requirements for fishing vessel personnel
The STCW convention sets health requirements for vision and hearing, and recommendations for physical and mental capabilities. Fishing vessels are, however not included in the STCW-convention.
The International Convention on Standards of Training, Certification and Watchkeeping for Fishing Vessel Personnel, 1995 (STCW-F 1995) entered into force on 29 September 2012. The convention sets the certification and minimum training requirements for crews of seagoing fishing vessels of 24 metres in length and above.
The ILO issued the Work in Fishing Convention, 2007 (ILO Convention 188)[1]. The C188 states that no fishers shall work on board a fishing vessel without a valid medical certificate attesting to fitness to perform their duties. The competent authority – meaning the national authority – may grant exemptions to this main rule, regarding size of vessel, availability of medical assistance and evacuation, duration of the voyage, area of operation and type of fishing operation. No such exemptions can be granted for vessels 24 metres and above, which normally remains at sea for more than three days.
The requirements for a medical certificate are to be issued by the national authorities, and no detailed recommendations are given in the C188. The convention states that hearing and sight shall be satisfactory, and that the fisher shall not suffer from a medical condition that is likely to be aggravated by service at sea or to render the fisher unfit for such service or ton endanger the safety or health of other persons on board.
Some nations, like Norway[2], had already made the STCW convention mandatory for fishing vessels, before the STCW-F convention entered into force. According to these regulations, personnel on fishing vessels of 15 meters length and above need a medical certificate.
The STCW-F convention sets requirements for medical certificates for personnel on fishing vessels 24 meters and above.
The implementation varies from country to country, and more so than the corresponding requirements for the merchant navy.
Risk assessment for personnel on fishing vessels
The working places on board fishing vessels are among the most dangerous out at sea, regardless of country[3][4][5]. The working place differs a lot between those working solo and self-employed on small boats along the coast, to those working on large purse seiners or factory trawlers in remote locations, maybe icy waters, days from shore and out of reach of helicopters.
Fishing equipment installed on deck is dangerous, and accidents related to their operations are numerous. Such work demands more of the physical capability and awareness than most deck operations on a merchant ship. Hence it could be discussed whether the medical requirements developed for the merchant navy are too lenient for fishing personnel. The requirements based on the STCW, the MLC 2006 and the STCW-F conventions do not take the consequences of these aspects.
Cruise ships
The cruise industry has yet another approach to medical selection of employees. Most companies have developed their own enhanced PEME standards. Some of these are very detailed, including many laboratory tests. With reference to the discussion of laboratory testing in this chapter (see above), it is doubtful that the use of this testing is justified in terms of safety risk assessment, capacity to work or in terms of antidiscrimination law. One important aspect of these selection procedures could be to make sure that the company will not get the bill, should a medical incident occur with the slightest possibility that it is connected to something in the past and mentioned in the medical record of the individual.
Work on cruise ships usually means working in big multicultural crews. It also implies that job tasks will be influenced by the main objective of the company – to serve at the pleasure of the passengers. Cruise ships have many positions, which usually are not found on regular merchant ships, where the employees have job tasks more comparable with working in a hotel, a shop, or in entertainment.
One advantage of working on a cruise ship is that they all have doctors and nurses working on board. Should a medical incident occur, medical assistance would be at hand immediately, although more complicated medical treatment in hospital on shore will be just as far away as on any ship in the same trade area.
Offshore petroleum industry
Amongst working places out at sea, we also find the offshore petroleum workers, working on installations for the production of oil or gas. Some of these units are afloat; others are standing on the seabed. Some floating units are mobile, others fixed with anchors.
There are no international requirements for workers on such installations, except for those installations that come under the STCW convention. In some periods the unit could be regarded as a ship (while moving) and hence covered by the STCW, and in other periods as an installation (when fixed during seabed operation), hence not covered by the STCW.
Most industrial oil and gas operations at sea occurs on the national continental shelf of a country. Hence, it is not ‘international’ in the same way as the shipping industry. The medical requirements are those of the national authority in the region where the operations are carried out, which means that the requirements may differ from country to country. In some cases, where operations are overlapping or the sea beds verge on each other, efforts have been made to achieve as similar requirements as possible. An example of this is the agreement (“Hardanger agreement”[6]) between OGUK[7] (UK), NOGEPA[8] (Netherlands) and the County Governor of Rogaland, Norway[9]. According to the agreement, a medical certificate issued according to the requirements in one of the three countries will be fully valid for work in the other countries.
Working places in the petroleum industry have similarities to working places on ships, but there are many positions and job tasks, which will not be found on ships. Hence, risk assessment is different.
It falls beyond the scope of this chapter to discuss the standards and criteria in detail.
Sea pilots
Sea pilots have work similar to navigators, but are not always regarded as seafarers. Their jobs differ a lot, from steering in and out of port to long distance piloting following complicated routes along a coastline. They are employed by organisations on shore, sometimes private, sometimes governmental. Medical requirements differ from country to country, and there is not international consensus as to their medical certificates. In Norway, they are employed by the Norwegian Coastal Administration. They have separate medical requirements[10], which are developed as close to the requirements for seafarers as possible. Risk assessment is simplified, as compared to seafaring. Physical requirements are stricter, as sea pilots on a regular basis have to climb ladders up to 8 meters length, but the area of operations always will be near-coastal, a fact that makes risk assessment different from that of seafarers.
[1] ILO C 188 – Work in Fishing Convention, 2007. Entry into force: 16 November 2017, at present ratified by 14 countries (per 29 October 2019).
[2] Regulations of 5 June 2014 No. 805 on medical examination of employees on Norwegian ships and mobile offshore units, Section 2, second paragraph, letters a and b.
[3] Bull N, Riise T, Moen B E. Occupational injuries to fisheries workers in Norway reported to insurance companies from 1991-1996. Occup Med. 2001;51(5):299-304. https://doi.org/10.1093/occmed/51.5.299
[4] Poggie J , Pollnac R B, and van Dusen C. Intracultural Variability in the Cognition of Danger Among Southern New England Fishers. Marine Resource Economics 11, no. 1 (Spring 1996): 23-30.
[5] Murray M, Fitzpatrick D, O’Connell C. Fishermens blues: Factors related to accidents and safety among Newfoundland fishermen. Work & Stress. 2007; 11(3):299-297. https://doi.org/10.1080/02678379708256842
[6] The Hardanger agreement: The e Offshore Operators Association from three countries involved in the North Sea: the UK (UKOOA); Norway (OLF); and The Netherlands (NOGEPA) have signed a reciprocal agreement known as the Hardanger Agreement which states that a valid medical certificate in one country will be valid in the two other countries within the agreement.https://www.nogepa.nl/download/hardanger-agreement-2000-07/?lang=en