The latest GP recruitment campaign features a GP signing a form so that a patient with cancer can take part in a skydive.
It may seem like an unusual aspect of general practice for Health Education England, the organisation behind the campaign, to highlight. But the MDU regularly gets asked by GPs for advice on whether they can certify a patient as fit to participate in a range of activities like bungee jumping and climbing and also to say they are fit to fly.
Perhaps this reflects our increasingly risk-averse society and the need to satisfy insurance requirements, but whatever the reason, now may be a good time to think about how you deal with requests. Consider the points below to ensure you comply with your professional obligations and avoid the medico-legal risks.
Do your research
You should take this guidance into account, particularly if you are unfamiliar with the activity the patient is asking you to certify them fit for. You will need to understand the level of fitness required for the activity, as well as reviewing whether the patient has any medical conditions or is taking any medication that might cause a problem.
Fit for travel
The Civil Aviation Authority provides guidance for doctors about certifying patients for air travel.
For pregnant women, most airlines require a certificate after 28 weeks gestation, confirming that the pregnancy is progressing normally, there are no complications and the expected delivery date. Most airlines will not allow travel after 36 weeks for a single pregnancy and after 32 weeks for a multiple pregnancy, although this can vary from airline to airline.
You will need to ensure that you have performed an adequate assessment of the patient’s condition, including any relevant examination or investigations. This should be carefully documented, so that if you are asked to justify your statement at a later date you will be able to provide evidence of the assessment and the basis for your opinion.
Ultimately it is the airline’s decision whether a person can fly, but they may ask the GP for their medical opinion. GPs should advise the patient to check with their airline and insurance company if they have any condition that could affect their fitness to travel, as this could affect the validity of their insurance. Again, this discussion should be documented in the notes.
Consider the wording of statements in any certificates you decide to sign and stick to factual information about the patient’s condition, such as that their condition is currently stable or that there has been a deterioration.
The MDU’s advice is to choose wording which reflects an opinion within your competence. For example, rather than signing to say a patient is fit to participate in a particular activity, or to travel, provide a factual report detailing relevant information about the patient’s health conditions and explain that you "know of no reason why the patient should not be fit for" the particular activity.
This is on the proviso you, as the signing doctor, feel you have sufficient knowledge of the activity to be able to make that judgement. Explaining to patients why you are using those particular words will help them to understand that you are acting responsibly and may avoid any potential complaint or claim if their health suffers in some way while undertaking the activity.
Don’t forget that you should also obtain the patient’s consent to disclose confidential information about them, and document this within the medical record. It’s a good idea to provide a copy of the report to the patient before disclosing it to a third party.
Stick to what you know
You may be asked by a patient to certify them fit for an activity which is outside your area of expertise. For example, a patient who asks you to certify them fit to fly shortly after surgery when you feel the surgical team is better able to given an opinion. Or a patient with an ongoing condition who wants you to certify them fit to take part in an extreme sport.
If this happens, you should explain to the patient why you are unable to sign the form, and suggest that he or she gets an opinion from a suitably qualified doctor. This could be someone with experience of sports medicine, or a specialist in the patient’s condition.
Ultimately, you must act in the patient’s best interests in deciding whether to sign a certificate and only provide an opinion within your area of expertise.