A Problem of Medical Certification in Industry, with Suggested Solutions

A. Kefalas
1942 BMJ (Clinical Research Edition)  
Works Medical Officer At a time of dire national need one of the serious problems of output is the reluctance of certain people to take up work which they suppose, often quite wrongly, to be dangerous, or, having started such work, to continue it. This is bad enough when the occupation is really dangerous, but when it is in fact harmless this attitude is unforgivable. It occurs generally in industry, random examples being a baseless fear of lead poisoning from processes with a negligible lead
more » ... sk, poisoning from "fumes " though adequate exhaust devices keep the atmosphere absolutely safe, silicosis in non-siliceous grinding or drilling, and so on interminably. The offender, alarmed at what he hears about these supposed dangers, " goes to the doctor." It is unfortunately true that some of them, disliking their job for some other reason altogether, make the " hazard " an excuse to get a more pleasant or an easier one. One very serious example will put the matter more clearly. In the wet grinding of " small tools " and drills (high-speed steel) these articles-the production of which is an indispensable preliminary to the making of most machinery, arms, and munitions-are either rotated singly in a chuck or holder or spun in numbers on a revolving,table, against a non-siliceous wheel, whilst a slow jet of water containing composite powders (none with free silica in significant amounts) runs over them. The atmosphere round the machines is dust-free and generally better than that in many houses and public buildings. Although there is definitely no danger of silicosis in this work, some of the operatives are convinced,to the contrary, while others dislike it because it is " rough on the hands." Deterinined efforts are sometimes made to leave it, and some of these are dishonest. The number of workers producing, mainly to the National Service Officer, medical certificates alleging that this work is inimical to their health is reaching such proportions in Sheffield that in some quarters difficulty is anticipated of keeping enough people working to produce these most vitally necessary articles. The Doctor's Dilemma The real difficulty is that the man can practically always get his certificate; for the doctor, when approached by a patient who says, " I am working as a steel grinder, and the work is affecting my health: 1 keep getting a cough and I do not feel well," must, especially if there is some respiratory catarrh, accept the patient's word and issue a certificate, which, of course, is merely an opinion and not a statement of fact. The doctor feels that anyone else doubting the accuracy of or being aggrieved by it should refer the case to another medical authority and produce a counter-certificate. The doctor's lack of knowledge of the grinding process, which may or may not be dangerous, does not affect the position. The mere fact that the patient is ill, or even claims to be ill, makes it incumbent upon the general practitioner to neglect nto possible precaution wvhatever, for if he does so nieglect aniy precaution he is plainly guilty of culpable negligence. He has perforce to take the view that the process might be dangerous, and therefore has to cover the contingency, for the simple reason that if it were not so covered and the patient came to any harm, or could convince a court of law that he had suffered harm (not always the same thing!), the doctor could be mulcted in damages and injured in reputation. If it be remembered that the practitioner often has to work at high speed, it will be seen that he is in an absurd and unhappy position, and doctors are continually finding themselves bound, both by the law and by the best traditions of their craft, to issue certificates which they feel they ought not to have to issue. It is useless to say that the doctor should refuse a certificate unless he finds some specific organic lesion directly connected with the alleged condition to substantiate the patient's statement, for if this principle were followed generally he would have to assume that a great proportion of all those suffering from some of the most dangerous diseases in their early stages were either malingerers or fools. A doctor treating a case, as distinct from one who is a referee, mtust give the patient the benefit of the doubt. It is even arguable that a neurotic working at a process which he wrongly thinks is dangerous might be seriously injured by the anxiety which a refusal to certify could produce, and a bad " breakdown " in such a case might be hard to explaih away. Even, again, in the comparatively rare cases in which a doctor can be absolutely certain of his facts and refuses to issue a certificate, he often does so at the price of great annoyance and injury from the angry patient, who does him all the harm which innuendo and disparagement can do, thereby adding still another pinprick to the many he suffers. It has to be remembered, too, that this issuing of endless certificates is reaching such proportions as to interfere seriously with the doctor's proper work, and many medical men have 20 to 30 patients each asking for from 2 to 5 certificates for various purposes in a single surgery. On the other side is the employer engaged in production of articles of superlative necessity for the national safety. Some of the processes in his factory may be irksome, less remunerative than others, or the cause of baseless fear like the ones cited above. He is constantly pestered by workers, most of them " dilutees," who produce certificates stating that they are unfit for their work. Many of these people have been trained at the cost of much time, trouble, and money, and their defection causes great loss of production and brings dire disaster to the men who are fighting for them. Their actions often end in the spreading of rumours about the shops regarding processes which have names associated with dangers tha,t have been nonexistent for many years. Alarm spreads like an epidemic, confidence is undermined, and the result is more doctors' notes and more loss and waste. The National Service Officer's Difficulty The National Service Oflicer finds himself in difficulties over cases in which medical certificates are produced. He feels, as a layman, that he cannot rightly ignore a doctor's certificate, and he is thus in a position as awkward as that of the doctor or employer. There is, however, a further difficulty. The way bad, lazy, dishonest, and hypochondriacal workpeople are dealt with varies from place to place according to the temperament of the N.S.O., and in many cases it is virtually impossible to get him to prosecute even in the most flagrant cases. In such places the employees openly jeer at the superior who threatens to appeal to this officer. Thus much time, money, expensive training, and material are lost, to the scandalous detriment of production, foX the grinding processes mentioned are but an example, and the trouble is widespread. I have seen it as a medical officer in two widely separated places concerned with steel, munitions, coal by-products, and collieries. The Remedy The cure appears to be simple. In fact, there are three ready remedies. The first would relieve the general practitioner from the responsibility of issuing certificates relating to specific processes and would make acceptable only a standard certificate something like this:
doi:10.1136/bmj.1.4242.531 fatcat:myiweglotvbndn6ost2yw2ekga