If you were not here at the previous session, these are my disclaimers. You are hearing my opinions and my opinions only, not the opinions of my employer. If you don't know me, I'm the Chief Medical Officer for the Transportation Security Administration, part of the Department of Homeland Security. What I'm talking about has nothing to do with my job. This is not a presentation about TSA. This is mostly about the legal concepts around fitness or duty, and hopefully you'll learn a few things that were not obvious to you. And unfortunately for our international colleagues, a lot of what you hear relates to unique American legal issues, which don't always make sense, but you still have to play by the rules. EEOC, that's the Equal Employment Opportunity Commission, that's a federal agency. And so look what you have on the screen, and I want to start from the end, looking at the bolded words. The first one you have, and repeated, is the word medical condition, which means you cannot, as an employer, management, cannot request a fitness or duty without a medical condition. So I don't like that guy, he's a jerk. Nah, that doesn't work. Can't do that. So they have to, the employee has to have a medical condition, we'll go back to that, but it has to be identified by management. And then they have a choice, one of the two, or the employee is unable to perform the essential function, or the employee will pose a direct threat. So let's go over each, direct threat, okay, you have the definition at the bottom, but normally if the employer orders a fitness or duty under direct threat, they are supposed to perform what's called a direct threat analysis. Again, you, we, we don't have to do it, but if it gets litigated, you know, they're going to ask, employer, did you perform a direct threat analysis? I mean, it's not necessarily very difficult, but you have to do it. The other one is the essential job functions, well, guess what? Do they have a list of essential job functions? And if you are the doc doing the fitness or duty evaluation, did they give you, did you ask for the list of essential job functions? Yeah, you probably should have that. Okay, then go back one step, reasonable belief based on objective evidence. So how do, how does the employee know that, so that also applies to the medical condition, and is that, they're guessing, is it, and is it reasonable? Again, the employer will have to, to prove that. The fitness for duty request has to be in writing, if I do it correctly, it comes from management, HR probably shouldn't be in a position to initiate a fitness for duty, certainly we should not be in that position. Now, could we recommend, maybe, but the request has to come from management. The request has to give you a very limited scope. Now, the medical condition has to be stated, in my opinion. Now, it can be known if the employee gives a sick note, an FMLA request with a diagnosis, that's usable. If it is not usable, then it's a little bit more difficult, but management can say, you know, based on the behavior I've seen, I suspect a mental health condition. That's probably, that's probably okay, but that's more difficult to articulate. So, you have that medical condition, and then you need to have cause, or concern, which could be, again, is it direct threat, or is it inability to perform? Ideally, the inability to perform, management has observed it, it's not absolutely necessary. So, if you're management, and you know that your employee has epilepsy, can you do a fitness for duty? Should you do a fitness for duty? Yeah, the answer is yes, but if you haven't witnessed a seizure at work, you know, that doesn't mean you can't do a fitness for duty, but it's just more difficult to evaluate, to articulate. By the way, that would fall under the direct threat. Okay, this is because Dr. Sammo said I had to expand your horizons, so I'm going to ask you, that's a quiz. Does anybody know where that is, or the name of that town? Has anybody seen the movie Happy Feet? Okay, so Happy Feet is there. It's called Gridvicken. It's in South Georgia. It's a British Antarctican island, and yes, I work there. Yeah, it's in the middle of nowhere, except, you know, they have the grave of Shackleton, you know, well-known explorator. Now, when you get the fitness for duty request, ideally you are going to train your clients or your management, if you're an employee of that company. They should send you all the supporting documentation they have and that they can legally share with you. If they observe performance issues, make sure they write it, and as I mentioned before, the list of essential job functions. Now, if they don't have a current and good list, there might be a way around, which is asking you a very specific question, i.e., can that employee drive or conduct emergency driving, drive licensed sirens? Maybe just a simple question like that, or can they apprehend suspects who don't want to go to jail or fight with people? But if you have long-standing interaction with a public safety agency, I think probably one of the best recommendations you can tell them is have, do a job task analysis and have an updated, up-to-date list of essential job functions. It's not that difficult to do. If you do it from scratch for a large agency, you could run into a couple of hundred grants, but there are some states that have done it, and you can use whatever list you can find on the Internet from another state and then make adjustments based on that list. Or you can look at surrounding agencies that are pretty similar to yours. You still need to do the adjustments. You can't just borrow the, you know, we're cops, they're cops. Not exactly, but you don't have to do everything from scratch. And I think your good trainers, whether it's on the police or fireside, they can get you a job analysis pretty quickly. A few times, and I'll have more detail later on when you should not get a fitness for duty evaluation, you'll see some quotes from a friend of mine named Phil Spotswood. Does anybody know Phil here? I see a few. Oh, you know Phil. Okay, so you'll see his quote. Phil, unfortunately, recently retired, but, you know, he got another job. Phil was the head of the medical programs at OPM. He's a lawyer with an MPH. He works for State Department now. So he called out the 3D, and he said, these are cases where you get that, you should say no. So distressed, disruptive, dangerous, this is not a reason to do a fitness for duty. There's a reason not to do a fitness for duty. And at least on your end as the medical person, you really need to protect yourself. That's management dumping their bad employees on you. Then you have the content of what you are going to do. So understand it's limited in scope to whether the employee can perform currently. So you see jobs related concerns and whether they are fit for duty now, not in the future. You know, they can't tell you, and unfortunately that has happened. You can find some consent decree with DOJs. There was one not too far from the place I lived before, so you can't guess that, where the public safety agency asked the medical group, it was an outside contracted medical group, ADOC, find a way to disqualify that employee. And my understanding, this is all documented, and part of the consent decree was that public safety agency had to change their medical contractor. Now, what do you do? So same, a little bit the same as the structure of the fitness for duty request. You find out whether they can do the essential job function and what is their risk of sudden incapacitation. In public safety, these two elements are important, but you look at their current risk of impairment, not the future risk. And the last one, that's a GINA issue, genetic information non-discrimination risk. That's a GINA issue, genetic information non-discrimination act. Again, for our non-U.S. colleagues, maybe you're allowed to ask for family history, but in the U.S., generally you're not. Yes, there are exceptions, but I think at least for fitness for duty, I think unless you have a very, very good reason that's vetted by several employment lawyers, don't ask for family history, and if you see it, don't use it for a fitness for duty determination. It makes it easier. It will make your life much easier. Now, when I do a fitness for duty, this is what I consider. First, you look at the diagnosis. Let's say they tell you the diagnosis is schizophrenia and it's a law enforcement officer carrying a gun. You really don't need anything else. It's very exciting that the person is not cleared to work for duty, but you could have additional criteria for mental health. If you look at the AECOM guidelines, we look at the time of functional impairment, whether for major depressive disorder, whether there is full remission. These are DSM-5 criteria. Comorbidities are, again, going back to the mental health, do they have substance use problems? Do they have sleep issues? Common comorbidities. Then the MMI. If the person has current work restrictions but they're clearly not at MMI, the restrictions will not be permanent, but if they have reached MMI, then the restrictions are going to be permanent. They don't need to find another job or be reassigned. The current job limitations, things like lifting, running, we rarely evaluate that ourselves, but let's say the person has surgery, the surgeon might give you some information. We could also recommend the job simulation to evaluate that, especially if the employee has reached MMI. Finally, you have medications. Medication that has anticoagulants could create restrictions on their own. This is something I got. I hear people laughing. I was wondering if that's an owl. Then your conclusions, put your medical opinions, put your recommendations, and your recommendation probably should be in the last bullet point in the form of work restrictions and obviously mention if it's permanent or not. In general in the U.S., somewhere around 12 month, employers can treat people differently. The employer might tell you are the restrictions going to be less or more than 12 months. Again, that's something you determine and that's based on your jurisdiction. Then you have bullet point number two, which I would make different than the first one. Does the person meet whatever medical standard that the employer wants you to use? Not everything in existing medical standards makes sense. That's why Dr. Sammo called the LEO and our public safety medicine guidance. These are not standards. These are not guidelines. What we write today we know will be different in a couple years. That's a long quote from Phil Spotswood. It hits the problem on the nail right away. You see, most fitness for duty are result of supervisors concealing their own failures. This is a lawyer at the office of personal management, the HR agency for the entire federal government. Right there, if you get a fitness for duty, it's probably because management is not doing their job. Then he tells you it is not the job of the agency to suggest that a medical condition is the cause of the problem. Problem being performance time or conduct. It is up to the employee to raise the issue as an excuse called an affirmative defense. Normally, in the U.S., to do that, the employee has to bring documentation that they have the medical condition but also that the medical condition is the cause in performance or conduct. By the way, you never see that. They always tell you, the one I have most of the time is headache, high blood pressure causing headaches. That's why they couldn't do their job? Really? They don't bring you any documentation or don't do a fitness for duty. It's so bad that they can't see. In the meantime, don't do it. Finally, what Phil adds, it is up to the employee to raise the condition as an affirmative defense but provide that documentation that they have the condition and that the condition is responsible. Be very careful. If you have a contract with an employee, it's difficult to tell the employer don't do a fitness for duty because you might just go somewhere else. If you are an employee of that agency that asking you to do a fitness for duty is much easier, that's probably where you want to be proactive. Have a policy. We are running out of time, so I'm not going to go over everything. Fitness for duty should never be used as a retaliation. The bias is when management tells you this is really a bad employee, he's complaining all the time, he's always late. This is information that should never be communicated to you. Misuse of information. Misuse of time and resources and safe behavior. Inappropriate physical actions. This is basically misconduct. Don't get there. These are not reasons to do a fitness for duty by themselves. I'm going to do a knowledge check. This is about driving. I'm going to ask you whether this employee can drive and safely drive. Better than some. Anybody have any Cialis we can fix this? Our next topic is fibromyalgia. It's a new chapter. The editor, the lead author is Dr. Gerald Taylor. He asked me to present this because we want to present it as one of our new chapters. I'm going to do my best. Advancement. We're going to have some of the butterfly farm in Aruba. I don't have any conflicts. I am open to them. If you have enough money, $100 is not going to do it. Fibromyalgia is a symptom-based disease. For us, it's very difficult to deal with. It's a definition defined by consensus without any objective criteria. There's nothing we have that we can use to diagnose this with. That makes it tough for us. These references are in the handout. They talk about the criteria that you use to diagnose fibromyalgia. I'll go over them a little bit with you. These are cool butterflies, aren't they? Multi-site pain. Pain needs to be above the waist and below the waist, both sides of the body. There are certain tender points I was doing a case, I forget why, and I was reading a decision by a judge in Minnesota. They were talking about tender spots and how that's diagnostic. Someone brought up, and it was in his opinion, that that was how they diagnosed witches It means it goes way back. It's not a new diagnosis. I think they had the wrong diagnosis before. It wasn't witches. These three are the main ones. Multi-site pain, fatigue and sleep disorder, and cognitive and mental health issues. Those are the three biggest diagnostic criteria. Then there are innumerable, when I'm telling you innumerable, somatic symptoms. Every organ system you can think of, every severity of them, they exist as someone says, I have a person with fibromyalgia and they have this. Pretty much anything you can think of is in there. Everybody agrees, that you have to be present for at least three months. You can't find any other reason. It's kind of a diagnosis of exclusion. how do you do the assessment? Well, you do a history. You know, these are pretty interesting. You go physical. You're looking for the tender points. Again, there really are no specific physical findings that you can say this is diagnostic of this disease. And then you need to look for functional limitations. Now, the functional limitations are things. So remember, the two top things were pain and weakness. And one of the functional limitations is that people with fibromyalgia, as they tend to exercise or exert, that gets worse, which really, of course, makes it hard to be someone in public safety medicine if they have that. But not everybody has all this. I mean, it varies very much in individualized assessment. Every one of these patients is somewhat different. The other thing you have to look for is are there any side effects from treatment and medication? You know, our public safety medicine guidance has a whole chapter on medication and which are going to cause problems and which aren't. So you can certainly go to that for some guidance on that kind of stuff. There really isn't much in the way of treatment other than medication. Exercise is good, unless the exercise makes you worse. But you should keep exercising, because you're often worse without exercising. Inactivity makes them worse. So it's really a rock and a hard spot for the patient. Comorbidities, biggest one is probably mental health issues. Depression, anxiety are the biggest ones. And then everything, GI, the irritable bowel is often associated with it. Interstitial cystitis, also associated with it. Autonomic dysfunction, so a thing like orthostatic hypotension, variability of heart rate. They get renal type syndromes. Renal type, but they don't have the microvascular changes. And so it's not really a renal syndrome, but it's similar to it, but without the objective findings. So a lot of them have also autoimmune diseases. And osteoarthritis, and for some reason, hearing loss is more common. It's also, one thing I didn't mention, the prevalence is, I think, eight to one, female to male. And no idea why. And environmental hypersensitivity. They'll say, you know, smokes and perfumes and cleansers and all that stuff really sets off their symptoms. So when you get one of these for a fitness for duty evaluation, again, you're not here to make a diagnosis. You're here to decide, can they go back to work? And in order to do that, you have to find out a few things. That they have no symptoms that would interfere with their safe and effective performance of their job. Again, the big three, pain, fatigue, mental illness, cognitive disorders, would be the first place to look. But all the other things could be, you know, if their irritable bowel is so bad that they have to wear a diaper, you know, that's probably going to interfere. That they have no disqualifying adverse effects from their treatment or the medication. So these are the things for fitness for duty things that you can assess. And that they have no disqualifying comorbidities. So these are good things for you to be able to look for. We suggest that they have, and this is a group consensus, that there be a doctoral level evaluation for cognitive and mental illness, which would include a neuropsych eval. Because that can sometimes be subtle, and not obvious just on a quick history and physical. We think that no matter who diagnosed it, that before you're done, they should probably see a rheumatologist for confirmation of the diagnosis, or to make the diagnosis. And we want them to pass a job task simulation test. We like this term. We call it the JTST, you know, that's the cool way to call it, because you all want to be cool, right? And we use this a lot in our guidance. Because there are a lot of things, it turns out that finding out if someone's going to be suddenly incapacitated in the next year, over 1%, is actually fairly easy to do with the literature. So things like heart disease, stroke, diabetes, things like that, we're actually able to figure out what the criteria are that can say if you can or cannot, you will or will not become suddenly incapacitated, greater than 1%. The other stuff, like my knees, my shoulders, my back, you know, a lot of the orthopedic stuff, there's very few things that you say, well, you absolutely are not going to be able to, or you absolutely will be able to. So at some point you could say, you need to go and try it. And basically, job task simulation tests, you send them back to the department and say, maybe a training exercises, or whatever it is they do in their department, that if you can pass that, you're okay. In other words, if you can do the job, you're okay, right? Then you're fit. Because they're not worried about the sudden incapacitation. And if they don't pass any of this, any parts of this evaluation, then you send them back to their provider, you say, we need to evaluate them again, see if there's any additional treatment you can provide, and then you bring them back and reevaluate them again. So here, what happened to my background here? Anyway, it was supposed to match the butterfly. So job task simulation tests should include for public safety people, for police obviously, defense tactics training, that is going to be the probably most strenuous thing that they do, right? Pursuit and apprehension, chasing people down, wrestling them to the ground, getting handcuffs on them, that kind of stuff, usually the most strenuous thing that a police officer has to do. Running, jumping, climbing up stairs, ladders, fences, jumping over fences, lifting, emergency driving. Again, if you have some issues with your vision and convergence, that could be an issue for police and correctional officers, sometimes firearms qualifications. Then the question comes up about periodic evaluations. The task group consensus, and actually the two documents that are referenced, do say that if they're stable, doing well, you should probably see them annually. If something changes, then you need to see them. I mean, it's not rocket science. So that's what we got. So that's what we got. Now this chapter is, so as with most of our chapters, the chapter part is short and sweet and helps you say, I got this patient in front of me, what do I do? A, B, C, D, E, this is what I need to do my evaluation to decide if they're fit to return to work. But then we have appendices in the back and pretty much all of our chapter, which are extensive. And so these are the appendices that are in this chapter, talks a lot about the medical aspects and the diagnosis and the lack of understanding of the disease, what you do for medical, fitness for duty, some guides. The guides from the other organizations that specifically talk about fibromyalgia, I think it's Coast Guard and Army are really the only ones that specifically mention it. All the others, it's not specifically about fibromyalgia. And then ongoing monitoring and again, about doing the job test simulation and the references. So now from my favorite butterfly for the last 55 years, we both wanna say thank you for your attention. And now, next we have coming up here and you guys don't listen. The next section is gonna be a new section that we're working on is oncology. And we have a new graduate and a resident who are working on this and we wanna encourage that. So lots of riotous applause and cheering and whistling, okay? Please welcome them up. Thank you. Thank you all for coming. I'm Dr. Nadeau. This is my colleague, Dr. Dabrowski. I graduated last year at Health Partners, and I'm working in the Twin Cities in Minnesota, and he's still at Health Partners in St. Paul. Where do I point it? The arrow to the right. So we are starting to write this chapter. It's not completely done yet, and we decided, let's pick a case and go over a scenario. So I want to ask, how many people have done a pre-placement type exam on someone, DOT, military, maybe even a law enforcement officer, with a cancer or had a cancer? Exactly. So you see somebody, oh, I have this type of cancer, and now you're thinking, I'm worried about it. So we have a case here where the law enforcement officer, it was incidentally a found cancer, and he's a 55-year-old male police officer. He had 22 years on the force, and he was actually involved in two really high-speed chase-type collisions. One was 15 years ago. His car actually hit the other car and rolled. He walked out. They made him go to the urgent care, and he was back to work the next day, still a little bit sore. And then three years prior to him seeing us, he was in a very high-speed collision, and he actually struck the median, and his car was totaled. The airbag went out. He was lucky to have walked out of it, and he went to the urgent care. He actually did bruise his face, but he was able to walk, and they gave him two days off work, and then he started right back up. He started having these headaches and low back aches, but he kept working through the pain for months, and finally he went to his primary care because he didn't know, is this work-related or is this something else? And they worked him up, and they found a large cerebellar tumor. These are typically aggressive or very aggressive, and he had also some extension into his spinal cord, and it was seeding into the cerebral spinal fluid. It was inoperable, so they were going to treat it with radiation and chemo. So he did chemo and radiation for a year and started doing physical therapy and occupational therapy. He was working with work restrictions, so time restrictions, and also he was working desk duty only for quite that period of time. He also continued to have this chronic right-sided back pain that he said was 5 to 7 out of 10, and that it was worsened by him wearing his police belt for sitting for prolonged periods of time or for lifting heavy weights, also with bending too. So they did try some short courses of different medications, the opiates, but he did want to get back to work, so he didn't want to stay on that for a long term. They also tried some SSRIs, and that didn't work for him either, and he ended up coming to see us for this Fitness for Duty with this back pain. So we sent him to pain management to see if they could do some type of radiofrequency ablation. They ended up finding the pain generator with a block, an axial block, and then they did the RFA. He came to see us after the RFA, and he had a really good response to it. So I did the physical exam on him. Everything looked good, maybe a little bit of disuse, muscle wasting, but, I mean, he passed with flying colors, his cerebellar exam, his muscle strength, reflexes, sensation, the full nine yards. And at that point, I asked him, do you feel like you can go back to work? Do you feel like you're 100%? And he said no, that he only felt like he was 80% back to work. And that's, I think, a common thing when somebody's been out or is doing light duty for a long period of time. So this brings up a lot more issues too. I don't want to go into that in this case, but I do think that it's a complex situation, and there definitely can be some underlying concerns. And a big thing was, is if you look up medulloblastoma, there's not all are cured cured. There can be a recurrence at five years, and then at eight years, it goes up pretty high. So I think that was part of the factor with him was, should I be working this job for the next five years, or should I get out of this job and spend some time enjoying my life? So I think that's, again, a part of the decision or hesitation to go back. I think, what are your guys' thoughts on this? Do you think he is fit for duty? Or do you think early retirement material? Or do you think more testing? He's fit for duty. He's got a year clear. He said five years out of medulloblastoma. So this gentleman says that he's fit for duty. He's been clear for a year. I like that. I like that. But even if he's not feeling like he can go back or safely perform, potentially. Early retirement is his choice. If I think somebody can work, occupational medicine has to keep people working, whether they want to or not. Mm-hmm. That's true. You've got to kind of sometimes push them in the pond. Actually, it's all about what is the risk of sudden incapacitation. Mm-hmm. That's one of it. One of it. So he said that, is there a risk of sudden incapacitation in this case? He's clear for a year. There is potentially down the road, but we're looking at today. What is his percentage as we have to assume he's cured today? Yeah. I have a question because I do these a lot. And it's sort of up to the department because when you say, is he fit for duty, all right, prior to this second episode, he was a desk duty. Mm-hmm. Is he fit for duty for being a full-blown police officer is a totally different question. Mm-hmm. OK? And so would he be fit for duty, in my eyes, as a police officer? Can he back up somebody else who is in trouble? Mm-hmm. OK, his partner. My answer would be no. Now, if the department wants to take that and give him some kind of job, then send me that job description, not police officer description. Right. He does have other moves and positions that he could be stepping into or options. I'm going to let Dr. Dabrowski go through the kind of criteria that we. Ashley? Yeah. Something more objective than just intuition and clinical documentation. Something like an FCE, functional capacity assessment or evaluation with the actual objective data. But I agree with the gentleman back there. He's deconditioned. Mm-hmm. And to be able to step into that as a full duty as he probably was before, he may be able to get there. I don't think it's safe for him or the community or whatever. Right. Please repeat. So he said that he felt like because he had been out or working light duty for so long that it wouldn't be the safest to just send him out right away. That maybe we should have him doing some type of work hardening, work conditioning type of program. I agree with that. I'd like to do those as well. One of the work restrictions I use a lot is needs to be restricted from restraint of uncooperative individuals. I really don't care if they can accommodate it or can't accommodate it. The medical restriction is based on what I see before me. And what administrative action about accepting or rather to accommodate or not accommodate the work restriction, that in my mind is not a medical decision. Thanks. Right. So this was actually done. This was around the time of George Floyd just recently after it during COVID. And there was quite a bit of chaos and riots and other types of things going on. We actually did end up sending him to a neuropsych because of the emotional component. And he was diagnosed with PTSD. And he was diagnosed with PTSD. So that is the little story. Yep. Yeah. You know, one thing I don't hear anything about from you guys is reasonable accommodation. And I'll tell you, this guy, when he couldn't do his job, he's not fit for duty, period. They send me to him, him to me. I go, not fit for duty. He can't do this, this, and this. And then I let them decide if they want to accommodate it or not. I don't write him restrictions. I don't tell him what he can and cannot do. Because then I turn around and distract them with some duties that they don't want him to do. But if I sit there and let him now, if he wants to be exempted from some duties, make that a reasonable accommodation request, submit the documentation to a supervisor, and let the management decide if they can accommodate that or not. In this case, he hasn't been fit for duty from day one. He couldn't do his job. And then if he wants to be exempted or accommodated, he requests that accommodation from management, and it's between management, him, and the training provider. Excellent. Thank you so much. Any other folks? What is it he can't do? What is it exactly he can't do? In my opinion, I thought that he was ready to go. I would have done a work conditioning type program. But there was definitely a lot of emotions, and that's what influenced the decision to go with the mental health. Yep. If chemo radiation comes to the end of the treatment, is it OK when it's chemo brain? Chemo radiation brain, how can you handle that? Yeah, so he asked about chemo brain system sequelae to the treatments. And actually, Dr. Dabrowski is going to talk about some of that. So I think that's a really good question and something to definitely think about down the road as well with these treatments. Yep. So in regards to instant or short-term incapacitation, I'm not, I don't do oncology a lot, but the medulloblastoma, is there a chance of relapse for those? And if so, what's the probability of that? And then my follow-up question to that is, regarding the lower back pain, you mentioned something about it involved the cerebral spinal fluid and the space in there. Is there any possibility for metastatic spread for this other complication secondary to the primary diagnosis? So that one was talking about, could his back pain be related to potentially the treatment or a progression? And during this time period, he had already had the treatments. He had already been clear for the last year. They were regularly checking his CSF. The likelihood of a relapse, I think, at five years is about, I want to say it's 60%. And at eight years, 80%. I forget the exact. And it also depends on what your staging grade is. And since he already had extension, he also had seating, his risk is a little bit higher than typical. But I didn't actually read the full pathology report on this. So I don't know how aggressive it was. And I'm not really an expert on this type of cancer. Did he have a detailed neurological exam with a cerebellar tumor? Yes, he did. By myself and by his treating provider, too. So he was cleared by his radiation oncologist. And he was now put on one-year intervals. If he was clear in a year, then it would be two-year intervals. And that was the plan. Yes? The radiation oncologist knows what he has to do. Because there's one thing about being cleared. But to do this, and to adopt function, there's a whole different thing. Because sometimes you get a one-liner from the treating provider, a clear treatment. They don't have a clue what the person does. Right, I agree. So she said that the radiation oncologist is clearing him. But they don't know exactly what they're clearing him necessarily for. And so I do agree with that. I think what the radiation oncologist is saying is there's stability at this point. And they're expecting that stability to continue. Not that they can actually necessarily do their job. OK, last one, and then. Yeah, what is the bonfire MRI result? OK, yeah. It showed multilevel disc degeneration from L2 to L5 mostly on the right side. All right, folks. I actually really love the passion. I love that everyone's got questions. I'll try to get through my part relatively quickly so we can get more questions out of the way after that. But as my colleague Dr. Nadeau mentioned, my name is Dominic. And I'm going to present a little bit more of a bird's eye view. We were looking at a case earlier. Now we're just going to try and look at the general overview, how to approach an oncologic case for fitness of duty evaluation. So it can be intimidating when you think about oncology in particular for a case. It can seem like something that's maybe out of our wheelhouse. But it helps if you can ground yourself and relate it to something that you're maybe a little more familiar with, like a DOT or an FAA, things that you see a little bit more of. So I'm going to start out sort of presenting that as an option. So with the history of the cancer, of course, the more documentation, the better, just like you would with a complicated DOT, for example. Ask for reports. Speak with the oncologist. Try to learn some of the lingo, but understand that there's a lot. Grading, staging, there's a bazillion mutations. There's subtypes of cancer. So do what you can, but know that there's always more that you could potentially learn. After that, the things to think about with the cancer case is not just the organ system involved and the potential downstream systems involved, but also they're getting a variety of chemo, a variety of radiation, perhaps, and other medications. And there are some good catch-alls or common body systems involved, such as derm, such as neuro, such as hematologic. But they're all going to be different. So you never can be completely sure what systems are being affected. With that in mind, doing a head-to-toe is not a bad idea. Looking at each body system, review of systems, physical exam, it's going to be very helpful because it's easy to miss some potential sequelae. And in some cases with our patient, not all the neurological sequelae were necessarily obvious. Some of them were very slight. Let's say like a four out of five strength, for example. That's something that can go unnoticed easily. So it's worth just being systematic in your approach with that. After that, as I said, the symptoms and the residual deficit should both be considered. And of course, you're going to see the whole patient. You're going to maybe order a functional capacity evaluation or other testing. So those are going to help inform you overall how fit in general and fit for the particular duty the patient might be. And with this particular line of work, Sammo had already mentioned a little bit of this in the past, but there's a variety of high stress, difficult duties that can be potentially dangerous. This includes high speed pursuit. This includes pedestrian chasing, armed or unarmed combat. So it's dangerous. And we definitely want to take our time and we want to really consider is everything potentially at a place where we can clear them. So we do really want to be considerate. This is not something that we developed. This comes from the Eastern Collective Oncologic Group, a group based out of Virginia. And what they found was that there is already a performance based scale that they put together. We wouldn't necessarily use this, but it's just to sort of get us thinking. It's maybe something we'd like to build a bridge to going back to occupational medicine. So that's potentially something that we're going to work on and put in the indices as well. Now, when it comes to return to work, we would be certainly comfortable with somebody who's a zero, even a one on the scale is questionable, but in certain cases might be acceptable. Past that, fit for duty becomes less clear, maybe less appealing, but there's still patients that we might see. We might see a two or a three or a four. So if we can modify that and move that going forward, it might be a potentially helpful tool. And then just to get a little bit of audience participation, we already touched on this a little bit, but in the case of our patient, whether or not they're fit or not, that is one thing. But what about follow-ups? Should we be following up with this patient? How often, if at all? To, again, harp back on to part one of this presentation, Dan presented the NMJ rule, not my job. So we wanna be careful not to play oncologist. This is very complicated. It can be infinitely difficult. It's a three-year fellowship, so there's just a lot to learn in that time. So we do wanna remind ourselves that our question is, can they return to work? So the three main questions that we want to ask, just broad general questions are, are they fit for duty? Are there any restrictions we should be implementing? And then, of course, what is the risk for sudden incapacitation? This isn't, we're not reinventing something very complicated. We just wanna offer you some guidance going forward. And then, finally, as I said, oncology is very, very detailed. There's a lot to learn. There's a lot of minutia. There's a lot of things being discovered all the time. So it's important just to constantly look for new resources. Always talk to your oncologist. And remember, the person behind the scenes, the pathologist, is also somebody who can offer you insight. Perhaps it's a little less functional. It'll be a little bit more biochemistry, a little bit more basic science. But that's potentially useful, too, depending on what your patient is in front of you. So thank you for your time. donations. Yeah, go ahead. Stand up. Jump. Scream. I was a resident at the time that I was seeing this case, and this was probably the most glaring kind of cancer case that I was seeing, and I was mostly worried about the fact that it was in the brain and any potential cognitive functional problems. And once he was having this emotional kind of situation, and we sent him to the neuropsych, we had kept him out of work at that time, and they diagnosed him with PTSD. So he went towards the PTSD presumption, and that's before Minnesota changed it now, because there was a lot of that during George Floyd and COVID, and so now they have to have treatment for two years. Also, he refused treatment. I saw him again. He refused the treatment, other than he was on the antidepressant, but yeah, no, he did go back. I just wanted to, yep. It's one other thing that somebody asked at one point about risk of sudden incapacitation of recurrence. Actually, you don't really care, right? Because if this tumor recurs, it's not going to make him suddenly incapacitated. So if there's no risk for sudden incapacitation, then that doesn't affect can they do the job today. Now, if they're at a greater than 1% risk of sudden incapacitation in the next year, then that's your business. Other than that, what happens in the future is not our business. My concern is, does he have a risk of seizure due to his old cancer? Yeah, it's a whole different question. And I think he does. I don't know how much, obviously. Mr. Google says the risk is a seizure with this specific cell type. 8%? Just more than 1%. 8% in the next year? So our seizure chapter does talk about it. It's provoked. Well, no. They didn't have a seizure. No, no, no. The seizure chapter is if you already had a seizure. Already had a seizure. Well, my guess is this guy's risk of seizure is too high, but the burden of proof is on us. We need to find a reference. We can't say just, oh, you know, you had something in your brain, you're done. No. Yeah. Sir? Hi. I have two clarifying questions. In the beginning of your lecture about the fitness for duty request from the employer or management specifying that there needs to be a medical diagnosis that you need to comment on, typically most supervisors and companies are concerned about if there is a medical impairment contributing to observable activities at work, and then they request the fitness for duty if a medical condition is contributing to this. Just want to clarify, at least, are you requiring or recommending that the employer specify the medical condition? No. What I wrote, so again, EOC says you need to have a medical condition. What I added is the medical condition has to be known or reasonably suspected, and good luck with articulating that. But again, if you see some type of behavior that looks unusual, I think it's acceptable for management to write, I suspect a mental health condition. But again, having this counterproductive behavior, employee's always late, no, you can't do a fitness for duty for that. Right. So I guess if the employer or HR calls in and they're concerned about a physical condition or a mental health condition, that vague statement is sufficient to move forward. If you think it's reasonable, here we are running a very tight line here. It's better if they already have a known medical condition, do they absolutely have to have that? Probably not. But look, I dealt with a case, another government agency, it wasn't mine, where one of their police officers and gun carriers, police officer, let's say he did stupid things on the firing line with his gun, and he got dementia, very early dementia, and he got a medical retirement but my friend Phil Spotswood, the lawyer, he got involved in the case early on and he said no, that's a performance problem. Your job as management is not to make that medical diagnosis. His recommendation was that the case should have only been handled as performance of conduct, not as a fitness for duty. I tend to agree with him. So again, you are on a very tight line here to go, you know, how do you know that management is telling you the truth or they are trying to get that medical excuse because if they have to deal with the performance of conduct, it's work for them, if it's a fitness for duty, it's work for you. So the first time you hear about a fitness for duty, really think hard about pushing back. Sure. The second set of questions that I had, well, just one, essentially if you do perform a fitness for duty and you determine that you need external consults or another specialist to weigh in on if there's any impacts to their function, do you have any recommendations when you feel that the recommendation doesn't really fit with what you want to move forward with? So an example would be police officer has this condition, their specialist said, yes, I've reviewed their essential job duties and I feel from a specialist standpoint they can perform it, but your opinion may be contrary. Yeah. Any suggestions on navigating that? You put yourself in a very tight spot, I tell you, first. Now, yes, using third party consultants, independent medical evaluation, that's probably a good idea in a lot of fitness for duty evaluations, but you do two things. First, you're in control of the questions you're asking the consultant, and you need to craft this question very smartly. And as much as we say you don't ask the treating provider whether the person can do the job or not, that's a big no-no. Consultant, I would say depends, but again, be very careful. But the other piece is the employer is asking you for your final determination, not asking the consultant. And if you think the consultant is wrong, you know, I think you need to clearly say that, but at the same time, if you ask for consultant's opinion, you need to be able to articulate why you're disregarding their opinion. But yeah, I mean, it's, I'm okay with that. I mean, the big thing I see personally is consultants have no idea what the word restrictions mean. Fine. And also, you know, for your cultural growth, that is sunrise over Lake Michigan and Chicago, so just so you, I just want you to grow. Dr. Mignogna. Thanks for that, Dan. One confusing and potentially contentious issue I've seen with some employers over the years for aerobic capacity testing of cops and firefighters is the methodology. So on one hand, we have one employer that did a one and a half mile run, and you have to get it done under so many minutes. Another employer sent him in for the treadmill. And so I'm doing him on the treadmill, and I'm monitoring, you know, monitoring heart rate, blood pressure, ST changes. So some folks passed doing the run, no idea what their blood pressure is. Other folks, I had to stop the treadmill before they reached their nine or 12 mets because of blood pressure issues. You said the word mets next to stance? I'm sorry. Aerobic capacity. Someone give him an EpiPen. So my question is, if you're doing a treadmill test for aerobic capacity and you see cardiac stuff going on, are you kind of crossing the line from an aerobic test into a medical evaluation? And how do you deal with that when they really only bought an aerobic capacity? So I want to say that we've come sort of full circle. There was a time an NFPA did not have an aerobic standard. And we, physicians, said, hey, you know, you want us to say if they're fit to do the job, we need to know how much aerobic capacity they need to do the job, and for some magical reason came up with 10 mets. And so that was, you know, what it was for a long time. And now we're realizing that that really doesn't tell you if they're able to do the job. Some people at 12 mets can't do the job, and some people at 8 mets can't. And that's not our job. Our job is, are they going to die when they're doing their maximal exertion? And if we do a max test and they don't die or they don't get ischemia, then we say you are clear to go to work. Whether you're capable of doing the work, we don't know, NMJ, right? That's for the department to decide, okay. So when he gets there, Joe is 350 pounds and he can do 6 mets, you know. But they say, okay, Joe, put on the 65 pounds of gear and run up fly flights of stairs, he can't do it. It's not a medical question. It's a performance question. And we don't do performance. So we've kind of come full circle and we're getting rid of mets as a measure of ability to do the job. Because there is nothing out there that says there's any level that you can measure that's going to let you know for sure that this individual, because you're doing an individualized assessment, can do this job. Right. That's a good mark. So we've come full circle. Got it. And it's nice to know that we can still learn. Right. Thanks. Even at my age. We're beyond time. I don't stick around. But thanks for coming. Yeah. A thunderous applause for these guys. Thanks, Bill.

fitness for duty evaluations

oncology

aerobic capacity testing

law enforcement officers

firefighters

medical conditions

job requirements

risk of sudden incapacitation

comprehensive evaluations

clear communication