Should Medical Physical Exams Be Combined with Functional Testing?
Richard W. Bunch, PhD, PT, CBES
The issue as to how many people are hired and become injured when performing their job duties due to inadequate job matching is becoming an increasing concern. Compensating for physical problems or poor physical fitness by using improper or unsafe body mechanics for example, can lead to an injury, or even a long-term disability. A heart condition that is exacerbated by physical exertion can lead to a disabling or even life-threatening cardiac event at work.
In the past, pre-employment screens were mainly limited to a medical exam and certain diagnostic tests such as radiographic studies (x-rays). These exams were represented as a method to identify medical problems that would make job applicants a high risk for injury on the job. However, the estimation of whether or not a person could work safely based on these early tests were too often subjective. While these assessments were useful in identifying certain applicants with conditions posing medical risk, there was no research demonstrating predictive value or whether the condition presented an imminent risk of injury. With the advent of the ADA, an emphasis on job-specific functional testing as a means to assess the abilities to work safely became apparent.
In order to improve the predictability of injury or determine if a condition posed imminent risk of injury, it was deemed reasonable to test a person’s functional abilities to perform job-specific simulated tasks such as lifting, carrying, pushing, pulling, climbing stairs, ladders, squatting etc. Today, any type of functional capacity or physical abilities test is actually considered a medical test if heart rate, respiration and /or blood pressure are monitored. Therefore, ADA regulations dictate that since functional testing that monitors vital signs for safety is a medical test, it cannot be conducted on a person until a conditional offer of hire had been made to the applicant. Therefore, it is technically incorrect today to call any type of medical test used to screen job applicants a “pre-employment” test. A more precise and correct terminology is a “post-offer, pre-placement” test.
A post-offer, pre-placement functional-based examination is designed to help determine whether a person with or without disability has the physical abilities to perform essential functions of a job without posing a direct (or imminent) risk of injury to oneself, co-workers and/or to the public. If such a test accurately assesses essential job functions, it can be considered valid and nondiscriminatory. Since many types of functional tests involve physical exertion, it is prudent, for safety reasons, to review medical history and current medical status as well as conduct a physical examination on conditional new hires prior to their engagement in job-simulated functional tests.
Today, there are various forms of functional abilities testing being used. To be legally performed, employers should ensure that the testing protocol is fully compliant with all state and federal anti-discrimination regulations (e.g., the amended ADA). This is best accomplished by testing the ability of individuals to perform only the essential functions of a particular job prior to placement in that job.
When assessing if there is a gap between a person’s physical capacities and the physical demand of a job, a medical or physical examination alone, without functional capacities testing, may miss important information about abilities to work safely during physical exertion, especially when testing for labor intensive jobs. In essence, a medical examination without job-specific functional testing will provide only an “educated guess” as to whether or not a person can perform the essential functions of a job safely. Job-specific functional tests can be used to “validate” or “invalidate” an evaluator’s impression that a person can work safely. In this regard, job-specific work-simulated functional testing is essential.
An example of how important the functional testing process can be to identify a disability not picked up by a standard medical examination alone is provided by the following actual case. A 39-year-old male who applied to work for an oil industry client underwent a standard medical physical before being referred for a post offer, pre-placement physical abilities test (PAT). He had cleared a standard employee medical examination and then was referred to a physical therapy clinic to undergo a PAT. The medical examination indicated that the individual appeared to be very fit. The physical assessment conducted as part of the PAT to ensure safety also revealed the same impression of the medical examination. However, upon physical exertion during the functional tests (i.e., lifting and carrying), the test recipient’s heart rate became highly erratic. This reaction to exertion triggered termination of the test due to safety concerns. His erratic heart rate response to exertion was documented and a note was provided to the person describing the exertional dysrhythmia with instructions to see a doctor or go to a hospital ER to have a more detailed cardiovascular examination. The urgency of the examination was emphasized. However, upon leaving the clinic, the person unfortunately disregarded the instructions from the evaluator and decided not to seek medical attention. Instead, he decided to apply for the same job with a different employer who did not conduct post-offer, pre-placement PATs. Approximately two weeks later this person suffered a myocardial infarction and died.
This tragic example describes how job-specific functional capacity testing as conducted during a PAT can identify signs of a potential medical problem that may be missed during a standard medical physical examination alone. It should also be noted that a medical examination alone can identify a condition or signs of pathology that functional testing may not detect. Obviously, the best approach to employee screening is to use a PAT process that involves both a medical examination and job-specific functional testing.
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