GPs may be unsure about declaring patients fit to take part in physical events. Dr Rachel Birch, medicolegal consultant at Medical Protection, provides advice on this common query

Query

A 23-year-old patient makes an appointment to see his GP. The patient presents a template medical form that he asks the GP to sign, so that he can take part in a marathon, outside of Ireland, in a few weeks’ time. The patient stresses that he has been training a long time for this marathon and has spent a lot of money on travel arrangements. However, he won’t be able to take part unless the doctor signs the form. The patient has recently moved to the area and hasn’t been seen by the GP before; his medical records do not contain any health concerns. The GP is unsure whether he should sign the form and whether he is indemnified to do so. He phones Medical Protection for advice. 

Expert advice

This is a common concern from GPs in the run up to marathon season. While you may want to be supportive of your patient’s involvement in sporting activities, if asked to sign fitness to participate forms you should consider the possible medicolegal issues. Put another way: should the patient suffer harm as a result of undertaking the event with an unknown, but detectable, medical condition, could you be the subject of a civil claim? The short answer is “in theory – yes”. However, as doctors we should treat patients as individuals and with respect, and refusing to support a patient’s request could be viewed as practising defensive medicine, which is of little benefit to both patient and practitioner.  

So how can I approach this safely?

It is all about good communication, from the wording used on the form you are signing, to the conversation you have with your patient. It may help to see the question from a different angle.  Rather than stating “this patient is fit for…..” think “are there any obvious reasons why they shouldn’t do this…?” If your answer to the latter is “no”, then stating as such based on the information available to you, would be a reasonable approach. It would also be advisable to explain to your patient that there are no guarantees and that you cannot mitigate for the ‘unknown unknowns’. You should consider taking a careful history (and family history) from the patient, ensuring that there are no concerning symptoms, in particular those that could be associated with undetected cardiac conduction defects. 

Work within your competence

Before assisting you must be confident that you understand the nature of the event and have sufficient knowledge about the patient. If you do not have the required expertise or information to assess whether the patient is fit to take part in an event, then you should obtain further advice. It is important not to work outside your area of competence. 
 
You should consider the patient’s current and past medical history, and any relevance this has to the event in which they are intending to participate. If in doubt about contraindications to participating in the event, you could advise the patient to seek further information from the event organisers.

If the patient’s medical history is not straightforward you may need to seek advice from a specialist; for example, if they have recently received treatment it may be appropriate to contact their consultant. If you feel that judging a patient’s fitness for an event is not within your expertise or knowledge of the patient, then you should not sign a declaration. 

Ensure that reports are not misleading

If presented with a form by a patient, as in the above query, you should consider the wording of statements and declarations carefully. It may be possible and appropriate to sign a form with a qualifying statement, and you should offer factual information about a patient’s condition that may be relevant.

The Medical Council states that “Reports must be relevant, factual, accurate and not misleading.” In addition they advise doctors that “If the report relates to the patient’s current state of health, you should carry out an up-to-date examination where appropriate.”¹

Summary

Requests for fitness to participate statements can be emotive and you may feel pressured to complete forms and sign declarations. However, it is important that you only make statements and sign forms that are honest and truthful, and you should always act in the best interests of your patients’ health.

In the event that you complete a form and a patient subsequently comes to harm whilst running a marathon, you should contact Medical Protection to request assistance.

Reference 

1. Medical Council, Guide to Professional Conduct and Ethics for Registered Medical Practitioners 8th edition. 2016.