GPs may be unsure about declaring patients fit to take part in physical events. Dr Emma Davies, medicolegal consultant at Medical Protection, provides advice on this common 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 the UK, 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.
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 also make the care of our patients our first concern, 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. The GMC advises in paragraph 14 of Good Medical Practice
that you “must recognise and work within the limits of your competence”.1
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 GMC states in paragraph 71 of Good Medical Practice
: “You must be honest and trustworthy when writing reports, and when completing or signing forms, reports and other documents. You must make sure that any documents you write or sign are not false or misleading… you must take reasonable steps to check the information is correct.”1
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.
Signing such forms for patients is considered private GP work and would not be covered by state-backed indemnity schemes. GPs should contact Medical Protection to ensure that they have appropriate indemnity for such work.
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.
1. GMC, Good Medical Practice