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April 2014

Best Practices

Addressing Fitness for Duty: Practical Steps

By Fred H. Kohanna

Every company must have a healthy and productive workforce to be successful. An employee who is fit for duty has the physical, mental and emotional capabilities to perform the essential functions of the job. Performance of these job tasks must not threaten the safety or health of the individual, coworkers or the general public.

Challenges of an Aging Workforce

In 2009, U.S. Administration on Aging estimated that 40 million people in the U.S. were over the age of 65 (12.9% of the U.S. population). This number will swell to 72 million people by 2030 and will represent approximately 19% of the U.S. population. University of North Carolina Institute on Aging anticipates that 45% of Americans will retire at a later age than they originally expected, and that 70% to 75% of Americans will continue to work after they officially retire.

The motivation to continue to work beyond the age of 65 will be driven by two factors. First, many Americans have not been able to save enough money for a comfortable retirement, and will need to supplement their income. Second, many older individuals realize the social and psychological benefits of working and being productive. The net effect will be a growing percentage of older Americans in the U.S. workforce.

Since older workers will have more chronic medical conditions than their younger counterparts, evaluating and maintaining their fitness for duty will be an even greater challenge going forward. A recent study in the U.K. and Europe demonstrated that the incidence of lost-time work-related injuries, days away from work and work-related injury recurrences all increased with the age of the workers (Berecki-Gisolf, Clay, Collie, et al., 2012).

Challenges of Presenteeism

Another factor to consider with fitness for duty is the problem of presenteeism. This term relates to an employee who appears to be physically, mentally and emotionally capable of being at work but is less productive due to a health problem. Presenteeism can result from:

  • stress;
  • illness;
  • medications;
  • substance abuse;
  • mental illness;
  • family issues.

Unlike absenteeism, presenteeism often goes unnoticed because the employee is physically present. Also, in many job categories, productivity is difficult to measure, so productivity loss can easily go unnoticed.

A U.K. study surveyed more than 6,000 employees at seven different organizations and found that nearly 60% of employees reported presenteeism over a 3-month period (Robertson, Leach, Doerner, et al., 2012). Presenteeism can have a significant, yet hidden, economic impact. The loss in productivity costs in the U.S. is estimated at more than $150 billion per year (Widera, Chang & Chen, 2010). Presenteeism also takes a toll on safety. A 2012 study showed that workers who had paid sick leave were 28% less likely to sustain a nonfatal injury than workers who did not have sick leave (Asfaw, Cryan & Rosa, 2012).

Triggers for Fitness-For-Duty Exams

Many events can raise concern about a worker’s fitness for duty. A significant health problem will sometimes be uncovered in routine exams such as preplacement, return-to-work, medical surveillance, HazMat, commercial driver or respirator certifications. In some cases, the employee directly or indirectly raises concerns about his/her fitness for duty. For example, the employee may:

  • minimize obvious health problems;
  • exaggerate health problems;
  • take frequent sick or unpaid leave;
  • try to return to work too quickly after an injury or illness;
  • make more errors than usual at work;
  • manifest reduced productivity;
  • experience more work-related injuries or near-misses.

In other cases, the employer may raise concerns about the employee’s fitness for duty. For example, the employer may:

  • want to minimize the risk of injury to the employee or to coworkers;
  • be concerned about the employee putting the public at risk;
  • be concerned about company liability or incurring workers’ compensation costs;
  • want to clarify poor job performance versus a legitimate health problem.

Fitness-for-Duty Policy

A fitness-for-duty policy must take into account other relevant legal requirements such as the provisions of the Americans With Disabilities Act (ADA), Family Medical Leave Act (FMLA) and guidelines of the Equal Employment Opportunity Commission (EEOC). A high-quality fitness-for-duty policy should include the following tenets:

  1. must be uniformly applied to all employees and not be discriminatory;
  2. must be based on the specific and well-defined essential job functions;
  3. should provide a concise fitness-for-duty form for the treating healthcare provider to complete;
  4. should be readily available to employees and supervisors;
  5. managers and supervisors should receive appropriate fitness-for-duty policy training.

FMLA allows a company to seek clarification of the returning employee’s fitness for duty. The employer must have the employee’s written consent. The employer can delay the employee’s return to work from a medical leave until the fitness-for-duty form is completed by the provider. If the treating provider needs additional evaluation or testing, the employee (not the employer) is responsible for any out-of-pocket expenses.

Pitfalls of Fitness-for-Duty Evaluations by Treating Physicians

The treating physician may not always provide an impartial and informed opinion with regard to his/her patient’s fitness for duty. This is because the employee is the physician’s customer and the physician may assume the role of the employee’s advocate. In addition, the treating physician may be unfamiliar with the employee’s company and with the specific job tasks being performed. The employee may provide inaccurate or incomplete information about the essential job functions to the physician. The treating physician typically does not know to what extent the employer can accommodate job restrictions.

An occupational health physician (OHP) can be an invaluable resource in the fitness-for-duty process. The OHP is more knowledgeable about the work environment and can be more impartial in making fitness-for-duty determinations. The OHP is better able to make specific recommendations for work restrictions and job accommodations. Often, an OHP is more willing to review job descriptions and to contact employers for more information or to discuss fitness-for-duty concerns.

Many companies, both large and small, utilize the services of a corporate medical consultant (CMC). The CMC is typically a board-certified OHP specialist who becomes familiar with the company’s business activities and with the specific jobs being performed daily. The CMC is aware of the physical demands of each job, any potential job hazards and the company’s ability to accommodate work restrictions. The CMC understands the workforce demographics, labor environment, recent hiring or layoffs, and whether an employee is having job performance issues. This individual is in the unique position to consider the best interests of both employee and employer so a win-win scenario can be achieved. The CMC is also able to contact the treating physician or specialist to clarify complex medical issues.

Fitness for Duty Requires a Multidisciplinary Team

Many stakeholders share an interest and critical role in the fitness-for-duty process. It is essential for the team to include:

  • OHP and/or CMC;
  • human resources;
  • SH&E;
  • legal/labor relations;
  • supervisor/manager;
  • risk manager.

The fitness-for-duty team should avoid some common pitfalls in fitness-for-duty evaluations. For example, the team should avoid inconsistency in applying the fitness-for-duty policy to employees. Nonhealthcare professionals should not seek, nor be privy to, confidential employee health information unless specifically released to the employer by the employee. Fitness-for-duty evaluations should never be used punitively or as a substitute for appropriate intervention by the human resources department for poor job performance. Lastly, the employer is not required to change the essential job functions to accommodate an employee. The employer must only provide reasonable accommodation so that the employee can perform the essential job functions.


The aging U.S. workforce will inevitably result in more frequent questions about employees’ fitness for duty and the need for medical evaluation and job accommodation. A less-obvious concern is the problem of presenteeism, which is an often underrecognized problem in the workplace that negatively affects productivity. Companies must have a comprehensive program for assessing employees’ fitness for duty whenever concerns arise. A multidisciplinary approach is essential to reach a win-win for both employee and employer.


American College of Occupational and Environmental Medicine (ACOEM). (2006, June). Preventing needless work disability by helping people stay employed. Elk Grove Village, IL: Author.
ACOEM. (2008, Dec.). The personal physician’s role in helping patients with medical conditions stay at work or return to work. Elk Grove Village, IL: Author.
Asfaw, A., Cryan, R. & Rosa, R. (2012, Sept.). Paid sick leave and nonfatal occupational injuries. American Journal of Public Health, 102(9), e59-e64.
Australian Institute for Primary Care. (2006, July). Facilitators and barriers to return to work: A literature review. Victoria, Australia: Author.
Berecki-Gisolf, J., Clay, F.J., Collie, A., et al. (2012, March). The impact of aging on work disability and return to work. Journal of Occupational and Environmental Medicine, 54(3), 318-327.
Robertson, I., Leach, D., Doerner, N., et al. (2012, Nov.). Poor health but not absent. Journal of Occupational and Environmental Medicine, 54(11), 1344-1349.
Washington Department of Labor & Industries. (2004, June). Return-to-work desk reference. Olympia, WA: Author.
Widera, E., Chang, A. & Chen, H.L. (2010, Nov.). Presenteeism: A published health hazard. Journal of General Internal Medicine, 25(11), 1244-1247.

Fred H. Kohanna, M.D., M.B.A., FACOEM, is corporate medical director for AllOne Health Resources, a company that provides a complete range of occupational health services. Kohanna is board certified in both emergency medicine and occupational and environmental medicine. He develops innovative, customized occupational and environmental health services solutions for a range of companies in diverse industries including oil and gas, petrochemicals, pulp and paper, hazardous waste, biotechnology, pharmaceuticals, insurance and transportation. He serves on the board of directors of the New England College of Occupational and Environmental Medicine and is a member of ASSE’s Greater Boston Chapter.


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