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074 When Can You Refuse A Physician Signed Medical Form?

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In this episode of The Dive Locker Podcast we discuss when dive professionals can refuse to teach a student with a physician signed medical form.

Welcome To The Show!

Welcome to The Dive Locker Podcast, the podcast for dive professionals where we bring you the latest in diving industry resources that make you excellent at teaching techniques, risk management and dive business.

It is great to have you here. Now since you’re a dive professional you are no doubt using the RSTC generated Medical Statement, the majority of you are at least. So as you know, a student for any certification course must fill out the statement and if there are any YES answers the student must get a physician’s approval to dive and to participate in your class. Sounds pretty cut and dry right? Well not in every situation.

What happens when a student gets a properly signed medical form by a physician but your still not comfortable teaching that student with the particular medical conditions he or she has? What about if the physician writes something in their remarks observations paragraph or attaches a letter or note telling you what the student can or can’t do? Or, what if the student tells you that he or she had to go to several physicians before one would sign it? Hmmm. These are all interesting situations and we are going to go over when you can and should say yes or no to someone that presents a physician signed medical form.

RSTC Diver Medical

So the more teaching experience you get the more medicals are going to pass through you. And the more unique situations with medicals are also gonna pop up. Just so we’re all on the same page you will use the RSTC diver medical form for use with beginner courses and continuing education courses.

This Diver Medical use to be called the Medical Statement. And the most recent revision by DAN, WRSTC, RSTC and UHMS has really made a fantastic change to the way we screen students for fitness to dive. For more on these changes listen to Episode 31 with Dr. Nick Bird as he describes the new medical form.

But sometimes there are issues. Issues that you don’t get a good feeling about. These come in a variety of situations. For example once I had a student who forged his physician’s signature.

Another time a student who had all no’s but then took his shirt off to put on a wetsuit and there was a scar from his throat to the bottom of his abdomen. He had open heart surgery and did not list that anywhere.

So yes, there are some that lie to cover up. You may catch them or you may not. My thing is that I stress repeatedly in my classes the need for absolute truth and accuracy on these forms because there is nothing to see underwater that is worth risking your life over.

So I do everything in my power today to strongly emphasize students being truthful on their medical forms.

When You’re Uncomfortable Teaching a Student With a Medical Condition

But the heart of this episode is what if the student is truthful, gives a positive yes response to a condition and then gets a physician’s signature that allows them to take your class. But you’re not comfortable with that.

Maybe its that the person is presenting signs and symptoms or acting in a behavioral manner that you know will be not only challenging for them or the other student or for you, but more importantly safety becomes questioned. We get challenging students all the time, I’m talking where that student could actually challenge the safety of themselves and or others.

Last year a student presented with severe anxiety and depression – medication for it ongoing counseling and more – the physician signed and then noted scuba diving could be a positive activity for this Patient. I did not feel comfortable with the level of issues this student was presenting to me. So we had a very open dialogue about what she will be going through and how her actions can impact others. She agreed that diving was not for her until she resolved her issues to a more manageable level. She also said her doctor who signed her form loved to dive, thus thought it would be good for the patient. This clearly wasn’t the right thing to engage in.

Now, you say but Tec you’re not a physician how can you question that – are we not to interfere? Well wait a minute, when a student presents a yes, you don’t get to play physician and say “oh you don’t need a physicians signature, that’s nothing”. But you can refuse to accept thus teach a student with a physician signed medical form. You are granted this by certification agencies because you must be comfortable teaching someone diving courses. If your not comfortable teaching someone you must articulate
the reason or reasons why. But you can say no, even if the student has a signed medical.

Strategies for Proper Medical Screening

Now here are a couple other strategies that I apply. First, I consult with Divers Alert Network Medical Line that number is 919-684-2948 put this in your phone. I always consult with them on complex cases. And I also invite the student to contact them as well and talk directly with them about their issues. Many times the medics have been very persuasive and helped a student make the right decision to not take a class OR to see a diving physician.

Which is another strategy. Sometimes I see a clearance to dive signature given by a physician at an urgent care or clinic or pediatrician or family practitioner and I wonder did that doctor actually go to the UHMS.org website to research this students condition as it relates to diving. Because in some cases they have approved someone with a Severe Risk condition.

Now let me explain that and how the doctors are to evaluate the yes answers on the patients medical history.

So if I believe a physician did not really read over the UHMS Diving Medical Guidance Form, then I refer to a diving physician. I have our local ones info ready to give to students. You can find them on the DAN Physician Network. This is great for sending students that you think could benefit from a physician with specialized knowledge in diving, and alternobaric maybe even hyperbaric medicine. So that is another strategy to help a student be properly screened.

And the final strategy that I do, is contact the risk management department of the training agency I’m certifying with. Often, the training agency will give you advice. And in some cases they can assist you when the answer is a NO, They are quick to say let the student be mad at us not you. That is really helpful when you have the agency giving you advice and even supporting your decision. So definitely use the training agency when you have a questionable medical.

What Are Conditionals?

Now what if you have a student with a yes, who gets a physicians signature and approval to dive but that doctor writes on the form or supplements it with a note or letter that gives you instructions? Well, this is called a conditional. And they are normally a no go. But it depends on what the doctor has written. If the doctor writes a note along with approval that says “patient agrees that if symptoms return, he will discontinue diving activities”. Well that is a conversation between the doctor and patient, it is on the patients shoulders to comply with what the physician has said. And it does not impact you , the pro, at all.

On the other hand if the note says, “patient shouldn’t do deep diving” “patient shouldn’t be in water for extended periods” “patient shouldn’t be in cold water”. Well there is no definition for deep or extended periods or cold. What are we talking about. You see, that could change the way you perform your classes. And since we have standards, these conditionals can become problematic for you. So whenever your faced with a conditional feel free again contact your training agency. Their risk management department should be able to tell you if that is a true conditional or not.

Now sometimes a conditional could say diver should not dive past 80 feet. But they are signing up for your Open Water Diver course, your limited to 60 feet on that. So could you do it, well some say yes, some say no. And I lean a little toward the no. Because that conditional exist beyond the divers training with you, but then they are on their own. Will they follow those instructions or not? Most conditionals make me uncomfortable. So again, get some advice from your training agency if you are uncomfortable.

Physician Shopping

And then what if your student tells you they had to see a few physicians before one would sign their form. Oh, why is the question. It could be that no one was comfortable or it could be the policy of some medical practices to not give approvals to dive. So it would be good to find out why and then, utilize the strategies of DAN medics and diving physicians to assist you in the screening process.

ADA

And finally we’ll close with this. ADA, is the Americans with Disabilities Act. They fight for people who have been discriminated due to their physical condition. You might have someone who is morbidly obese, and they receive a yes from their physician. But you are just uncomfortable teaching this person.

If you say no, they might fire back with ADA compliance issues. Again, you should consult with your training agency when your not comfortable so that they can assist you in your decision and keep you out of ADA issues. They would help you state that operationally, you are concerned that you would physically not be able to get the individual out of the pool in an emergency. And the rental wetsuits are not going to fit, and we can’t have you take the class without exposure protection.

There has to be a well articulated message that states these things. Plus, other professionals can come to your defense saying it is not because your morbidly obese, it is because your obesity makes you not fit to dive. Again, going back to that one physician might feel scuba is a nice activity to help someone lose weight and be active. But another physician might understand the multiple risks associated with obesity and diving and be able to make it a medical concern, not an ADA compliance issue.

In Conclusion

So there you have it. You do possess the right as a diving professional to refuse to teach any student. Even students who have received an approval to dive by a physician. But the thing is you want to articulate your rationale, you want to use your resources like DAN’s Medic consults, and DAN Physician Network as well as consulting with your training agency. And especially remember that you must be consistent in the way you handle these situations. Have the same process in place each time so that it does not appear you’re playing favorites.

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Thanks For Listening!

That’s it for today, everyone. Thank you so much for listening. Remember to subscribe to this podcast on iTunes, Google Play or Stitcher, that way you’ll be notified of new episodes as soon as they go live and please leave a rating. Items talked about in this episode can be found on the show notes Page at scubaguru.com . There you can also click the microphone and leave us a comment. Thanks again. We’ll see you in the next episode. Safe diving and take good care of my friends.

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How to Fill Out the Scuba Medical History Questionnaire

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Truthfully and accurately completing the Divers Medical Questionnaire is extremely important to divers' health and safety
Truthfully and accurately completing the Divers Medical Questionnaire is extremely important to divers’ health and safety

At the beginning of every scuba class, students are required to fill out a Medical History Questionnaire.  This questionnaire is part of a larger document called the Medical Statement, and this Statement was created by the RSTC (Recreational Scuba Training Council) and is widely used among U.S. scuba training agencies.  The purpose of the Medical History Questionnaire is to find out if the diver should be examined by a physician before beginning scuba training.  So why post an article on how to fill out the form?  Well, over the years as an instructor trainer, dive training agency director, and a forensic diving accident investigator, I have seen countless examples of how the improper use of this form has been extremely harmful (even fatal) to multiple individuals impacted by it.  Both new and seasoned divers, as well as all diving professionals, need to know how important this form is for their own well-being, and the well-being of their instructors, divemasters, students, and dive buddies.

Here are the steps for properly filling out this extremely important document:

Step 1:  Be Truthful – The questionnaire asks if you have had at any time a condition within the list of medical conditions.  If so, you will give a positive response (“YES” answer) to the condition noted.  A positive response to a question does not necessarily disqualify you from diving.  Rather, it shows that there is a pre-existing medical condition that may affect your health and safety when diving with compressed air under varying states of pressure.  Thus, a physician is called upon to examine your ability to proceed with the scuba training or not.

But here is where people get into trouble.  The diver is on vacation and wants to take a scuba course.  He signs up for the course which starts that night.  Upon arriving at the course he fills out the paperwork and the instructor notices a “YES” response to the line “Asthma, or wheezing with breathing, or wheezing with exercise”.  This form now requires a physician’s approval for the individual to continue in the course.  But, how will that happen when it is late afternoon or on a weekend?  Here are the things that go wrong:

  • The diver decides that the episode was when he was a child so he crosses the YES out an writes a NO.  WRONG! The diver had the condition, even as a child, so it must be noted.
  • The instructor recognizes she will lose this diver’s registration in her class and decides to inquire about the condition and whether or not it should really be given a YES.  The instructor finds out the asthma occurred in childhood, and concludes that the diver is fine.  She rips up the form and tells the diver to fill it out again, this time with a NO in the Asthma line.  WRONG! The diving instructor or divemaster is not the physician of the diver, and cannot make a call on a medical condition – only a physician can.

Step 2:  Be Accurate – The Medical Statement can be inaccurate when improperly filled out.  It is important to write the actual words “YES” or “NO” on the Medical History Questionnaire.  Simply writing a “N” or “Y” or even a “–” is not acceptable.  Nor can you write one word and then draw a straight line down the list to in an attempt to include all (see examples).

 

Improper: No abbreviations, dashes, or letters
Improper: No abbreviations, dashes, or letters

Improper: No lines or strikethroughs
Improper: No lines or strikethroughs

Also be sure to fill in every other area a) legibly and b) in detail.  Be as accurate as you can about your physician, or even past physician if you no longer live in the same location and have not seen a new physician.

Sign and date the form properly.

Step 3:  Be Willing to Get a Physician’s Signature – As mentioned in step 1, some people have lied on their diving Medical Statement to forgo obtaining a physician’s signature.  This can have drastic consequences – don’t do it!  If you have a “YES” response to ANY of the items in the Medical History Questionnaire you have a couple options:

  1. Fax the form in its entirety to your physician and ask if he or she will approve you to dive.  If your physician has regularly seen you for checkups and can pull your medical file and review it, chances are your physician will select the appropriate box, sign it,  and fax the forms back to you.
  2. Go see your physician.  You can either go see your physician or go see a new one if you currently don’t have one.  Bring all six pages of the Medical Statement with you.  You will be given a routine check, with perhaps more of a focus on airway, ears, sinuses, and lungs.  This is not generally a Diving Physical Exam – those are more formal and used often for military, commercial, and/or scientific diving purposes.  After your examination your physician will select the appropriate box, sign it, and hand you the forms.

A note on physicians reviewing your eligibility to dive – not all physicians understand the myriad of medical complexities surrounding diving with compressed air in varying pressure environments.  If the physician is a diver, it does not qualify the physician in the areas of Diving Medicine or Hyperbaric Medicine.  However, physicians who are divers may have an increased understanding of the items to consider for healthy diving.  In either case, the last four pages of the Medical Statement are called the “Guidelines for Recreational Scuba Diver’s Physical Examination” and is for the physician to use in determining divers’ medical fitness for scuba diving.  These guidelines help a physician ascertain whether a certain medical condition is a relative risk, a temporary risk, or a severe risk condition in diving.  Make sure the physician has all four pages of the guidelines.

You could also seek a physician with specialized knowledge of diving.  One of the best resources for this is through the Divers Alert Network (DAN) Physician Referral Network.  If you are looking for a physician to conduct a diving physical or would like a consultation from a diving medical specialist in your area simply go to http://www.diversalertnetwork.org/medical/network/physician.

Bottom line:  There is nothing underwater worth risking your life to see.  Be truthful and accurate on your Medical History Questionnaire.

Welcome Dive Professionals

Welcome to ScubaGuru.com!  The ScubaGuru brand is dedicated to giving dive professionals tools and techniques to be GREAT LEADERS – leaders in the classroom, leaders underwater, and leaders in their diving businesses.  With unique leadership skill-sets, the dive professional can create:

  • Better divers
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See what we mean by Go Beyond the Standard and enjoy the rewards of being truly great at what you do!

Sincerely,

Tec Clark

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