Re-employment medical examinations: assessing fitness to work in ageing healthcare workers

INTRODUCTION Singapore is experiencing significant demographic shifts due to its rapidly ageing population. This presents challenges such as staffing shortages across many industries.[1] Extending the working lives of older workers is a potential solution. However, ageing increases susceptibility to medical conditions that may affect fitness to work (FTW). In the employed ageing worker, FTW assessment may be conducted as a requisite for re-employment. An effective re-employment medical examination (RME) ensures appropriate match of functional capacity to job demands, while also providing opportunities for bespoke work accommodations and, if needed, job role redesign.[2-4] Additional benefits of an RME include preventative screening and health promotion.[1] Re-employment medical screening programmes (RMSPs) should be periodically evaluated for efficiency and effectiveness. Key considerations include functional components screened, screening tools and overall financial sustainability. This paper details pertinent considerations in the review and introduction of changes to an existing RMSP. Components that do not significantly contribute towards FTW assessment were removed, and enhancements were made to allow for the timely detection of health conditions that may functionally impact the worker. We have focused on the healthcare sector, which has traditionally faced manpower constraints and where job demands are high. Our review framework may serve as a reference for other industries looking to introduce RMSP. Singapore Health Services (SingHealth) is a healthcare cluster comprising a network of acute and community hospitals, national speciality centres and polyclinics. The total staff strength was 32,829 as of 31 March 2023. Recent legislative changes have increased the statutory retirement age to 63 years and the re-employment age to 68 years.[5] Eligible staff who attain the minimum retirement age are offered re-employment, contingent upon undergoing an RME. Re-employment medical examination starts at age 63 years and is repeated at age 66 years and 68 years, and then conducted annually thereafter. In the last two decades, over 10,000 RMEs have been conducted, and this number is expected to increase in view of the ageing workforce.We sought to review the existing RME to improve its efficiency and effectiveness. As the review was aimed at improving clinical efficiency and effectiveness, and did not involve personal data, institutional review board approval was not required. FRAMEWORK FOR RE-EMPLOYMENT MEDICAL EXAMINATION Functional capacity assessment Physical function Vision and hearing: Age-related changes in vision and hearing can impact job performance, particularly in healthcare settings where attention to detail is crucial. Regular screening ensures that healthcare workers can effectively communicate and perform tasks safely. Cardiorespiratory: Physical demands, such as patient transfers and cardiopulmonary resuscitation, necessitate good cardiorespiratory health. As workers advance in age, their physical workloads should be adjusted accordingly and they should be encouraged to engage in regular exercise.[2] Musculoskeletal (dexterity/functional ability): Balance, gait, range of movement and overall motor coordination can decline with age and should be assessed to protect the worker from accidents and injuries. Preventive education on healthy work postures and guidance on muscle resistance exercises should be included during RME.[3] Dexterity may be particularly important in certain job roles (e.g. surgeon/procedurist), and further objective assessments may be necessary. Chronic disease: Early detection and management of chronic diseases reduces the likelihood of premature workforce exit. The RME serves as a platform to encourage workers to participate in the free basic health screenings offered by the cluster. Where relevant, vaccination counselling and administration serve to protect workers from biological hazards. Cognitive ability: Healthcare workers need to be sharp-minded to provide quality care. Cognitive assessments can identify potential issues and allow for appropriate interventions. Psychological capacity Ageing workers are not spared from the stressors of a fast-paced, dynamic and emotionally exhausting healthcare environment,[6] which may impact mental health.[7] Vulnerable groups include those with chronic medical conditions who fear the risk of contagion and those with pre-existing mental illnesses. Social capacity The RME can serve as a platform to identify social realms in which the worker requires support. Examples include interpersonal relationships with colleagues, support from supervisors and time-off for caregiving commitments or medical appointments. Job assessment To align job requirements with functional capacity, we collated information from the job descriptions, along with input from supervisors and workers. These include the type of tasks performed, pace of work, working hours and shift patterns, and hazards at the workplace. Where necessary, workplace visits were conducted to optimise workers’ health and safety. Workplace accommodations were recommended as needed, such as ergonomic equipment to protect the worker or job modifications such as restricted job tasks, improved work organisation for physical or cognitive breaks, shorter working hours and reduction in exposure to workplace hazards.[8] Protection from job-specific hazards Healthcare workers may be exposed to a variety of hazards such as alcohol hand rubs, which may irritate the skin. Screening for eczema, which predisposes the healthcare worker to contact dermatitis, allows opportunistic education on preventive strategies that the worker may adopt. SCREENING TOOLS The Montreal Cognitive Assessment Brief was chosen for mental capacity screening, as it has been reported to have high sensitivity and specificity for detecting mild cognitive impairment (MCI) and is easy to administer.[9,10] It has also been used across various cultures and languages,[10] which is important in our setting where a substantial proportion of healthcare workers are foreigners. The Vulnerable Elders Survey may be used to screen for functional disability, with scores of 3 or more requiring further assessment via the Short Physical Performance Battery. Both tools are useful for identifying ageing adults at risk for functional decline, increased morbidity, mortality, institutionalisation and falls.[11,12] The Purdue Pegboard Test can be used for dexterity screening for workers in jobs that require gross and fine motor dexterity. Selective use of the test during RME can detect loss of function in ageing workers afflicted by basal ganglia diseases such as Parkinson’s disease.[13] SCREENING FOR INFECTIOUS DISEASES Screening for blood-borne viruses (e.g. hepatitis B or hepatitis C and human immunodeficiency virus [HIV]) enhances patient safety and promotes occupational health. Screening occurs before entry into local healthcare courses and at pre-employment medical examinations. For those who were found to be non-immune to hepatitis B at those timepoints, vaccination and follow-up antibody testing are conducted to ensure protective levels. Carriers are not allowed to perform exposure-prone procedures. Routine testings for hepatitis C and HIV are not recommended under national guidelines.[14] Hence, recommendations were made for a one-time screen at re-employment, only if there had not been a previous screening. Screening for pulmonary tuberculosis (TB) via chest X-rays is required at pre-employment. Foreign applicants found to have active TB will not be issued work permits. Risk of pulmonary TB transmission at the workplace is low, as staff are protected by comprehensive infection control measures. Staff with latent TB infection are strongly encouraged to undergo treatment. Therefore, it was decided that staff would undergo a one-time chest X-ray at the initial RME. Table 1 summarises the changes made to the RME programme based on our review, the rationale for the tests and the consequent cost savings.Table 1: Summary of the components of a re-employment medical screening (RME).DISCUSSION The Tripartite Workgroup on Older Workers was formed in 2018 to review matters relating to retirement and re-employment. The workgroup recommends that FTW should be based on the objective assessment of job requirements and relevant health or physical conditions rather than age.[15] The RME framework aligns to these recommendations by focusing on assessments of physical, mental, psychological and social capacity. Validated screening tools were recommended to enhance functional screening. Blood tests (only when necessary) and radiological investigations were conducted at a reduced frequency, considering the low risks and existing national and institutional safeguards. We included only assessments relevant to occupational demands. The necessity, frequency, and most appropriate tests were determined based on scientific evidence, as well as legal, ethical, and economic considerations. We also considered the costs, inconvenience of unnecessary screening, and the potential harm of false-positive results. For cognitive screening, we considered the prevalence of MCI and the impact of clinician MCI on the quality of practice and patient outcomes. In healthcare workers aged ≥70 years, 12.7% were found to have impaired cognition on screening before re-credentialing.[16] Among physicians, 22% of those ≥75 years had gross deficiencies in practice.[17] It has been reported that MCI in clinicians affect patient outcomes, with patients treated by older physician-hospitalists recording higher mortality rates.[18] Screening for MCI was deemed to be overall beneficial. However, mandatory cognitive screening should only be introduced when accompanied by safeguards to protect employee confidentiality and mechanisms to manage abnormal results. Additionally, there must be institutional commitment towards reasonable job accommodations. Making an adverse employment decision because of disability may also be seen as discriminatory.[19] Given these concerns, cognitive screening was introduced as a pilot for proof of concept for mandatory cognitive screening. It is currently conducted on a voluntary basis for healthcare workers aged ≥75 years. CONCLUSION Even the best RME programme has its limitations; therefore judicious exercise by attending physicians is still important. Although RME is conducted at a single time-point, it should not preclude FTW assessments when needed, such as when workers return after prolonged illness. In general, re-employed workers should be presumed medically fit to continue working.[15] Best efforts should be made to reintegrate workers into their original roles through modified work duties or job restrictions. Work accommodations, part-time scheduling or restricted duties in the same role should be explored first. If that is not possible, redesignation into a more suitable role may be an option, failing which retirement may be necessary. Finally, only medical information relevant to FTW and required for work accommodations should be shared with the worker’s consent. Acknowledgement We thank the SingHealth Senior Management and all contributing experts for their support in the review of the RME. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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