Fabrice Czarnecki, MD, MA, MPH, FACOEM, Medical Director, Public Safety Medicine, Northwestern Memorial Physicians Group; Immediate Past-Chairman, Police Physicians Section, International Association of Chiefs of Police
A police officer has poorly controlled diabetes and receives insulin shots. One day, while on duty, that officer suffers from low blood sugar. As a result, the officer becomes mentally impaired and fires the handgun inappropriately, resulting in the wounding of a bystander. The police agency is sued, and the cost of the out-of-court settlement is over $1 million.
A law enforcement agency refuses to hire applicants with insulin-dependent diabetes because incidents caused by low blood sugar can never be completely avoided. The agency is sued, and the plaintiff’s counsel argues that this is a “blanket exclusion.” The cost of the out-of-court settlement is over a $1 million.
While these two scenarios are fictional, similar occurrences have impacted several law enforcement agencies in recent years. This article will review methods and best practices from the American College of Occupational and Environmental Medicine (ACOEM) Guidance for the Medical Evaluation of Law Enforcement Officers to ensure that medically qualified officers are hired while complying with anti-discrimination laws.
Timing of Examinations
Under the American with Disabilities Act (ADA), subjecting applicants for employment to medical questions and examinations is generally not permitted before a conditional offer of employment is made. It is, however, permissible to obtain a medical clearance from the applicant’s personal physician to participate in a physical agility test. The agency may not ask any medical information at that stage. The ACOEM guidance offers such a medical clearance, which points out to the primary care physician specific medical issues of concern, such as heart and lung diseases.
After a conditional offer of employment has been made, a physician chosen by the law enforcement agency conducts the preplacement (also called “post-offer”) examination. ACOEM Medical Guidance for Law Enforcement Officers Task Group recommends that law enforcement agencies not rely on personal physicians for that step, as most personal physicians are not educated in the specific physical demands of police work. Personal physicians are trained to be “patients’ advocates” and tend to help their patients obtain (or retain) employment. The author recommends that law enforcement agencies employ or contract with physicians (“police physicians”) who are experienced in occupational medicine and knowledgeable about the job functions and demands of police work. Where allowed by law, non-physician medical providers such as physician assistants and nurse practitioners may also evaluate police applicants.
The pre-placement examination starts with a review of the applicant’s medical history. A standard medical history form should be used for every applicant, and all applicants should sign the medical history questionnaire and certify that it is true and correct. The medical provider should review the form with the applicant and cosign it. The medical history is by far the most important step in uncovering applicants who may not be medically qualified. Questions must be comprehensive enough to uncover all relevant medical disorders and specific enough to avoid negative answers by “intended” omission. For example, an actual case involved an applicant with a bleeding disorder. This applicant had made multiple visits to emergency departments for nosebleeds, but he did not disclose his condition on the questionnaire. On the medical history form, he answered no to the question “Do you have frequent nosebleeds?” He later stated that, in his opinion, the nosebleeds were not frequent, despite being severe enough to cause life-threatening anemia.
The second step of the pre-placement examination is the physical examination by a medical provider. Vital signs and complete examination by organ system should be performed. For example, vision testing should include distant and near vision acuity (with and without correction), peripheral vision, and color vision assessment.
In addition to a physical examination, a battery of routine diagnostic tests are recommended, including the following:
- Creation of a consistent medical hiring process that is compliant with ADA and all applicable laws
- Evaluation of applicants by a police physician rather than personal physicians
- Use of the ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers during the medical evaluation process
- Hearing test
- Blood tests—complete metabolic panel and complete blood count
In addition to the routine diagnostics, the following optional tests may also prove useful:
- Gamma-glutamyl transferase (to screen for alcoholism)
- Lipid panel (cholesterol and triglycerides)
- Lead and zinc protoporphyrin (to screen for lead exposure, especially in lateral transfers)
- Immunization titers
- Tuberculosis testing
- Urine testing
Further testing, such as cardiac stress testing, might be recommended depending on personal risk factors and specific medical issues, as might pulmonary function tests (depending on the type of respirator used by the agency) and consultations with specialists, such as orthopedists and cardiologists.
The police physician then makes a recommendation to the police chief from a medical standpoint as to whether the applicant can or cannot perform the essential job functions with or without accommodations. The police chief then takes this into consideration and makes the final hiring determination.
The medical assessment complements, but does not replace a psychological evaluation by a qualified a police psychologist following IACP guidelines.1
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
At the first IACP conference, held in Chicago in 1893, one of the topics discussed was “uniform standards to select all police officers according to mental and physical qualifications.” Guidelines help police physicians (and their agencies) ensure consistencies in the decision-making process and deflect accusations of discrimination. Guidelines are also needed to cover gaps in the knowledge of police physicians, especially when evaluating public safety workers is not their main professional activity. Several states and agencies have developed guidelines and standards to address that issue. Unfortunately, most existing standards are not exhaustive, nor based on science, and they commonly include vague statements such as “case-by-case assessment,” “reasonable degree of certainty,” or “moral certainty” to establish whether an applicant may or may not work as a law enforcement officer.
The American College of Occupational and Environmental Medicine (ACOEM) has undertaken the publication of the first evidence-based guideline for police physicians that aims to be national and international in scope. The first chapters of the ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers were published in 2010, with the endorsement of IACP, National Association of Women Law Enforcement Executives (NAWLEE), and International City/County Management Association (ICMA).
The ACOEM guidance was developed by a task group of the Public Safety Medicine section of ACOEM comprising occupational medicine physicians with extensive public safety medicine experience in state, local, federal, military, and international agencies, along with representatives of police executive organizations (IACP, NAWLEE) and municipal management (ICMA).
Before drafting a new chapter, a review of the medical literature and of existing medical guidelines (for example, guidelines by National Fire Protection Association, U.S. Department of Transportation, and U.S. Department of Defense) is conducted. Each chapter is drafted and discussed in public meetings over a period of approximately two years, and key stakeholders and advocacy groups are invited to participate in the process. Prior to publication, chapters are submitted to outside experts (physicians and non-physicians) and to the Public Safety Medicine section of ACOEM for comments. The final version is then approved by the ACOEM board of directors.
Chapters published as of March 2014 address diabetes, vision, hearing, cardiovascular diseases, medications, pregnancy, infectious diseases, substance use disorders, sleep disorders, and amputations and prosthetics. Published chapters have been endorsed by IACP, NAWLEE, and ICMA. Chapters under development include initial evaluation, seizure disorders, bleeding disorders, wellness, risk assessment, musculoskeletal disorders, psychiatric disorders, and pulmonary disorders. While these chapters have been written specifically for patrol officers, other chapters under development address the specific needs of tactical officers, bomb squad officers, and corrections officers.
This online subscription-based guidance provides police physicians with information to assist them in making medical qualification recommendations that promote the health and safety of law enforcement officers. This information can also be used by chiefs, incumbents, and applicants to understand the criteria for hiring and retention. The ACOEM guidance can be accessed online at http://www.acoem.org/leoguidelines.aspx.
Medical Criteria for Police Applicants
There are some medical conditions that would exclude an applicant from working as a full-duty law enforcement officer. One example that comes to mind is significant visual impairment—an officer with severe visual impairment would not be able to drive or recognize suspects and weapons. Other types of medical conditions are often permissible as long as they allow the officer to perform the essential job functions. A list of essential job functions should be provided to the police physician to make that determination and should be updated on a regular basis.
For each medical condition, the police physician will consider the following two issues:
- What is the risk of sudden incapacitation?
- Is the applicant able (physically or mentally) to perform the essential job functions?
Medical conditions that could create a risk of sudden incapacitation higher than that which is acceptable include epilepsy, heart disorders, uncontrolled diabetes, and the use of certain blood thinning medications. Individualized assessment by a qualified police physician is necessary to make sure that the medical condition is actually causing that risk in the applicant. The mere diagnosis of epilepsy, heart disease, or diabetes should not lead to an automatic disqualification. The ACOEM guidance uses a threshold of 1 percent per year for the risk of sudden incapacitation, which is a generally accepted risk threshold in occupational medicine. Ultimately, it is up to the police chief to decide what risk is acceptable to his or her organization; however, such decisions must be consistent to avoid discrimination claims.
Medical conditions that could render the applicant unable to perform the essential job functions of a law enforcement officer because of physical impairment include amputations, paralysis, limited range of motion in a joint, hearing loss, and visual impairment (such as monocular vision, loss of peripheral vision, or color blindness). Significant cognitive impairment can be caused by sedating medications, low blood sugar (see Scenario 1 at the beginning of this article), psychosis, substance abuse, and sleep disorders.
The creation of a standardized medical hiring process can help ensure that qualified individuals are hired and can decrease litigation and workers’ compensation costs. The hiring process for police applicants should involve qualified physicians using appropriate medical guidelines. The IACP Police Physicians Section (http://www.iacp.org/Police-Physicians-Section) is a resource that IACP members may use to find qualified local physicians and to obtain comprehensive consultative assistance for creating a medical hiring process, as well as assistance with other challenging situations. ♦
1IACP Psychological Services Section, “Pre-Employment Psychological Evaluation Guidelines,” IACP Resolution adopted at the 116th Annual Conference of the International Association of Chiefs of Police (Denver, Colorado, 2009), http://www.iacp.org/portals/0/documents/pdfs/Psych-PreemploymentPsychEval.pdf (accessed February 6, 2014).
|Fabrice Czarnecki, MD, MA, MPH, FACOEM, is the medical director of Public Safety Medicine for the Northwestern Memorial Physicians Group; immediate past chairman of the IACP Police Physicians Section; vice chair of the ACOEM Public Safety Medicine section, and a member of the ACOEM Guidance for Medical Evaluation of Law Enforcement Officers task group.|
Please cite as:
Fabrice Czarnecki, “Medical Screening of Police Applicants,” The Police Chief 81 (March 2014): 46–48.