Franco Giuliano
Azienda Ospedaliera-Universitaria Policlinico di Modena, Università di Modena e Reggio Emilia, Largo del Pozzo, 71, 41100, Modena, Italy.
Int Arch Occup Environ Health. 2006 Aug;79(7):607-11. doi: 10.1007/s00420-006-0084-9. Epub 2006 Feb 1.
Workers' medical examination by the occupational physician (OPs) is a decision-making process whose output consists of a variety of evaluations, including assessment of fitness for work. The medical literature reports that there is no complete agreement among OPs assessing the same workers, evidencing a critical aspect of professional performance. This study aims at evaluating the inter-individual variability of medical decisions by different occupational physicians.
Four specialists in occupational medicine participated in the study. Each specialist examined 100 records of subjects with different medical conditions selected from about 2,500 health care workers. Each physician completed a form including the following items: assessment of fitness for work, advice to workers, need of further investigations, report of occupational disease, recommendation for the general practitioner. To assess the inter-individual variability the percent agreement and the agreement strength or Cohen's kappa were measured.
The study shows a variable agreement in the assessment of fitness for work among different professionals, with percent agreement ranging from 58% for the whole group to an average of 77% for physicians' pairs. By taking into account the variability expected by chance, the agreement ranged from fair to substantial. The agreement of other decisions (workers' advice, referral to other specialists, request of further investigation, report of occupational disease, recommendation for the general practitioner) was more variable.
The study shows that an inter-individual variability exists for some decisions taken by OPs. According to the need to continuously improve professional practice, in the absence of qualitative standards based on the outcome, reduction of inter-individual variability that should be considered as a quality requirement of the performance of the occupational physician.
职业医生对工人进行医学检查是一个决策过程，其结果包括各种评估，其中就有工作适应性评估。医学文献报道，在评估同一批工人时，职业医生之间没有完全达成一致，这证明了专业表现的一个关键方面。本研究旨在评估不同职业医生做出的医疗决策的个体间差异。
四位职业医学专家参与了该研究。每位专家检查了从约2500名医护人员中挑选出的100份患有不同疾病的受试者记录。每位医生填写了一份表格，其中包括以下项目：工作适应性评估、给工人的建议、进一步检查的必要性、职业病报告、给全科医生的建议。为了评估个体间差异，测量了一致率和一致强度或科恩kappa系数。
该研究表明，不同专业人员在工作适应性评估方面的一致性存在差异，整个组的一致率从58%到医生对之间的平均77%不等。考虑到偶然因素导致的变异性，一致性从一般到高度不等。其他决策（给工人的建议、转诊给其他专家、要求进一步检查、职业病报告、给全科医生的建议）的一致性变化更大。
该研究表明，职业医生做出的某些决策存在个体间差异。根据不断改进专业实践的需要，在缺乏基于结果的定性标准的情况下，应将减少个体间差异视为职业医生表现的一项质量要求。
