If a student has a signed Medical can I as a Dive Professional decline to train them?

If a student has a signed Medical can I as a Dive Professional decline to train them?

The Recreational Scuba Training Council (RSTC) diving medical screening system was first published in 1989.  This screening questionnaire was a collaborative project orchestrated by and through the Undersea and Hyperbaric Medical Society (UHMS) Diving Committee and subsequently endorsed by the RSTC.  

Since its inception, this tool has become the most frequently used method of efficiently and effectively screening scuba divers for training or diving activity participation.

After almost 30 years, there was sufficient evidence to support a revision, and an independent international group of diving medical experts, the Diver Medical Screen Committee (DMSR), was brought together in 2017 to initiate an evidence-based review and an updated diver screening questionnaire underwent field testing for efficacy and screening sensitivity and was published in June 2020.

Can an Instructor decline to train a student with a signed Medical?

As a dive professional, you know a student for any certification course – that is from beginner courses and all continuing education courses must fill out the RSTC diving medical questionnaire (in addition, if you run a club and organised events it is strongly recommended that you hold an in date medical on file and it is annually reviewed).
If there are any YES answers on the questionnaire then the student must get a physician’s approval to dive prior to participating in any training with you (the latest form is 2020 Diver Medical Participant Questionnaire)
So, cut and dried – well our training agencies would have us believe that, but it is never that simple.

What is the definition of Physician?

In the context of the Diver Medical Participant Questionnaire, the term “Physician” has a specific meaning. 
In most countries, this means a medical doctor, one who focuses on the non-surgical treatment of patients’ conditions.
The ideal medical provider to perform fitness to dive examinations has undergone training in diving and hyperbaric medicine as evidenced by board certification or certificate of added qualification (the designation of these qualifications varies around the world). 
However, the Diver Medical screening system was designed to equip physicians who don’t have this specialised training with resources to assist in their medical consultations.  The Diving Medical Guidance to the Physician provides insight from the Diver Medical Screen Committee into medical conditions as they relate to diving, and where there is any doubt concerning a patient’s condition, the Divers Alert Network has referral specialists around the world that can be reached for this purpose or in the UK an AMED doctor http://www.ukdmc.org/medical-referees/)

  1. What happens when a student gets a properly signed medical form by a physician, but you are still not comfortable teaching that student with the particular medical condition.
  2. What happens if the physician writes something in their remarks or attaches a letter or note telling you what the student can or cannot do?
  3. Or the student tells you that they had to go to several physicians before one would sign it.
  4. Or during training something comes up or happens which brings the divers medical into question.
  5. Or a student becomes ill or injured during training

During your course orientation or initial conversations with potential students stress the need for absolute truth and accuracy on these forms because once underwater there is nothing worth seeing that is worth risking their and your life over.

When you are uncomfortable teaching a student with a Medical Condition

You have a student who has truthfully completed the medical statement with a YES and then gets a physician’s signature that allow them to proceed, but you are not comfortable with their fitness to dive.
Maybe the person is showing signs or symptoms, acting in a manner that you know will be not only challenging for them or the other student(s) but for you and your instructional team; more importantly safety becomes questioned or flagged in the training risk assessment.  We all get challenging students at times but what we are talking about is where the student is actually presenting a challenge to their own safety or that of others around them.
We are not physicians and our training agencies say if the student has a medical, they can commence training. If a student had a YES, you do not get to play physician and say, “Oh you do not need a physician signature that’s nothing.” As an instructor, you can refuse to accept to teach a student with a physician signed medical form.  We are granted this by our certification agencies because we must be comfortable for our safety and the students, we have a duty of care to while teaching diving courses.

If you are not comfortable teaching someone you must be able to articulate the reasons why, but you can say no, even if the student has a signed medical.

What happens if the physician attaches a letter or note telling you what the student can or cannot do?

Medicals prior to the 2020 Diver Medical there was a section for Physicians to write comments, this has now been removed with the Physician only able tick Approved or Not Approved on the Diver Medical in the Physician’s Evaluation Form section, but this does not stop the Physician from writing additional notes or attaching a letter or note!
If a Physician does attached a letter or note, then in PADI terms the instructor manual covers this very clearly and states that there can be no restrictions or conditions noted by the physician (for example depth limits, water temperature restrictions etc.)

The student tells you that they had to go to several physicians before one would sign it

This always raises a red flag, and you should understand the reason for this and that can be done with a “Oh really, why was that” type of question.

It could be that their local physician was not comfortable signing a medical questionnaire as they declared they are not a diving doctor and do not understand the implications – Great that is honesty.
It could be the local surgery policy is to not sign these types of forms and we are seeing this more and more in our local area.

It could be the cost of the local physician to sign was prohibitive – yes it happens.

Now it could be that one physician advised the student to not come diving and the student then ‘shopped’ around until they found a physician who would sign it.

In this latter case, politely advise them to have a conversation with a diving AMED, after all they understand diving medicine.

During training something comes up or happens which brings the divers medical into question

Yes, there are times a student fills in the medical statement and puts a NO when they should have put a YES.  After all they want to come diving and experience all of the amazing things we talk about and put over our social media channels, who would not want to experience that after all.

Something might come up in conversation with a member of your professional team it might be something you see – it could be a serious scar and they have put NO to major surgery.  It is at this point you need an open and honest conversation with the student and politely point out the NO on the medical statement and see if it changes to a YES, it probably will and then stop training until you have a signed medical statement from a physician.

A student becomes ill or injured during training

In PADI terms the instructor manual covers this very clearly and states that a student diver who becomes ill or injured during a PADI course is to complete a new Medical statement before further in water activities.  Use the medical form to rescreen the student to determine if the changed medical condition would cause the diver to check off something new on the medical.  If so, the diver must be cleared for diving by a physician prior to resuming in water training

Form Signed by a Physician

We have had forms signed by our local GP practices and potentially the student has paid a lot of money to get that signature, but we inwardly question if the physician actually read the guidance documentation or did any research into the student’s condition as it relates to diving.  Because they have approved someone with a condition that we have previously seen students not approved to dive.  We might not be physicians but a number of us are aware of conditions and medication that a student would be advised not to dive with or on.
In this case, you technically cannot decline to train the student, unless the criteria outlined in part one is present.  What we do is gently refer the student to a diving doctor which here in the UK is an AMED doctor and we give our students the name of number of our local ones, explaining that we think the student would benefit from talking to the AMED doctor as they are understanding diving medicine whereas their doctor probably does not.  In fact, if a student declares a medical condition in our early conversations, we advise them to go to an AMED over and above their local physician. Our local chamber doctor has been incredibly helpful over the years.

Disabled Diving

We are an inclusive sport, and we should do everything we can to include disabled divers.  There are plenty of parliamentary acts to ensure that no one is unfairly discriminated against and quite rightly.  But everyone needs a medical BEFORE they can undertake any diver training.
But let us take just one example - you have someone who is morbidly obese, and they receive a yes from their physician.  (This potentially should not happen – see the DDRC article that answers the question “Can I dive if obese” on https://www.ddrc.org/diving/can-i-dive/can-i-dive-if-obese/)
But you are uncomfortable teaching this individual.  It could be an operational risk – you are concerned that you would physically not be able to exit them from the pool or open water site in an emergency.  The rental equipment is not going to fit, and you are not going to train them without exposure protection.  This would require a well-articulated message that states all of this.  Plus, other professionals can help with the message The Dive Centre Risk Assessment has raised a number of issues that we cannot remediate that would make you the student safe and us the instructional team able to safely deliver the course.
Everyone has to be “Fit to Dive” and we have other articles that cover this subject as Fit to Dive covers your physical, emotional and mental fitness