title: Do approved doctors and medical referees in the UK agree when assessing a seafarer's fitness?
abstract: BACKGROUND
  The seafaring industry remains a hazardous occupation that requires sophisticated systems of risk and fitness assessment. This study aims to investigate the extent of agreement between Approved Doctors (ADs) and Medical Referees (MRs) when they assess a seafarer's fitness.
  
  
  METHODS
  Between 2003 and 2009 a total of 232,878 seafarer medical examinations were carried out by ADs, of which 465 were considered by the MRs because the seafarer appealed against the AD's decision. The extent of agreement between ADs and MRs was studied.
  
  
  RESULTS
  Two hundred and sixty-eight (58%) cases seen by the ADs were classed as category 4 "permanently unfit"; the referees only placed 85 (18%) of them in this category. On the other hand, 252 (54%) cases seen by the MRs were classed as category 2 "fit with restrictions", while the ADs had only placed 111 (24%) in this category. The overall agreement between the assessors (AD vs. MR) was poor (Kappa K = 0.18).
  
  
  CONCLUSIONS
  For cardiovascular diseases and for mental ill-health, access to additional information by the MR was the commonest reason for changing the fitness category, but for all other conditions factors such as the experience and knowledge of the MRs or their different interpretation of the standards were the most frequent reasons for a change to fitness category or to restrictions.
  
  
  CONCLUSIONS
  This study found that there was poor agreement between the AD's decision and the subsequent MR's decision regarding the fitness of those seafarers who decided to appeal against the AD's initial assessment. The reasons for this are considered.
authors.affiliation: Health Management Ltd, Meriden, UK. isamrustom@gmail.com
authors.forename: Isam
authors.initials: I
authors.lastname: Rustom
authors.forename: Tim
authors.initials: T
authors.lastname: Carter
mesh_terms: D000328:Adult; D002318:Cardiovascular Diseases / Q000175:diagnosis* / Q000453:epidemiology; D055317:Evidence-Based Practice; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis* / Q000453:epidemiology; D008875:Middle Aged; D009326:Naval Medicine / Q000592:standards; D009787:Occupational Medicine / Q000592:standards*; D010808:Physical Examination / Q000592:standards*; D010809:Physical Fitness; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000592:standards; D012767:Ships; D006113:United Kingdom; D055815:Young Adult