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11.1 Code of conduct for DAMEs, DAOs and COs
In accordance with subregulation 67.060(1)(b) of the CASR, a DAME must observe the Code of Ethics of the Australian Medical Association, as that Code is in effect from time to time.
The AMA Code of Ethics is designed to guide the conduct of medical practitioners in a general context and does not relate specifically to the statutory function assigned to DAMEs, DAOs and COs under the CASR.
This code of conduct supplements the requirements of the AMA Code of Ethics in order to address the particular role that DAMEs, DAOs and COs play in the process of medical certification under Part 67 of the CASR.
For the purposes of subregulation 67.060(1)(a) of the CASR, it is a requirement that each DAME, and DAO must comply with this code of conduct in the performance of his or her duties and functions as a DAME, or DAO. This code of conduct serves as a best practice guide for COs (as they are not currently covered by Part 67).
For ease of reference, the use of the term DAME in this document should be taken to mean DAMEs, DAOs, and (where applicable) COs. The term doctor should be read to mean 'doctors or optometrists where applicable'.
The purpose of the medical examination
The purpose of a medical examination performed by a DAME is to assist in determining the suitability for medical certification of medical certificate applicants. The DAME may perform these medical examinations as the applicant's own doctor (also referred to as the treating doctor) or purely in the capacity as a DAME (non-treating doctor).
As a DAME, the examination will include a consultation with the applicant, a physical examination and where necessary a file review of the applicant's medical history.
The role of the DAME
A DAME performs a medical examination and provides an impartial medical opinion to CASA. The DAME's role does not include providing any form of treatment to the applicant.
Certification decisions will be influenced by the DAME's opinion. Therefore, the DAME has a responsibility to ensure that professional opinions and recommendations are accurate, documented, objective and based on all the available evidence.
Aviation-related health promotion
DAMEs are required to implement appropriate aviation-related health promotion for pilots and controllers. [ICAO Annex 1 Chapter 6 184.108.40.206]. Identification of health-related factors which can be managed to improve the health status will contribute to lowering the overall health-related risks.
A summary of these factors should be provided to the applicant, with a recommendation to attend the registered General Practitioner for further advice and management. Typical matters include lifestyle, alcohol, diet, exercise, weight, sleep etc. DAMEs should be careful to note the distinction between the regulatory role and that of the treating doctor. [See 'The role of the DAME' above.]
The DAME applicant relationship—the standard of care within the framework of the assessing relationship
The basis of the relationship between the applicant and the DAME is not the same as that within an established doctor-patient relationship (even when the DAME is also the applicant's usual doctor). However, applicants being assessed are often vulnerable and DAMEs are still required to maintain a professional standard of care. In this regard, the DAME must adhere to the principles in the Code of Health and Disability Services Consumers' Rights.
As such, the DAME should treat the applicant with respect, and ensure that they are not coerced, discriminated against, harassed or exploited. During any consultation with the applicant, the DAME is required to respect the applicant's dignity and communicate with the applicant in an appropriate professional manner that enables him or her to understand the information provided, and the role of the DAME.
Effective communication and consent
Some recurring problems in medical examinations performed by non-treating doctors are those related to poor communication with the applicant. This can lead to unmet expectations, misunderstandings and confusion about the DAME's responsibility to the applicant. Therefore:
- The DAME must ensure that the applicant understands the purpose of the medical examination and the role of the DAME. Although the applicant will usually be aware of this, the DAME should confirm this, and, if necessary, provide further explanation. This explanation should include discussion about the differences between the role of the DAME and the role of the applicant's own doctor.
- The DAME should clarify to the applicant that the role of the DAME is to gather the information and forward it to CASA. It is CASA's role to make the decision about eligibility for different classes of medical certificates, with or without restrictions or conditions. In certain circumstances, Class 2 assessments may be undertaken by DAMEs. (Refer 12.1 DAME's assessment and issue of Class 2 certificates).
- The DAME must explain what will happen during the examination and also ensure that the applicant is aware of what the DAME is doing throughout the consultation. This includes explaining the scope of the consultation and any tests that the examination may require.
- The DAME must obtain the applicant's informed consent to be examined. The DAME should ensure the applicant understands that any aspect of the medical examination will be included in the report to CASA. The DAME should not proceed with the examination if the applicant does not provide his or her consent. The DAME should also advise the applicant that he or she has the right to withdraw from the examination at any time and inform him or her that the report of the consultation (even if incomplete), will be forwarded to CASA. In such circumstances the DAME should record in the report to CASA at what point the examination was terminated and why.
- Ordering of additional tests and reports. CASA has identified a set of 'routine periodic' examinations that are required to be carried out at specified ages. Additional requirements may be requested by CASA. Where DAMEs choose to request additional tests, they should clearly spell out the reasons for the tests (likely to be required for assessment of aviation fitness, useful for applicant's health surveillance etc) and allow the applicants to exercise the choice of whether they wish to have the tests conducted and the consequence of declining to be subject to a test.
- The DAME must explain and ensure that the applicant understands what will happen after the consultation.
- Specifically, the DAME must ensure the applicant understands that the report must be provided to CASA. It is strongly recommended the DAME provides to the applicant a copy of the declaration and consent before the consultation. This gives them time to read and understand it.
- Any questions or requests for information should be directed through CASA's Freedom of Information process.
Recording a consultation
An applicant may want to record the consultation by video or audio tape. The DAME should consider such a request carefully and, if the DAME does not consent, ask the applicant to arrange for another DAME to conduct the examination.
Reports for CASA
Once the medical examination has been completed, the DAME who performed the examination must submit the medical examination form (and where necessary, additional reports) to CASA with his or her medical findings and/or opinion. Reports must be accurate and objective. In doing so:
- The DAME should not speculate or base recommendations on insufficient or flawed evidence.
- If the DAME is not satisfied that their medical opinion can be accurate, based on all available information, the DAME must clearly state this in the report.
- The DAME may choose to recommend further methods of investigation if appropriate (i.e. medical tests, x-rays etc).
- The results of any tests or investigations the DAME has ordered should be copied to the applicant's usual doctor.
- If the DAME detects a new medical condition as a result of the examination, the DAME should inform the applicant and refer him or her back to his or her usual doctor for further investigation. The DAME should notify the applicant's usual doctor in writing.
- Full, complete and open disclosure is fundamental. There will be occasions where there are conditions that DAMEs may believe are of no aviation significance. These conditions should be disclosed to CASA with comment as to why the DAME does not believe they are aeromedically relevant (with any justification). Where the DAME believes that there may be a risk to aviation, this should be clearly communicated to CASA.
- Even when it is CASA's role to make decisions about eligibility for different classes of medical certificates, with or without restrictions or conditions, DAMEs are able to make recommendations about restrictions or conditions.
Medical examinations of applicants who are the DAMEs general practice patients
In some circumstances the DAME may be the applicant's treating doctor as well as their DAME. This may be because the applicant lives in an isolated area where another DAME is unavailable. In this situation the DAME should clearly explain the difference in their role, so that the applicant understands that the usual dynamics of the doctor-patient relationship are different.
The DAME must ensure that any medical examination of an applicant for the purposes of medical certification under Part 67 of the CASR is accurate, objective and based on all the available evidence.
Financial influences for the non-treating doctors
The DAME must not allow for their interests or the applicant's personal interests to influence their examination, opinion or recommendations.
Declining to perform medical examinations
If a DAME does not consider themselves suitably qualified to conduct an examination, or identifies a conflict of interest in relation to the examinee, the DAME must decline to examine the applicant. The DAME does not have to provide CASA with an explanation for doing so.
Advocacy and Conflicts of interest
DAMEs must ensure that any reports that they provide to CASA for medical certification purposes under Part 67 of the CASR are objective and expressed in professional terms.
Conflicts of interest should be actively managed. For example, DAMEs must not carry out medical examinations for members of their family and should avoid doing so with persons with whom they have commercial, financial or other relationships. For example, DAMEs should not examine business partners, or co-owners of aircraft.
Due to the paucity of aviation medicine specialists in Australia, DAMEs may occasionally find that they are requested by applicants or holders to provide evidence in support of reviews or appeals in tribunals or courts.
In doing so, DAMEs must use their best endeavours to identify and disclose actual and potential conflicts of interest and manage the conflict between their appointment as a DAME and that as an expert witness appropriately.
In the performance of any functions and duties, or the undertaking of any activities related to medical certification under Part 67 of the CASR, DAMEs must ensure that they remain objective and independent at all times and do not act as partisan advocates for the interests of medical certificate applicants or holders.
More information about conflicts of interest is good medical practice available from codes, guidelines and policies on the Medical Board of Australia website.
Obligation for professionalism in dealing with CASA
DAMEs must ensure that they maintain an appropriate professional relationship with CASA and that they do not engage in conduct which might bring CASA or any of its staff into disrepute.
This includes by:
- operating with CASA in a 'no surprises' manner
- communicating with CASA at all times in a professional manner
- disagreeing with, and arguing a point of view in an objective and evidence-based manner, and avoiding emotional or inflammatory statements
- not making disparaging or derogatory comments about CASA or individual CASA staff to applicants or other persons.
Managing complaints with CASA
There will be occasions where applicants or DAMEs may be dissatisfied with the way CASA has processed a medical application or about the decision that has been made.
Where the DAME has a complaint, the first point of contact should be the DAME Liaison Officer, with escalation to the Principal Medical Officer (PMO), the Industry Complaints Commissioner, and the Director of Aviation Safety.
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