Not every injury/illness requires time off

Panel recommends different approach to time off

Occupational health professionals are constantly looking for ways to improve return to work (RTW) for injured or ill employees, but there has been little in the way of research into what makes disability leave, RTW, and stay at work (SAW) plans work — or fail.

A panel of occupational health experts has taken a look at the RTW/SAW process and found that, in many cases, the way disability, RTW, and SAW are handled is not always in the patient’s best interest.

"Helping people minimize the disruptive impact a disability has on their lives is a team sport, and we’re not playing like it’s a team sport," says Jennifer Christian, MD, MPH, an occupational medicine physician who served as chair of the Stay and Work and Return to Work Committee for the American College of Occupational and Environmental Medicine (ACOEM), which late last year issued a report, "Preventing Needless Work Disability by Helping People Stay Employed."

What Christian and her colleagues found is that "the disability system typically turns an impersonal face toward a person whose life has been disrupted and who may need guidance in managing a new life situation." The result of this is that in many cases, an injury or illness that could have been only of minimal disruption to the person’s life and livelihood instead is turned into a major disability that changes their lives and takes away their ability to work.

With the aging of the American work force and the rising burden of chronic disease, the impact on workers’ function also is rising. Episodes of prolonged disability due to common conditions such as depression and low back pain are becoming more common.

Christian says that while statistics show the incidence of work-related injuries and illnesses has been falling steadily for the last several decades, the length of disability following work-related injury has been climbing, as have the number of medical services and their costs. Paradoxically, employers are paying for more — and more expensive — medical services, but people, nevertheless, are losing more time from work for medical reasons.

"The focus of our report is on the large number of people who end up with prolonged or permanent absence from work due to medical conditions that normally would cause only a few days of work absence," says Christian.

"Many of those who end up receiving long-term disability benefits of one sort or another have conditions that began as common everyday problems like sprains and strains of the low back, neck, shoulder, knee, and wrist, or depression and anxiety."

The ACOEM committee set about to test their shared belief that a good deal of work disability can be prevented or reduced by finding new ways of handling important nonmedical factors that are fueling its growth.

"Why do some people who develop common everyday problems like backache, wrist pain, depression, fatigue, and aging have trouble staying at work or returning to work?" Christian says the committee set out to answer that question. "How can employers and insurers work more effectively with health care providers to reduce the disruptive impact of injury, illness, and age on people’s daily lives and work, and help them remain fully engaged in society as long as possible?"

Some nonmedical aspects of the SAW/RTW process, Christian and her colleagues say, are causing harm to the health and well-being of the same people that these systems were designed to protect, as well as harm to their families, employers, communities, and society as a whole.

"We see how often participation in the disability benefits system is counterproductive in our patients’ lives, some of whom are particularly susceptible," she says. "The disability system typically turns an impersonal face towards a person whose life has been disrupted and who may need guidance in managing a new life situation. We also see how often the SAW/RTW process is both openly and surreptitiously distorted by other interests."

As a result, Christian says the disability benefits system too often:

  • fails to provide nonfinancial support to people who need help because their life has been disrupted by illness or injury;
  • fails to help people adapt or understand the course of their illness and their future life options, and defeats what would otherwise be a successful medical result;
  • wastes resources on people who do not need them;
  • causes people to refocus their lives and adopt a new identity as disabled people, resulting in society’s loss of potentially productive members.

"In some ways, it was two kinds of fundamental ideas — that disability is often preventable, and the corollary that a lot of today’s disability is not medically required," says Christian.

The cost to employees and employers is substantial, Christian says — the employer loses the employee’s contributions as a worker, the employee loses the fulfillment of working.

Many times, occupational medicine physicians have a clear picture of how often the amount of time an injured person is actually off work is out of proportion to how much time he or she needs to be off, Christian says.

"Look at the difference between a self-employed person and someone who is not self-employed," says Christian. While an employee with a large company behind him or her can take the maximum amount of time off when sick or injured, the self-employed worker with the same disability can’t afford as much downtime, and is back to work much more quickly.

The group made four general recommendations for improving the system, a process it says has to start with a dialogue between ACOEM and stakeholders in workers’ compensation and the nowork-related disability benefits system, including employers, unions, workers, the insurance industry, policy-makers, health care, and lawyers.

Unless complete work avoidance is medically required for healing or for protection of the worker, co-workers, or the public, Christian says, case managers, occupational health nurses, physicians, and the ill or injured employees should be looking for ways to prevent or reduce absence from work.

"Expecting and allowing people to contribute what they can at work and keeping them active as productive members of society is good for them, and for us all," she says.

The ACOEM committee recommends everyone on the RTW "team" stop assuming that absence from work is always medically required. Nonmedical causes can contribute to "discretionary" and unnecessary disability; the committee proposes that employer-sponsored, on-the-job recovery reduces the lure of discretionary disability. Removing administrative delays and bureaucracy, and educating employers about taking a stronger role in determining SAW/RTW results also can help.

• Address behavioral and circumstantial realities that create and prolong work disability.

Scientific research shows that workplace factors such as job dissatisfaction or poor job fit have a powerful effect on disability outcomes, Christian says.

The occupational health nurse should become comfortable with the idea of intervening in both the medical and nonmedical barriers that can make nonmedical issues — bureaucratic tangles, interpersonal conflicts, institutional customs — appear to be medical issues.

• Acknowledge the powerful contribution that motivation makes to outcomes, and make changes that improve incentive alignment.

The ACOEM committee suggests that doctors be paid for disability prevention work to increase their commitment to it.

"Stop asking the treating physician to certify disability or set a return-to-work date," Christian suggests. "Instead, ask them about functional ability, unless there is a clear reason why it would be medically inappropriate for the worker to do work of any kind."

• Invest in system and infrastructure improvements.

The SAW/RTW committee advocates training practicing clinicians on why and how to prevent disability, as well as why and when to disqualify patients from work. This education should encourage physicians and other health care professionals to broaden the focus of their care to include disability prevention and to develop clinical skills in this arena.

• Disability is rarely medically required.

The ACOEM panel states that at least one formal survey and numerous informal polls of treating physicians consistently estimate that only a small fraction of medically excused days off work are medically required — meaning that all work of any kind is medically contraindicated. The rest of the days off work are caused by a variety of non-medical factors such as administrative delays of treatment and specialty referral, lack of transitional work, ineffective communications, lax management, logistical problems, and so on.

The fact that these days off may be unnecessary seems to be lost on the participants in the disability benefits system, Christian points out. Most workers are told only that the days off are excused and their doctor’s signature sets in motion a system through which they get benefits for a diagnosed disability.

"People often end up sitting at home collecting benefits because their employers have made the discretionary business decision not to take advantage of their available work capacity," she says.

"Common-sense evidence abounds that keeping people at work and productively contributing to society is good for them and for society. To avoid the unfortunate outcome of iatrogenic or system-induced disability is worthwhile. To improve the appropriateness and usefulness of services available to people who are coping with illness and injury in their lives is also of value. And it is sensible, if not urgent, for us as a society to curtail the needless use of resources and loss of personal and industrial productivity."

The ACOEM committee report on needless disability is available at www.webility.md.