Return-to-work programs benefit workers, workplace, ACOEM says

Lack of credentials, training may be the rule, not the exception

Return-to-work (RTW) programs are seen as such an integral part of occupational medicine that it would never occur to most observers that there are a number of physicians who are ill-prepared to appropriately address RTW issues. But the current situation apparently is of enough concern to the Arlington Heights, IL-based American College of Occupational and Environmental Medicine (ACOEM) that it has issued a position statement on the subject.

"The Attending Physician’s Role in Helping Patients Return To Work After Illness or Injury," recently published on the organization’s web site (www.acoem.org/guidelines/article.asp?ID=55), offers physicians guidance in developing and implementing RTW plans 

In setting forth its rationale, ACOEM states that it recognizes:

  • that a fundamental purpose of medical care is to restore health, optimize functional capability, and minimize the destructive impact of injury or illness on the patient’s life;
  • that prolonged absence from one’s normal roles, including absence from the workplace, is detrimental to a person’s mental, physical, and social well-being;
  • that a return to all possible functional activities relevant to the patient’s life as soon as possible after an injury or illness has many beneficial effects;
  • that physicians positively affect the likelihood and rapidity of healing by setting clear expectations for recovery with patients.

But why now?

Given the general consensus that RTW programs are important and limiting absences and lost productivity are essential components of occupation health practice, the questions still arises: Why now? What makes the issue so pressing today?

"We clearly see a growing employer interest in maximizing productivity and minimizing unnecessary absence; there’s a fairly large movement in industry in the area of realizing the potential connection between health and productivity," says Jennifer Christian, MD, MPH, chair of ACOEM’s work fitness and disability section.

But there’s an even more pressing issue, she adds. "As occupational doctors, we work in a variety of settings; some as corporate medical directors, some in private practice and some in consulting, and we often end up in the position
of looking at the process of care for many companies and seeing how their physicians handle the process of return to work," Christian notes. "We see that they are often not clear on what their role is or on how to perform it, and there are actually a lot of unfortunate outcomes."

David Randolph, MD, MPH, a member of ACOEM’s RTW Process Improvement Committee, is equally concerned. Randolph, who is a past president of the Chicago-based American Academy of Disability Evaluating Physicians (AADEP), notes that the organization shares a number of members with ACOEM. "When I first joined the ranks of AADEP, there were very few professionals who had credentials in both arenas," he notes. "I found a lot of physicians were not particularly knowledgeable in the area of disability or did not understand what transpires in this arena. They may not be up to date on treatment, such as for back pain, or causes, like those for carpal tunnel syndrome. They may make erroneous presumptions and just proceed to disable the worker. There’s an awful lot of ignorance."

This ignorance is of even greater concern given the current regulatory atmosphere, says Randolph. "What we have in front of us is a looming disaster," he charges. "Our society has been experiencing a burgeoning of people applying for and receiving disability benefits, sometimes for more statutory than practical reasons. For example, you can be granted Social Security disability benefits simply by meeting certain requirements; if you have clinical ridiculopathy and you are 52, you can be considered disabled."

The wrong message

Randolph says the General Accounting Office (GAO) issued a report in August 2002 indicating that in 2001, Veterans Affairs and Social Security paid out a total of $90 billion in disability benefits. He fears we will follow the path of Europe, where roughly 47% of their population currently receives disability benefits. "This would not only result in a horrendous financial load on those not receiving benefits, but more important, it would give the wrong message to a huge percentage of the population; that they can’t work. And since our society values work, it’s a tremendous statement for medicine to make."

Christian couldn’t agree more. "There’s a sort of pathetic condition we call iatrogenic [caused by the healer] disability. It may not be a perfect word; it’s not just what the doctor did, but it also involves the patient’s interaction with the disability system," she explains. "The system can cause a worker to be disabled functionally much more than their biologic condition would require. As an extreme example, I’ve seen a man out of work for two years with an injured big toe."

The disability becomes emotional as well as physical, she continues. "I, myself, got very interested in disability prevention in the mid-’80s, when I saw people out on workers’ comp for two or three years, and you’d meet these shattered hulks of people who had previously been skilled workers with self-respect. They had turned into whining, depressed people whose lives had fallen apart," she recalls.

Christian came to realize in her own practice that fairly shortly after someone stops working, they become unsure about whether they can return to work. "If you do not get back on that horse quickly, the devil of doubt will creep back into your mind," she notes. "And if you get benefits only when you’re sick, you need to prove yourself sick to keep those benefits safe."

Randolph agrees. "It’s a major mental health issue — and if it wasn’t before, it will be in the future."

Awareness must increase

One of the benefits of the ACOEM position statement is that it will increase awareness of the problem, says Christian. "Even in occupational medicine there has been little awareness that disability is created by withdrawal from work," she notes. "You create an invalid simply by having the disability system and by not getting people back to work soon enough."

In her occupational medicine residency, she did not learn much about workers’ comp and learned nothing about preventing disability, Christian notes. "That’s not unusual — it’s not part of regular medical school education or even an occ-med residency, which is more about occupational disease, rather than musculoskeletal problems and a variety of other common injuries."

Not much has changed since then, she says. "About five years ago, a guy who had recently graduated with an occ-med residency was working for me," she recalls. "He still had books on his shelf from that residency, so I suggested we look up disability and see what was there. In all the books, we never found one reference to it, other than sample cases. It’s in a blind spot."

In med school today, she says, students receive a total of five hours on occupational medicine. "That doesn’t include the impact of medical conditions on work," she notes.

Still, says Randolph, in terms of actually treating patients, "these are skills that are taught from day one. These doctors have the requisite knowledge; it’s not rocket science."

One of the keys may lie in better communication. For example, Randolph suggests, you might send the ACOEM position statement to attending physicians who seem to be unreasonably delaying return to work.

"In general terms, this means the individual physician who is involved in primary care — it could be an occupational physician, the family doctor, an internist — anyone on the frontline assessing the worker’s ability to perform his daily living or work activities," Randolph explains.

Randolph has a number of opportunities to assess the work of such physicians. "Sometimes I’ll be asked [for my opinion] by a third-party insurance company or by a law office," he says. "I’m handed a stack of information and asked, Should this person be off work?’"

Just recently, he says, he saw the records of a woman on short-term disability since last May. "In the record, her physician kept giving her excuse notes month after month, and the reason behind the notes was never clearly provided," he asserts. "The disability was just maintained because the notes were presented that said she couldn’t work."

A significant number of physicians will bend the rules to allow their patients to stay off work, Randolph asserts. "Technically, that’s fraud," he says. "When I call them and ask why the patient is out of work, they often just say, She says she can’t work; she is not feeling well.’ I’m all for confronting these physicians."

Of course, many physicians might get defensive in such situations. Recognizing this, Randolph suggests you establish a good rapport with the attending physician first. "Invite them to the plant for an inspection," he suggests. "Discussing the ongoing clinical problem may help. Everyone has to trust you are not there as a hired gun, but rather to try to make things work better."

The use of independent evaluators can be priceless to doctors at plants, Randolph says. "The treating physician may say one thing; the occ-doc may see things differently, so you send out for another opinion. What’s critical is keeping open the lines of communication with the treating physician."

Christian concurs, suggesting that you can send the ACOEM statement to treating physicians as a matter of course. "They may find it useful in terms of laying out of a paradigm, and an approach or method to thinking about having employees stay at work and return to work sooner," she says.

There are really two options, she declares: To send the statement to a doc in a problem case where he seems to be particularly unaware of certain key issues, or to be more proactive — to reach out to treating physicians with whom you regularly interact. The latter approach may help avert defensiveness on the part of the treating physician.

In those communications, it should be emphasized that staying at work is equally as important as returning to work, Christian notes. "With an aging work force, we can predict declines over time. Staying at work is an example of anticipatory management, while returning to work is reactive management," she observes. "Using the position statement can not only help get employees back to work sooner, but hopefully, they maybe not have to leave work at all."

[For more information, contact:

  • David Randolph, MD, MPH. Telephone: (513) 965-8770. E-mail: dococcmed@aol.com.
  • Jennifer Christian, MD, MPH. Telephone: (617) 803-9835. Internet: www.webility.md.]