Negotiate return-to-work issues with injured patients

Injured workers' anxiety can contribute to real pain and extended disability. Physicians' inability to measure patients' symptoms and their uncertainty about the patients' degree of disability can strain the doctor-patient relationship.

Reply: Primary care physicians often find themselves treating a patient with an illness or injury either caused or exacerbated by the patient's work. The illness or injury may be self-limiting, so that the individual can return to work after only a few days. In this situation, a short "excuse" note might be sufficient to document for the employer that time off was needed for a medical condition.

For a work-related condition, however, the patient relationship is affected -- and may be strained -- by the extra requirement that the physician complete workers' compensation forms, so that the employer's insurance carrier or a third-party administrator can be assessed the appropriate fees, rather than the patient's insurance company or the patient.

When an employee's injury or illness is severe and extended time off is anticipated, the treating physician may be asked to document clearly the nature of the condition and the treatment plan. This, of course, is what any physician is expected to do for any patient in any situation. When the patient's workplace is involved, however, the physician should realize that the case and the documentation may be scrutinized by other parties, and under a workers' compensation system, it definitely will be. The treating physician must become familiar with the law, regulations and forms that govern medical care in the jurisdiction where the work-related injury or illness occurred.

Patients are nearly always concerned about when or whether they will be able to return to some sort of employment, most particularly their current jobs. Therefore, diagnosis and treatment should focus on restoring functional abilities. Let the patient know that restoring function is a major goal of the treatment regimen and that you will be monitoring his or her progress very closely. Scheduling follow-up evaluations within two or three weeks, for example, demonstrates your interest in recovery to the patient, family and others.

Monitoring progress means measuring and documenting objective changes, such as range of motion, strength, endurance, ability to carry out activities of daily living, cognition and psychological behavior. Reports of pain and function should be documented and weighed in light of their correlation with objective anatomic and physiologic findings.

If, despite measurable improvement, an ill or injured employee expresses or shows anxiety about returning to work, it does no good for the physician to accede to the employee's request for "a couple more weeks of leave." A discussion with the employee about dealing directly with management on workplace issues or a referral to a mental health specialist may be in order.

Evidence-based guidelines

Some jurisdictions, such as California, Colorado, Washington and recently New York, have instituted evidence-based treatment guidelines that encourage close monitoring of progress in workers' compensation cases. Colorado and Washington developed their own guidelines, while California's and New York's are based partly upon treatment standards developed by the American College of Occupational and Environmental Medicine. In these jurisdictions, a decision to follow or ignore the guidelines may have implications for both the employee and the treating doctor. The guidelines' goal, like the physician's, is to help the employee return to functionality efficiently and effectively, so they should not be viewed as burdens, and they have value even outside of the workers' compensation arena.

Many employees work for companies that are required to implement the Family and Medical Leave Act, which provides unpaid, job-protected leave for personal medical conditions or close family members' medical conditions for up to 12 weeks a year. When a patient brings in an FMLA form to complete, the physician must keep in mind that the form is completed not for the employer's sake, but for the patient's. His or her job security might be on the line.

Employers who provide paid leave for ill or injured employees want to know that leave time is being used appropriately. To comply with these programs, the physician may need to complete forms on a deadline or send the medical records to a third-party medical reviewer, with the signed consent of the employee. Failing to provide the requested information may have economic consequences for the patient, from nonpayment of wages or salary to termination of employment. The employee is alerted to this by his or her employer, and the treating physician needs to keep it in mind.

In all three situations -- workers' compensation, FMLA and disability management -- physicians may be asked to provide an anticipated return-to-work date; they definitely will be asked to do so under workers' compensation. The standard FMLA form requires this information when the employee is requesting medical leave, as would a company's disability manager. All parties know that the date can be changed, if need be, due to comorbidities or other clinical reasons.

What is not helpful to anyone is setting a return-to-work date further in the future than the physician thinks will be needed, so that the employee will be "covered" under any circumstance. First, this gives the employee-patient the notion that he or she is expected to be on medical leave for a long time, the psychological effect of which might hamper recovery. Second, the practice frustrates employers, who might take administrative steps for a long-term absence, including beginning the job-termination process, only to find out later that the employee is able to return to work much sooner than thought possible.

Most physicians make an educated guess about expected length of medical leave, but there are databases that can assist: Two are the Medical Disability Advisor and the Official Disability Guidelines. Each has its own approach to deriving medical leave guidelines based upon ICD-9 code.

The latter guidelines, for example, are deemed "official" because the company that created them uses government data sources, but they are not official government guidelines.

When the physician advocates for an injured or ill employee's return to some functionality, including work, as soon as possible, relationships with the patient, the employer and other interested parties should occur quite naturally. Providing the employer with the employee's capabilities at any propitious point during recovery, so that the employer can determine if a temporary work accommodation is possible, is not forbidden under the Health Insurance Portability and Accountability Act or by any ethical considerations, as long as specific diagnostic and other clinical information are not part of the communication.

Two publications that address the physician's role in helping employees return to work are "The Personal Physician's Role in Helping Patients with Medical Conditions Stay at Work or Return to Work," a position paper by the ACOEM, and the American Medical Association's "The Physician's Guide to Return-to-Work."

A primary care physician treating an injured or ill employee, either within or outside a workers' compensation program, need not feel torn or burdened by having to satisfy the information requirements of interested parties other than the patient. Even if a physician shies away from dealing with workers' compensation cases because of the perceived burdens of paperwork and dealing with parties other than just the patient, helping a patient regain functionality, including return to employment and all of its benefits, requires that the physician be open to communicating with employers and others to bring about an effective and efficient return to work.

Alan L. Engelberg, MD, MPH, associate attending physician, Employee Health and Wellness Services, Memorial Sloan-Kettering Cancer Center, New York; 2010-11 Speaker of the House of Delegates, American College of Occupational and Environmental Medicine