Return to Work:

Why can’t we all be on the same team?

Kevin Bourke MD MRO CAME

2014 CAPA Conference

Ideal RTW Process

1.Got sick / injured.2.Off work for treatment &

recovery.3.Got all better.4.Got back to work.5.All within Presley-Reed

timeline!

Real World RTW• Not coordinated.• Attendings not exposed /

experienced.• Occurs by default / tradition

– E.g. - 42d off for Cesarean or tib-fib

• Default = laissez-faire.• Laissez-faire = longer off

work.• Longer off work = harder to

return.

RTW vs. Time off

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 4 8 12 16 20 24 28 32 36 40 44 48 52

Number of weeks

Approach:• “The RTW Space”

– Players/roles • “Company PA” vs. “Attending PA”

– Aim of RTW

• Concepts– Impairment vs. Disability– Employment Limitations– Tolerance

Approach (II):• RTW Challenges:

– Communication (Not!)– Guiding other roles– Silos

• Solutions / work-arounds– Teach ‘em!– FORMS! (Pitfalls and Pearls)

Roles:• Employee / worker• Attending clinician*• Employer

– Supervisor vs. corporate body• Third Party Insurer ?• You, the “Company PA”*

Employee / worker• Work = Good!

– $, stuff, esteem, self-worth– Positive benefits on health no

longer disputed– Another talk:

• Motivation, cultural issues (Sick Day banks, 42 days for hyst, etc.)

GP• “… to provide medical

treatment and guidance … to restore health; optimize social, psychological, and functional capabilities; and minimize the negative effects of injury.”1

1“Can you go back to work?” Can Fam Physician 2011;57:202-9

RTfW: Let’s Back up:• Why do people Return to (full) Work?

• Because they were “off sick” or restricted in their duties due to illness/injury.

• Received investigation / treatment for illness/injury

• GP/clinician identified the illness / injury / ”Sick” status...

• Illness / injury occurred.– 3 of these 4 involve the attending

physician(s)…… !!!!

Positions:

• Canadian Medical Association 2013 – “The Physician’s Role in Helping Patients Return to Work...”

• American Medical Assoc. 2004 – “Physician Guidelines for RTW”

• ACOEM 2008- “The Personal Physician’s Role in Helping Pts ... Stay at Work or Return to Work”

AMA Guide to RTW

• “The physician must communicate and support a reasonable (accurate??) clinical estimate of what the patient can do and can no longer do.”

• A Physician’s Guide to RTW – Talmage and Melhorn Eds. AMA Press 2005 …..Great read, and gift!

Clinicians‘ challenges:• Occ Med rare in curricula

– Dal / Irving establish Chair; before that?

• Work for their patient, not his/her boss– Goals broader, “the greater good”.

• GP ≠ disability decision-maker!– GPs often expand to fit role(s)... “can

do” attitude

Clinicians‘ challenges:• Haven’t been on the shop

floor!– Work described by patient:

• “gotta be 110% before I go back...”

• Work forms / liaison not “covered”.

• Goals broader, “the greater good”.

RTW Aim:• To safely resume previously

limited work duties, in a timely manner.

• WORK IS NOT DIGITAL,• HEALING IS NOT DIGITAL,• WHY SHOULD RTW BE ??

CONCEPTS• Impairment :

– loss of / loss of use of a body part, system, or function.

– Measureable / consistent

• Disability:– real-world impact of an

impairment.– varies between individuals

Employment Limitation(s)• Based upon IMPAIRMENT(s)• “Cannot do...” vs. “Should not

do...”• Shouldn't be a surprise to

employee• Means somebody is not paying attention

• Want clinician’s (neutral) assessment, not transcription of their pt’s opinion

• “Just the facts, Ma’am...”

Employment Limitation(s)

• KNOW THE JOB.– Establishes credibility– Reduces BS exposure

Know the job!

Employment Limitation(s)

• Detail specific task(s)– not the job, location, or boss– Suprvr gets to actually manage.

• Be inventive!– ANY return to workplace =

momentum

Example Limitation(s)

• “No lifting or push/pull over

25kg.”

• “Must be able to change

physical position (e.g.-

sit/stand) up to hourly.”

• No repetitive

bending/stooping.” • “Should not be employed in

supervisory role.”

Confidentiality

• EL’s are task-specific–Contain NO MEDICAL INFO

–Therefore not confidential.•Fit to file in HR.

TOLERANCE• Ability to continue

work/activity at a specific level.– Personal decision:

• Pros ($, other benefits)• Cons (shifts, commute, symptoms,

etc.)• Like EtOH, boredom thresholds...

highly variable

Getting the info you need:

• IMPAIRMENT(S)!– NOT placement / HR advice.– REALLY want to ask that fitness

question?– Can ask about Pt’s safety with

Dx/Tx

• YOU know JOB, attending knows Dx/Sx

• Yes/No questions = Yes/No answers

Modified work:

• No excuse in 2014 .... (maybe CEO)

• KNOW THE JOB / SHOP.– Be seen there by suprvr’s– Nurture RTW tasks

What are we (you) asking them?

• Yes/No questions get Yes/No answers....

• “Please indicate the nature of the illness....”???

• As a result of treatment, the patient/claimant’s condition has: □ Improved □ Deteriorated □ Remained the same □ Stabilized

Answers useful?

• Does GP understand what you want to know?

• Deduce their role from your questions?

SUM:• GP inherently involved in pt’s

“Sick Status”• Reporting and RTW

assessment added later• RTW / Occ Health not Med

School “required elements” • GPs work for their patient(s)

… “advocate”

Challenges:

• Yes, sometimes they won’t answer/rtn call.– MD<>MD can help.... got one? Hire

one?

• Delays in responding?– Explicit req fax... For right reasons,

and $delta

• Strays into HR/admin realm?– Thank 'em but re-ask the initial

question(s)

Challenges (cont’d):

• Teach old docs new tricks?– Maybe not… but clarify… hold

their feet to the fire, or get someone who can….

• Info seems incoherent with case– “quick look” by Occ Doc for

way fwd..?