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The role and obstacles faced by family GP's assisting patients to return to work

At a glance:
Primary care providers, such as family practitioners and GPs play an important role in determining whether a sick or injured employee is able to work, and how quickly return to work is possible. This study identified typical approaches doctors take, the barriers they face in achieving this goal, and some suggestions on how work disability
disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 might be better managed.
Perspectives:
Employee
Treating practitioners focus on you as their patient and many start from the position of advocating for you.

Treating doctors often find it difficult to overcome workplace barriers to return to work. Therefore, you should encourage your treating practitioner
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
 to communicate with your employer. It can be an advantage for your treating doctor to visit the workplace, as this can establish relationships between the doctor and the return to work coordinator, and can improve outcomes.

When all parties are working together you are more likely to achieve a successful return to work outcome.
Employer
In this study most treating practitioners asked their patient for information on modified duties. The patient is not always in a position to know the answer to this question. Return to work can be supported by letting the treating doctor know about available alternative duties and the workplaces approach to modifying work tasks.

A simple fax or e-mail to the doctor identifying available duties can make a significant difference. Some companies support a short description of the duties with a series of photos or a video which helps the treating doctor understand the available tasks.

Workplace disharmony was cited as a frequent issue by treating practitioners. Advise the doctor about your workplace's approach to supporting an individual returning to work. Be a positive employer and support return to work, and the treating doctor is more likely to work positively with you in response.
Treater
Internationally, treating practitioners are asked to act as gatekeepers to the return to work system. There is no scientific method for assessing a person's ability to work, although medical factors and understanding the medical condition is important. Return to work is heavily influenced by other issues and the doctors in this survey identified a number of factors such as workplace disharmony and job satisfaction as influencing the situation.

Treating practitioners feel a substantial part of their work involves advocating for the patient, and relying on their statements. This is an appropriate role for treating practitioners. However, difficulties arise when short term needs take precedence over longer term outcomes. A number of studies indicate that people's health is worse when they remain off work in the long-term. It is important that the treating practitioner lets the patient know about the importance of return to work. It is important the patient understands the long-term implications of remaining off work. This includes dealing with the system, poorer emotional health, and often negative financial consequences.
Insurer
Assessing an individual's capacity to return to work is not a black and white issue. It depends primarily upon the physical condition. However, patient distress, workplace issues, availability of modified duties and the natural history of the condition can all influence a treating practitioner's approach to identifying a person's readiness to return to work.

Encourage employers to work positively with the employee, and treating doctors to focus on the medical condition, rather than being influenced by the person's attitude to the workplace. Encourage employers to provide simple but clear lists of available modified duties, so the practitioner is aware of what suitable tasks are available.
Original Article, Authors & Publication Details:
Pransky G, Katz JN, Benjamin K, Himmelstein J.

Improving the physician role in evaluating work ability and managing disability: a survey of primary care practitioners. Disability & Rehabilitation 2002;24(16):867 - 874.
Background, Study Objectives, How It Was Done:
Most treating practitioners do not have specific training in work disability or occupational medicine. Nonetheless, they frequently evaluate how a person's illness or injury might affect their work. They are called on to recommend how much time off work is needed, to refer patients to rehabilitation
rehabilitation
The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition.
 programs, and to verify information to insurance agencies, employers, and worker's compensation bodies.

The doctor has an essential role in helping employees to return to work after an injury or illness and to continue working safely and productively. A recent study has found that some patients are unsatisfied with their doctor's performance in this area. This study aimed to identify what factors make the process successful or unsuccessful, and how it might be improved.

A questionnaire was developed by 24 primary care providers and sent to 423 family practitioners, general practitioners and doctors of internal medicine in Massachusetts. The questionnaire asked the doctors to explain how they established a patient's ability to work, how they perceived their role in managing work disability, their typical approach to treating patients with a work disability, barriers to helping patients return to work, and how they thought management of work disability could be improved.
Study Findings:
182 doctors replied to the survey.

The survey found that:

66% of doctors' patients were employed
Doctors were asked to give information about patient's ability to work in about 10% of consultations
Of this 10%, about half of the patients had a work-related injury or illness
Only 32% of doctors had received training in treating work disability

Determining a patient's ability to work:

Doctors were given different strategies or sources of information that they would use to determine whether a patient was able to work or not, and asked to give these a rating of 1 (unimportant) to 5 (very important).

Clinical observations, past experiences with the patient, objective test results, and the patient's description of their work were all rated highly (an average rating of greater than 4).
Doctors placed approximately equal importance on input from the employer and the patient's requests and expectations (an average rating of around 3.5).
The patient's level of job stress was also seen as quite important (average rating of approximately 3.5), but if the patient needed time off to qualify for benefits, this was not seen as an important factor in the doctor's decision (average rating of approximately 2.5).

Doctors were asked how they would discover alternative tasks available at work when a patient's illness or injury made them unable to do their usual duty.

70% responded that they would ask the patient
15% responded that they would contact the patient's employer

How doctor's perceived their role in treating work disability:

Almost all doctors agreed that they should be involved in decisions about patients' ability to work.
Most saw their main role as to support the patient and advocate their interests rather than those of the employer.
56% stated that they would always support the patient's requests, whereas only 6% saw themselves as supporting the interests of the employer or insurer.
24% did not think they could influence a patient's beliefs about whether they had a disability or not

Doctors' typical approach to treating work disability:

78% appreciated the importance of an early return to work, and only 5.5% said they would give a patient time off work if the request was unreasonable.
18% did not feel they had any real incentive to get patients back to work quickly
In passing on information about a patient's ability to work, 65% of doctors said they would recommend “light duties' or say the patient was unable to work. Only 34% would give more specific details.

Barriers to helping patients return to work:

Lack of light duties available at work (identified as a problem by 73% of doctors)
Conflict between the patient and their employer (57%)
Job dissatisfaction (55%)
Excessive requests for time off by the patient (64%)
Economic incentives to stay away from work (58%)
Psychological problems, including physical symptoms caused by psychological
psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
 distress
distress
Severe suffering, pain, anxiety or sorrow
 (64%)
Lack of clear guidelines for the doctor about when to return a patient to work (58%)
Unable to objectively measure whether a patient is ready to return to work (53%)

Few doctors were concerned about their own liability or about being reimbursed for time spent communicating with employers and providing other services.

Doctors were sometimes under pressure from patients and employers to quicken the return to work process.

Opportunities to improve the management of work disability:

Education for patients, employers and doctors
Clear guidelines for doctors about when patients can return to work
Incentives for employers to offer alternative tasks for returning employees
Better communication between doctors and employers
Access to case-management services
Conclusions:
Primary care providers play a crucial role in managing work disability. The majority of doctors recognise the importance of returning patients to work as quickly as possible. This study identified several problems in the way many doctors approach this issue, the barriers they face in helping patients return to work.

Improved communication between employers and doctors is required, as is more education for employers, employees and doctors. Doctors require more specific guidelines for when patients can safely return to work, and they require more details from employers about what tasks can be assigned to the returning worker.
References:
PubMed Abstract
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