by OMA Committee on Work and Health (Alice Dong, MD, Chair, Lisa Doupe, MD,
Michael Ross, MD, Edward Gardiner, MD, James Mendel)
Mental illness is widely acknowledged to be a leading cause of workplace absenteeism
and a major correlate of general work-related illness. In 2000, it is estimated
that depressive disorders ranked second among the most common reasons for visiting
a physician in Canada, after high blood pressure.1
Maintaining productivity at work and home is the main difficulty that a depressed person faces. The challenge facing the primary care physician is to sort through the many factors that underlie a person's illness, identify the patient's needs, and develop a treatment and return to work (RTW) plan accordingly.
The following article illustrates the complexity of mental illness as it impacts return to work. The article describes the most common factors that influence a timely RTW, and suggests how the busy primary care physician can effectively identify these factors. A cause-and-effect tool that can be used as a short-cut for this process is discussed.
Return to work issues are central to the mandate of the OMA Committee on Work and Health. As a primary objective for the coming year, the Committee will explore key barriers that physicians face in assessing and facilitating the RTW process, and will work to identify and develop best practice models to assist physicians in returning patients to work.
The importance of work
The relationship of work to personal identity, esteem and function is well understood
through research on the impact of job loss and unemployment. A new study on
the relationship between work and life issues supports this theme.2 The survey
of working Canadians found that high job stress is twice as prevalent now compared
to 10 years ago. Moreover, workers experiencing high work/life conflict were
found to have absenteeism rates three times that of workers with low work/life
conflict.
The cumulative economic impact of mental illness is enormous. In 1998, the economic burden in Canada was estimated to be $14 billion.3 This figure accounts for the cost of health-care services and lost productivity. Absenteeism resulting from work/life conflict costs Canadian firms an additional $3 billion a year. Such conflict also results in extra visits to the doctor, adding $425 million annually to the cost of health care, as well as increased hospital stays, medical tests, prescription drugs, and demands on other practitioners.4
Risk factors
Generally speaking, the longer a person is away from a job, the less likely
it is that he or she will ever return to a productive working life. Statistics
show that an individual has a 50 per cent probability of returning to work after
six months on disability leave, 20 per cent after one year, and only 10 per
cent after two years.
Therefore, a return to work plan is essential to maintaining patient employability. Not doing so may have a negative impact on a person's physical health, as well as social and economic circumstances.
Although the specific mechanics of RTW are variable, it is well known that early intervention is critical to improving the likelihood of a timely return to work. Further, a modified work strategy is one of the most important factors in improving RTW outcomes when a return to full duties is not possible.
While there is a large volume of research on barriers to RTW, it is difficult to isolate one or two factors. In many cases, there is a complicated interaction between an array of factors that will influence how and when a person returns to the worksite.
The interplay between different areas of life can serve to mask the underlying cause of illness, leading to inappropriate treatment strategies, a cycle of illness, and an ineffective return to work. In many cases, there is a dynamic relationship between these areas, such that a change in one area will influence another. As the effects reverberate throughout the system, a person's recovery and RTW is further limited. A person that returns to a job too soon following an episode of illness may be at risk for further absences, and a repeating cycle of illness. So, while RTW is desirable, it should not be premature.
The contributing factors that may affect RTW are described below:
Employee
The employee is at the centre of any RTW scenario. Response to job performance
issues, personal and family issues, and perceived or real workplace harassment
can all contribute to stress-related illness, and act as barriers to timely
RTW. After the onset of illness, inappropriate treatment strategies, poor compliance
with treatment, enriched compensation packages, and poor workplace management
of RTW can all act and interact to delay the return to work.
Employer
An increasing number of employers are recognizing the importance of maintaining
a healthy workplace, as evidenced by the prevalence of employee assistance programs
and occupational health and safety programs. There is, however, significant
variability in how employers manage employees returning after a period of mental
illness. The existence of meaningful modified work programs is critical. Job-matching
and access to extended psychological counselling are also important variables.
Insurance
The insurance system is closely related to employer functions, yet timely RTW
can be frustrated by a seeming inconsistency between employer and insurer policies.
Ineffective case management, complicated forms and processes, and restrictive
timelines can place undue pressure on employees and physicians in the management
of RTW. On the other hand, overly generous benefit packages can be a disincentive
for RTW.
Physician
The physician's role in the RTW process is fraught with potential conflict.
As the point of primary health care, physicians are sometimes perceived as a
barrier to timely intervention by other stakeholders, such as insurance companies
and employers. This view tends to underestimate the complexity of the physician-patient
relationship, the role of the physician as patient advocate, and the physician's
perception that cost factors drive insurance/ employer RTW agendas.
Assessing the sometimes tenuous relationship between work and mental illness can amplify all of these issues. Early and appropriate treatment is one of the most critical factors that will influence timely RTW.
Recommendations and decisions should not be made in silos, and there must be appropriate communication between all stakeholders to encourage RTW and function.
Societal
When patients become unproductive, they are at risk of becoming unemployable,
and thus unable to contribute to their family economy. The negative impact in
emotional, physical and economic terms weakens the social fabric of the country.
Cause-and-effect tool
To illustrate the interaction between these factors, a cause-and-effect model
is shown on page 38. This illustration is adapted from a model of quality control
used in hospitals and other complex organizations.
Cause-and-effect diagrams are prepared to illustrate the various causes impacting
a process. For every effect, there are likely to be several causal influences.
For example, in administrative areas, this may include policies, people and
procedures. To draw a business analogy, getting to the bottom of a problem sometimes
requires a critical path analysis in order to identify the parts of the system
that could be improved. A detailed cause-and-effect diagram will take on the
shape of fishbones, hence the alternate term "fishbone diagram."
Case study
The following case study is accompanied by the expanded diagram below, which
illustrates the multifaceted nature of the RTW process.
"Joe" presents with backaches and headaches, and wonders whether you could write him a note prescribing that he not work nightshifts. Joe is a 59-year-old security officer who has worked for company ZYX for 12 years, and has missed a lot of time from work in recent years due to back pain.
In talking to Joe, other important information comes to light. Two years ago, ZYX merged with another company, and the organization now requires all security employees to rotate three shifts. Joe also doesn't care for his new manager, who he describes as a young upstart. Joe's wife just started a new job working evenings at a call centre. The couple has a 10-year-old autistic child who requires considerable home care, and this has been a significant financial and emotional drain on the family.
You proceed with obtaining the appropriate diagnostic tests. As expected, Joe's headaches are due to tension and the back pain is mechanical. With active physiotherapy, and following the Agency for Health Care Policy and Research (AHCPR) guidelines, Joe should be able to perform the duties of a security officer according to the physical demands analysis/job description received from the employer.
You have called the occupational health physician and are made aware of the merger and resulting low staff morale. You also learn that the company has a supportive employee assistance program (EAP) with a broad range of services that Joe can access. You also were not aware that Joe had missed so much time from work. His application for insurance benefits was denied because he is not totally disabled.
Your next visit with Joe is very productive. You refer him for counselling to enable him to cope with the stresses at work. You also refer him for supervised active physiotherapy with a sports rehabilitation approach.
In a subsequent visit, Joe reports that he has been in contact with a "parents of autistic children" support group through EAP. He is hopeful of the home support services that may be available. You have been in contact with the occupational health physician who has co-ordinated a meeting with the employee and the manager, and has encouraged performance coaching and ongoing communication between Joe and his manager. As a result, the employee feels less anxious and his physical symptoms have improved.
Conclusion
The increasing costs associated with psychiatric disability claims will exert
pressure on plan managers to resolve claims. Health-care providers represent
a pressure point, one that will come under increasing attention from payers
wanting to mitigate the costs of disability claims. Ideally, a person will make
the transition from patient to employee in a process that respects the provision
of health care.
The ability of the physician to positively influence a patient's RTW is contingent on the minimization of barriers constructed in each of the silos. Organizational politics, a poorly developed human relations policy, aggressive management, and other factors will continue to form serious impediments to RTW, exclusive of any role or involvement that the physician might assert.
The physician is limited in the ability to resolve these fundamental conflicts. However, bearing a critical position in the RTW process, the physician can exert a positive or negative influence.
The physician's role is clearly set out in the OMA benchmark policy as that of "assessment of impairment." Beyond this, the physician must negotiate a delicate balance to ensure that RTW does not compromise health outcomes. Communication with the employer is appropriate to assist the patient in returning to appropriate work on a timely basis.
The OMA Committee on Work and Health hopes that the diagram illustrated in this article is a useful tool to help in management of RTW.
The Committee welcomes feedback from general and family practitioners on what additional tools, information and education would be useful in the managing the RTW process.
Finally, returning to the Committee's mandate, the central theme is to promote the physician's role in optimal RTW strategies. This theme will be carried through during all future meetings with insurance carriers, employers and other stakeholders.
References
OMA Involvement in Work and Health Issues
The OMA is a leading voice on the physician's role in RTW issues. In 1994, the OMA produced a landmark position paper entitled Timely Return to Work Programs and the Role of the Primary Care Physician. Since then, the OMA position has been recognized by other organizations, such as the Canadian Medical Association and American Medical Association. These concepts have also been integrated into models of primary care reform. The OMA also initiated the development of the Physicians Education Project on Workplace Health (PEPWH), culminating in the publication of the Physician's Guide to Injury/Illness and Return to Work/Function, released in 2000. The guide is a collaborative effort between the OMA and various other stakeholder groups. Throughout this period, the OMA Committee on Work and Health has contributed to the development of these resources.
The OMA position paper sets out a timely return to work model of disability management, with the following key elements: