EXECUTIVE SUMMARY

Employers are dissatisfied with the existing model in which physician certification supports in "all or none" approach to work and absenteeism due to sickness or injury. This model of physician certified absenteeism is based on the following understandings:

1.    The patient stops work when he/she feels illness/injury justifies absence.
2.    The physician certifies illness/injury and decides when the patient is fit to return to work.
3.    The patient returns to the same job, but only when fully recovered as determined by the physician.
4.    Management plays no direct role in return to work, but attempts to control abuse by demanding medical certification.
5.    Disability insurance tends to support this system by not providing benefits for partial disability.

As more employees access sick leave and stay off longer, employers, employees, and physicians seem ready to accept that disability management by way of "medical certification is not working.

The Ontario Medical Association recommends the introduction of timely return to work programs and a coordinated move away from the "full recovery" model of disability management.

THE TIMELY RETURN TO WORK MODEL OF DISABILITY MANAGEMENT

The OMA feels the new program should include the following understandings"

1.    When the patient is off work due to sickness or injury, he/she would bring an employer's proposed return to work program to his/her physician.
2.    Physician provides objective reports on impairment, medical restrictions, and other supporting advice to the employee.
3.    Employer offers the employee a plan for returning to suitable work in a timely fashion.
4.    Employee and management have a primary responsibility to initiate a timely return to work which incorporates input from the physician.
5.    Management control of "sick leave" abuse is through work place "culture"" and timely return to work programs, not medical certification.

The timely return to work model of disability management seeks a shift away from control of abuse by a passive reliance on physician certification to a proactive model where employee and employer work together and use objective medical input from the employee's personal physician. The OMA will outline in some detail the value that an occupational health service and Occupational Medicine can add to timely return to work programs in the near future.
 

Appendix

The purpose of this paper is to suggest that many of the current friction's experienced by physicians, employers and employees around the management of short-term disabilities might best be addressed by a fundamental change in their respective relationships, expectations and responsibilities.

This issue seems to break into two perspectives. One is the employer's overall efforts to manage,i.e reduce, employee absenteeism (frequency x duration) from the workplace for health reasons. This is the employer-employee relationship. The second arena is the physician's efforts to manage the effective medical treatment and medical rehabilitation of the patient's condition. This is the doctor patient relationship (DPR).

Employer Perspective
Currently, employers appear to see their relationship with a sick and injured employee and their personal physician in terms outlined in Figure1.

Figure 1

From the employer's perspective the doctor/relationship (DPR) is a black box which has some very negative features to it in terms of the employer's ability to control or reduce the costs of short-term disability to the firm. These features are as follows:

1.    Physicians appear reluctant to recommend that workers return to work as soon as they are able and seem not to support well-designed modified work programs.

2.    The privacy of the doctor-patient relationship and the patient's control of the doctor's information about the workplace allows some patients to abuse the system.

3.    Physicians are too ready to uncritically accept the patient's opinion on their fitness to return to work.

4.    The employer has no way of verifying that treatment and the most effective rehabilitation plan is being pursued to minimize the time the patient spends away from work.

5.    The employer has no way to ensure that the physician's opinion that the patient cannot work is objective, knowledgeable, accurate, and well-founded.
 

The Physician's Perspective

From the personal physician's point of view, employer disability management efforts seem to place the physician in between two competing and opposing forces. This is illustrated in Figure 2.

Figure 2.

In the context of the right side of this equation, the physician's relationship with the patient and the patient's goals for treatment and rehabilitation usually dictate what gets done. Release of information about what is going on in the doctor-patient relationship and the patient's diagnosis is regulated by the patient's consent backed up by regulations enforced by the College of Physicians and Surgeons.

Direct approaches from the employer to the physician for information and an opinion on the patient's ability to return to work may or may not be consistent with the health goals or expectations set by the patient in the dcotor-patient encounter. When the doctor cooperates with a direct approach from an employer for information or opinions, this always puts the doctor at greater risk of appearing disloyal to the patient, of breaching the doctor trust relationship, and losing the patient from the practice.

The OMA is increasingly aware of the social value placed on patient autonomy and full patient partnership in medical decision-making. The days when physicians can assume that every patient wants the doctor to make medical decisions for them is long past and currently doctors have to assess with each patient the degree of decision-making the patient wishes to assume in the management of their illness or injury. This degree of decision-making can of course vary over time and with the severity of the illness.

There is also a strong push from society to hold individuals more accountable for their personal decisions and lifestyle as they relate to the development of illness.  There is increasing recognition that ultimately we have to rely on individual decision-making to reduce the demands for acute care treatment services, e.g. through smoking cessation, improved diet and cardiovascular fitness, and safer sexual behaviour.

In the current social climate, therefore, it makes increasing sense to suggest that the management of illness-related absenteeism and disabilities within the workplace really should fall primarily to the employer and the employee. If this locus of responsibility were well established, the physician then becomes a resource to the employee who brings his/her goal of rapid re-employment into the doctor-patient relationship. This is expected and agreed to as part of the contract of employment. At the same time, the employer is aggressive in providing modified return-to-work opportunities. Where this isn't possible, such as in very small businesses, the employer-employee relationship focuses on the potential for full recovery and return to original occupation as efficiently and effectively as possible.

The employer and employee are also responsible for pursuing other specialized assessments relating the diagnosis to the means of the workplace and for workplace specific rehabilitation, et cetera. I do not know how this should be coordinated with the medical rehabilitation program by the family physician.

The figure that would describe this relationship is as follows:
Figure 3.

In this context the employer and patient are primarily responsible for managing the patient's safe and rapid return to work. The patient is assumed competent and has primary responsibility to be informed enough about their condition (by taking to their doctor) to be able to bring this information to bear on the modified work opportunities available from the employer. The employer and patient accept and understand the philosophy of "partial disability" and rapid return to work through rehabilitation and recovery as well as the role of modified work opportunities in achieving this goal.

The patient is 100 percent responsible for taking this philosophy on partial disability and return to work into the doctor-patient relationship and presenting it to the doctor as the patient's agenda. The patient's responsibility is to ask the doctor for the information and understanding of their condition that they require to safely re-enter the workplace. The doctor's responsibility is medical diagnosis and treatment, medical rehabilitation and the provision of medical information. The employer is responsible for providing modified work options for the patient to choose from. Where these options are not possible, as in very small business environments, the employer and patient together focus on rapid recovery and rapid return to their original position. It is the patient's responsibility to keep the employer informed about all aspects of the their rehabilitation process. This will require enhanced dialogue with their physician but that is to be encouraged anyway.

The role of the physician, then, is to actively help the patient in accomplishing the patient's  goals of rapid recovery and rapid return to work and to respond to the patient's needs for information and understanding of their condition. The patient is helped into the position of being able to manage their workplace- re-entry in a graduated and safe manner.

The OMA might well consider creating a booklet for employees along the lines of what you need to know about your condition to manage your own re-entry in a graduated and safe manner.

There is no question that some patients will make this approach more difficult than others (ESL), but these can be treated as exceptions to the rule and modifications of the fundamental approach described above introduced accordingly.

Part of the difficulty in answering Mercer's question about a form for the transmission of medical information between doctor and employer is that it doesn't recognize questions about the fundamental relationships between the parties involved. Once these relationships are put properly into place, perhaps as described above, it seems to me we will have advanced our ability to determine the information that the physician should be asked to provide.

My conclusion is that the family physician should provide information to the patient/employee and that the patient/employee is primarily responsible for negotiating re-entry with the employer. In this context there may not be the possibility of a standard form because the information the employee needs to manage their own re-entry will be a function of each employee, their diagnosis, and each workplace. Until we make the current allocation of responsibilities more visible and how they might be reorganized, I am not sure we can make as much progress as we would like on the issue of information required from the family physician.

John Krauser
Ontario Medical Association
January 7,1994

* The World Health Organization definition of "impairment" is "any loss or abnormality of psychological, physiological, or anatomical structure or function".

This report was prepared for the Ontario Medical Association's Medical Care and Practice Committee by a three member Subcommittee Dr.Michael Devlin (chair), Dr. Pat O'Neill and Dr.R.MacBride. Ontario Medical Association staff support came from Mr. J. Krauser, Associate Director of Health Policy, Mrs. Tess George, Senior Secretary and Mrs. Susan Gardhouse, Senior Secretary.

The Subcommittee circulated earlier drafts and received useful suggestions that have been incorporated sometimes verbatim into text.

At some stage the following may, or may not, formally support this report, but their individual input hs been valuable and should be recognized:

                        Dr. Lisa Doupe,Chair of the OMA Section on Occupational & Environmental Medicine
                        Mr. David West, Associate - William Mercer Ltd.
                        Ms. Karen Guillemette, Associate - William Mercer Ltd.
                        Dr. Douglas Morrison, Consultant in Occupational Health
                        Dr. John Ludwig, Chair of OMA Section on General & Family Practice
                        Dr. Michel Lacerte, Director, Disability Evaluation Program, Parkwood Hospital
                        Dr. Daniel Fleming, Vice President & Chief Medical Officer of North America Life Assurance Co.
                        Mr. Vici Mummery, Clinic Coordinator of London & District Workers Health Clinic
                        Dr. Michael Wills, Occupational Health Clinics for Ontario Workers Inc.
                        Ms Anne Duffy, Consultant - Care givers of Ontario Safety & Health Association
                        Dr. Barry Malcolm, OMA Section on Orthopaedic Surgery
                        Dr. John Patcai, Past-Chair of OMA Section on Physical Medicine & Rehabilitation
                        Mr. Jim Pare, Director of Organization Services, Ontario Federation of Labour
                        Mr. Andrew King, Ontario Federation of Labour
                        Ms. Judith Andrew, Director of Provincial Policy, Canadian Federation of Independent Business
                        Mr. Sean Ford, Manager, Special Services, Office of Employer Advisor, Ministry of Labour
                        Ms. Elizabeth Braun, Freedom of Information Coordinator - Workers' Compensation Board

Valuable comments on subsequent drafts of this report were received from:
Dr. Lily Cheung, Dr. P. Conlon, Dr. Richard Johnston from the OMA Sections on Occupational and Environmental Medicine, Psychiatry, and Obstetrics and Gynaecology respectively; Dr. R. Kosnik and Dr. David Dunham.