1.  Introduction 2.  Scope of this OMA Policy Statement 3.  Employer and the Role of the Family Physician 4.  Large Disability Insurers and the Role of the Family Physician 5.  Patient Advocacy 6.  The Evolving Science of Evaluating Occupational Handicap (WHO) 7.  The Doctor-Patient Relationship and The Employer-Employee Relationship 8.  Recent Ontario Developments around Timely Return to Work 9.  OMA Recommendations for Timely Re-Employment Programs In summary Appendix Employer Perspective The Physician's Perspective Acknowledgements EXECUTIVE SUMMARY

    Over the last five years, the OMA Committee on Medical Care and Practice has become increasingly aware of employers' concerns at the rising cost of employee absenteeism due to illness and injury (Andrew 1992,1989). These concerns span both occupational and non-occupational conditions and are not only dissatisfaction with WCB operations and the rising cost of WCB assessments.

    No doubt the impact of absenteeism due to sickness with its accompanying loss of control and predictability on the production line, and human resource replacement  costs, stands out more in today's more competitive and sluggish business environment. Economic reality has finally forced a realization on most citizens that all benefit programs, whether directly or indirectly tax supported, must avoid abuse or mismanagement if a healthy economic/business/employment climate is to be sustained.

    When employers talk to the OMA about medical absenteeism, their frustration seems to be related to their perception that doctors lack interest in their attendance problems. They believe that the medical community functions mainly as patient advocates. In addition the medical community does not directly share any of the costs of medical absenteeism, they believe doctors have too little incentive to encourage and help employees minimize the length of their absence. These two beliefs lead employers to a feeling of disappointment with the medical community. These beliefs minimize employers' responsibility for some of the workplace culture and other social realities that drive this problem. Nevertheless, the OMA recognizes that employers are raising appeals for help. These appeals are a constructive force for improvement.

    However, this positive climate is threatened by employer experience with some physicians who are giving employees irresponsibly generous access to paid time off on disability without medical necessity or accountability. While the global dissatisfaction amongst employers includes questioning how occupational disability is being evaluated, even in employees with good work affiliation, employers are really angry when they see employees easily obtaining medical restrictions when they are clearly not well founded.

    The primary purpose of this paper is to make it clear that medicine is open for dialogue with employers and employees. We recommend that future initiatives to reduce absenteeism due to injury or illness be based on data and data analysis regarding the pattern and courses of such absenteeism over and above the clinical diagnosis.

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    Also, prolonged absence from work until the patient is fully recovered is inefficient. It should be remembered that such behaviour can be driven by policies requiring injured or ill workers who may be, or feel, unable to perform all of their duties to continue to demonstrate disability in order to preserve their economic supports. Policies end up reinforcing what employee/ patients cannot do rather than what they can do. The rest of this discussion addresses timely return to work programs for the majority of sick or injured employees with neutral to positive feelings toward their workplace.

    This paper focuses primarily on the treatment and rehabilitation role of the family physician in the context of the employer/employee relationship. The general principles it describes we feel applies to all physicians, but there are different medical roles in practice. Trained occupational physicians with a knowledge of the workplace and occupational medicine are an important resource tap for rehabilitation, modified work and early return to work programs. Disability insurers are also an extremely important part of the larger picture, and the family physician may have a slightly different role in  conjunction with the insurance adjudication process. Insurers for example have strong views on their unique need for full diagnostic information from the family physician. Timely return to work programs will not have a need for the same medical information. Apart from this issue of confidentiality, it is clear however that some evolution in our clinical role may be required to help integrate rehabilitation, claims adjudication by insurers, and timely return to work programs.

    It is an evolving issue in Ontario as to who takes the lead at a system level in designing innovative return to work strategies, e.g,. insurers, employers, or other senior bodies. The various models that will be useful in the workplace will no doubt vary according to the sector specific pattern of absenteeism due to illness, the size of the corporation, the regional resources, and whether the work force is unionized. The majority of workers are not employed by large employers nor are they unionized. For example, 0.5% of Ontario firms have more than 500 employees while 90% have fewer than 20 and 70% fewer than 5. Workplace with fewer than five employees may not have modified work available and some unique approaches to helping them are required. Unionization rates range from 1.5% in finance to 68% in government (Ontario Ministry of Labour,1993). This paper articulates some general principals and medical values while recognizing the need for a very flexible approach to their implementation according to need and local conditions.

    This paper will not include much information from sector specific studies of occupational epidemiology, e.g the changing trends in time off due to back strain, nor will it describe the changing technology of medicine and its contribution to reducing recovery times. For example, there is increased flexibility in the time required for post-operative recovery with the introduction of major laparoscopic procedures. In addition, we need to look into potential or real bottlenecks in accessing specialized medical resources and any contribution this makes to delaying the timely return to work. These are important environmental conditions, but beyond the scope of OMA work at this point.

    This paper highlights 1) the role of the family physician in helping employers and employees achieve return to work objectives; 2) the value of work in rehabilitation and treatment; 3) early return to work as an intervention to encourage long-term retention of the valued employee in the workforce.

    While the paper also notes the unique contribution of occupational medicine as the medical speciality in the field of workplace health issues, clearly, a wide variety of medical and surgical specialities provide all levels of medical care to employees. They too will have a relationship to the return to work program in the workplace. The following incomplete list is only for illustrative purposes, but we are talking here about physical medicine and rehabilitation, addiction medicine, psychiatry, orthopaedic surgery and other surgical specialities, respiratory medicine, etc. The OMA can develop descriptive material for employers and employees on how each speciality may help their patients realize the benefits of timely return to work.

    This paper will not raise the issue of physician remuneration; it is important first to clarify and describe the medical contribution of the personal  attending physician. But, having done this to everyone's satisfaction, the next step is to ensure the financial incentives and disincentives on physicians are consistent with their performing this role. For example,  there is good family physician support for individualized written rehabilitation plans. They make an effective contribution to the return to work process. These plans take physician time to develop and fill out, and will require attention to issues of appropriate remuneration.

    What is new in the environment is the movement to modify the work and the workplace so it can safely accommodate an earlier re-entry of the still healing employee. What is also new is renewed medical determination to encourage patient return to active life so as to avoid reinforcing social withdrawal and disability. These goals require changes in the clinic and the workplace and a new interpretation of the physician's role as an advocate for his/her patient.

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    The tradition of asking the patient's family physician whether the patient can return to work is a major source of dissatisfaction experienced by employers and employees. The patient usually returns to work when the family physician determines there has been a full medical recovery but this determination is not precise as chronic pain and soft tissue injuries make clear. Disability programs of many types still make return to work the key question for income replacement benefits. Normally, most physicians rely on their patient for information about the conditions in the workplace and the patient's self evaluation of his/her capacity to do the original job. In addition, while the employee may be completely accurate in the information provided, the physician who knows nothing more about the work site may only feel safe recommending a return to work when the employee is fully recovered and able to resume his/her original duties. This approach is reasonable given the physician's lack of assurance that the workplace will safely accommodate a recovering worker any earlier.  It may also reflect how the vast majority of physicians approach medical rehabilitation and treatment.  Where an occupational health physician is affiliated with the patient's employer, it is normally possible with the patient's written agreement to discuss the medical/rehabilitation needs of the patient directly and discover the precise ability of the workplace to offer modified work opportunities.

    There is a particular concern to ensure that rapid return to work programs do not inadvertently allow exposure of the injured worker to the same tasks that caused the illness or injury in the first place. As we change the gatekeeper/adjudicator role of the patient's family physician, we do want to preserve the physician's responsibility to address secondary prevention issues.  If this is our intent, what is a reasonable re-statement of the family physician's responsibility and contribution to prevent re-injury. Depending on the patient's history, the precise workplace cause of, or contribution to, the patient's problem may or may not be obvious to the family physician in the office. In the case of illness rather than traumatic injury, the causal connection to the work site is most often a matter of profitability.  The issue of work relatedness in the case of disease is a complex issue and requires the expertise of occupational medical specialists. The OMA feels the family physician can help the employee explore the workplace as a potential contributor and in those situations where it is indicated, encourage the employer and the employee to explore job modifications with medical help.

    Current concepts now place great value on the therapeutic importance of the patient being as active as possible, as early as possible, in the course of the illness/injury. Physicians are now encouraged to help patients focus on their capabilities and to keep active; timely re-employment programs discussed in this paper would provide a safe opportunity to do this in the workplace let alone at home. In summary, the physicians' concern about the safety of the workplace during medical rehabilitation has been a factor in driving up the cost of disability to employers by causing physicians to include a significant margin of time off in favour of the employees' recovery.

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    In the late 1980's, the OMA was not as aware of the employer's perspective as it is today. At that time, we were addressing complaints, literally from all parties, with the way family physicians were asked to certify disability under the General Welfare Assistance Act and the Family Benefits Act.

    We found the discussions going on at this time to be hopelessly confused because of the lack of a common conceptual framework and well understood terminology. As a result, we recommended these two disability adjudication processes be structured using the WHO definitions of "impairment:, "disability" and "handicap" (WHO,1980). In the WHO terminology, "impairment" refers to the patient's physical or psychological limitations; "disability" links the impairments) to activities of daily living, and "handicap" links impairment(s) to the patient's ability to perform tasks. Since 1988, the OMA's policy is that the family physician should provide an accurate and objective assessment of impairment while the return to work and/or claims adjudication process should connect this medical information to the demands of the workplace and/or benefit criteria. This is the reason we say family physicians should not be asked by insurance adjudicators whether or not the patient can in fact  return to work. There are several reasons for this OMA position:

1.    The physician may not know the human work culture, or the job, and does not do vocational rehabilitation.

2.    The physician may not be aware of the possibilities in work strengthening or ergonomic support and analysis.

3.    Medical restrictions do not correlate well with the ability to work.

4.    There is a major psychosocial component to the ability to work including the employee's work affiliation that is not         objectively accessible to the physician.

5.    Many diseases causing absence exhibit few if any confirmatory, objective diagnostic signs, e.g headache (Coe, 1975).

    We feel family physicians should have a choice in whether or not they answer questions on insurance company claim forms on the patent's ability to return to work. Answers to such questions should be based on the physician having all the required expertise, and information. The company claims adjudicator is responsible for the decision that the insured is, or is not, entitled to contractual benefits.

    However, the clinical role of the patient's personal family physician is still patient centred and remains:

1.    to activate medical treatment, medical restrictions, and rehabilitation

2.    to co-operate with the patient's efforts to obtain third party benefits by providing timely objective information as requested

3.    to accept overall responsibility for the patient's medical care

4.    to request and help co-ordinate appropriate auxiliary treatment and rehabilitation services

5.    to advocate for the patient in ways described in this paper

6.    to protect the patient's medical confidentiality

    The physician's social responsibility is to help insurers and  employers determine what clinical information about the patient is really necessary and where unnecessary breeches of patient confidentiality begins. Concerns in this regard can frequently be minimized, with the patient's agreement, through direct clinical discussion with an occupational physician and/or with the physician or health care worker acting on behalf of the insurance company, e.g. a case co-ordinator.

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    We have heard concerns from some physicians about our equating the role of the primary care physician with the provision of impairment information. They point out that the role leaves out a great deal of the patient advocacy work done routinely by family physicians. In addition, the No Fault Automobile Insurance Secretariat have also expressed the expectation that the family physician will help provide some balance to adjudication decisions by serving as a strong patient advocate during claims processing. Patients recovering from illness and/or injury who can do modified work may find their employer unable to provide remunerative employment and in some jeopardizing continued coverage because of this residual capability. Family physicians asked whether their patient can work find themselves directly linked to the possibility that their patient will be without work and without  disability benefits from an insurer. There has been a drift in the patient advocacy mission of physicians beyond advocacy on medical matters to include being legal, vocational, and/or social advocates where their expertise and resources are less than adequate.  The OMA feels the way to correct the patient's  vulnerability in return to work and disability adjudication is not to distort the role of the physician but through the design of balanced adjudication and rehabilitation decision making that is fair to both employers and employees. In this context, the patient counseling, psychosocial support, and in these ways appropriately fulfill his/her responsibilities to the patient as a medical advocate (Morrison, 1993).

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    Since 1988, the immediate priorities around us have expanded beyond adjudication of income replacement benefits under welfare, to the quite different context of the role of the physician in employee sick-leave and absenteeism from a particular job. We felt initially that the provision of impairment information by the family physician also applied in the occupational setting and consequently, we have discouraged employers, the WCB, and Ministry of Labour (Office of Employer Advisor) from perpetuating the practice of relying exclusively on the employee's personal physician to say when the employee can return to work. This practice is a holdover from a social environment where the only adjudication available was through the family physician's assessment (Stone, 1984).

    We recommended greater recognition that the patient/employee makes a significant (but still unacknowledged) contribution to when he/she can return to work, over and above the flexibility of the workplace and the work culture environment. In addition, in recent years there has been a major explosion in the services and practices to determine what work an employee can do. A recent state of the art review (LaCerte, Wright 1992) describes in detail these separate evaluations: Medical, Work Capacity, Ergonomics, Vocational Rehabilitation and Psychosocial. It then goes on to describe the analysis and planning process based on these evaluations and distinct goals around rehabilitation interventions and official resolution, including ongoing medical monitoring. The parties involved are a care coordinator, the rehabilitation team, the worker, employer and physician. The WCB return to work program also mentions co-workers, the occupational health service, claims adjudicator, Disability Management Specialist, Nurse Specialists, Ergonomic Specialist and the Vocational Rehabilitation Care Worker.

    Coming back to our initial thought, that the role of the family physician in this process is to provide objective impairment information, all of the above quickly made it clear that providing employers and employees with a report on the patient's impairment would not be sufficient to meet the health and safety needs of patients prepared to go back to work in a timely manner or to help reverse the disability cost trends of concern to employers. For example, there is a need to reinforce for physicians the concept that maximum medical rehabilitation in many chronic pain and soft tissue problems lies in functional restoration to maximize the patient's ability to deal with their problem. The rest of this paper attempts to address what else is required.

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    Our first analysis of what more needs to be done is attached for convenient reference (Appendix I). This diagnoses of what has become dysfunctional about the family physician's traditional role as adjudicator of paid sick leave has received support and encouragement when shared with family physicians, interested organizations, insurers, and employers.

    In brief, we recommend shifting the employer's focus from the employer/physician relationship to the employers relationship with the employee to set out his/her health goals with their personal physician. In effect, we feel that the primary responsibility for creating the opportunities within which disabled employees can return to the workplace before full medical rehabilitation, rests mainly within the employer-employee relationship, the workplace culture, well designed re-employment supports at work, and most importantly, employee understanding, support and cooperation.  The cost of disability will fall when the employee brings a timely return to work agenda into the doctor-patient relationship. Policy support from insurers, WCB, and employers is required to encourage the employee in this behaviour. The doctor provides the employee with prompt treatment, an active approach to rehabilitation incorporating "current concepts", medical restrictions that are as firmly grounded as possible and proactive support for the employee's disease-specific capabilities. This kind of program infrastructure contrasts sharply with the traditional approach where the family physician looks for a full recovery before advising the employee to return to work.

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    Over the last few years, the WCB and the Office of Employer Advisor (OEA) in the Ministry of Labour have independently come up with their own diagnosis of what is going wrong. Their perspective focuses on how the work culture must change if employers are effectively going to manage and control their disability costs. In brief, the new role of the family physician as supportive to, and an advocate of, the employer/employee relationship fits into the changes now being recommended in the workplace by the above bodies. All of this has come together in what are known as co-operative, early or rapid return to work programs. Manuals describing these return to work programs have been, and are being, developed to train employers, unions and employees in this approach. The OHA also published a manual in 1991 and program manuals are about to be launched by the  WCB and the Office of the Employer Advisor (OEA). Both the Board and the OEA have asked for OMA endorsement of there respective programs. The goal of the WCB's Co-operative Return to Work Program is "to return an injured worker to essential duties of his/her pre-accident job within a maximum of 45 days post-accident". The OEA states its Rapid Re-employment Program provides a process that allows (the employer) and

    "...workers to collaborate in returning every injured worker to full employment." The OHA's Modified Work Programming for Health Care Providers "... is a means of gradually integrating recovering worker in the workforce so that both the worker and employer benefit".

    The purpose of OMA support is fourfold; (1) an expression of understanding by physicians and a willingness to co-operate with employees anxious to have information from their personal physician that will allow them to return to a safe workplace in a timely fashion; (2) to ensure medical confidentiality and therapeutic integrity of the doctor-patient relationship; (3) to acknowledge that family physicians can work well in the role assigned to them by these programs, and (4) OMA support for the philosophy of timely return to work so as to encourage the active acceptance and implementation of these programs in the workplace.

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    Where have we been?

    Traditionally in North America, physicians have the role of adjudicating the medical necessity of initial employee absenteeism.  Once off work, the physician protects the patient from re-injury or from aggravating his/her condition by timing the patient's return to work. Physicians also define for the patient the level of inactivity required by the recovery process. Given the total medicalization of the duration of disability, the corporate culture has not needed much infrastructure to carry out its very limited responsibility and involvement in this decision-making. This corporate position has been paralleled by a similar passivity, acceptance and reliance on the doctor by patients. In effect, the amount of legitimate time away from work for medical reasons has been determined by the decisions of doctors. One U.S. physician's perception of this situation is as follows.

    "Doctor and patient each have social roles to perform and expectations to meet. For example, patients in American society are usually relieved of their normal social obligations for a as long as they remain ill. The doctor is the person authorized by  society to certify illness and officially to dispense the patient from these obligations. The patient's freedom from work obligations is based on the social assumption that patients are not responsible for their illness.  The patient is, however, obliged to want to get better and to try to do so by going to the doctor and co-operating with the doctor's therapeutic interventions. Doctors are also obliged by society to undertake the work of curing and to make sure that patients do not derive anti-social advantage from  their illness". (Drane, 1988)

    Where are we going?

    Since 1988, the OMA has questioned the appropriateness of this role and in this paper proposes that the major responsibility and supporting skills to address employee absenteeism shift from the patient's physician to the employer-employee relationship. It is  easy to articulate the more focused medical role to be played by the patient's physician. It is much more difficult for the OMA to outline for employers and employees options for income and work security, techniques to achieve flexibility and modified work, the workplace understanding, attitudes, skills and processes required to implement timely return to work programs. We are talking about a new workplace culture that can incorporate a greater share of responsibility for employee absenteeism and maximizing the health promoting features of work. The key to operationalizing the OMA's view of the appropriate role of the physician lies in successfully effecting required changes in the employer-employee relationship. Both have to change in tandem to minimize the cost of disability to employers, to maximize the positive health effects of timely return to work for recovering employers, and to accomplish these goals with little or no risk of any new morbidity.

    How do we get there?

    Change requires recognition that many employers. Employees, and physicians do not understand the resources, case management skills, organization, job functions and the interpersonal skills required to put cost-effective early return to work programs in place. No doubt, the state of this art and its many components need to be made much clearer for everyone concerned. Proactive use of the workplace to promote employee health and timely return to work requires the availability in the workplace of a level playing field and neutral ground for dialogue between the employer and disabled employee in the context of a healthy employer-employee relationship. These conditions are critical if we want continuous quality improvement in our overall management of absenteeism due to sickness,  if we want to move the medical profession towards a role more in line with its unique expertise. The OMA is certainly prepared to help employers design various models of early return to work programs and can  contribute experience and scientific knowledge from a wide variety of specialities in addition to family practice, i.e. occupational medicine, physical medicine and rehabilitation, general practice, psychiatry, orthopaedic surgery to mention only a few.

    We need policies that place greater emphasis on returning the ill or injured worker in a timely fashion to a productive role in the workplace where the employee and employer are comfortable, rather than the more passive approach traditionally pursued of certifying patient inactivity and the flow of income replacement benefits. The OMA is not saying that these are mutually exclusive aims, but that timely return to work should have more influence on the decision-making behaviour of all the various players.

    The role of the physician in medical rehabilitation extends to the workplace when patients are returning in a modified capacity and physicians should play an active role.

    Medicine must implement clinical approaches that build on the patient's strengths and help promote patient activity outside medical restrictions. Employers and employees must modify the workplace and the workplace culture to support the recovering worker. Together these two initiatives should assist physicians in helping employers minimize the cost of absenteeism due to illness and injury.

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    The OMA recommends the continued diffusion of well designed co-ordinated efforts to create workplaces that can promote the safe and timely return of workers while caution and medical restrictions still are necessary.

    We suggest timely return to work programs incorporate the following core values:

1.    The primary responsibility for successful timely return to work lies within the workplace-employee relationship. Senior management provides commitment, support, and a clear understanding of the health and cost containment benefits of these programs.

2.    It is recognized that personal responsibility and the co-operation of employees is  critical. This includes advocacy for a quality employee-employer relationship given its critical role in timely return to work programs.

3.    Policies, roles,  and responsibilities clearly specify co-ordination among stake holders, e.g. the workplace, its culture, colleagues, the employee, union if applicable, and, if available, occupational physicians affiliated with the workplace.

4.    Familiarization of the workplace with the new attitudes, knowledge, psychosocial and other skills, and logistical supports required to integrate the worker with his/her abilities and medical restrictions into the workplace.

5.    Advocacy for outcome based medical research and the development of practical information systems to evaluate what works, to improve practice, and for purposes of occupational epidemiology (Coe, 1975).

6.    Primary prevention of accidents and injury in the workplace in partnership with the timely return to work philosophy.

7.    A balance of incentives and disincentives so that employees with medical restrictions and still in treatment or medical rehabilitation return to work without undue financial costs.

8.    Accountability for the company's early return to work program is assigned to the employee's supervisor.

9.    Recognize occupational medicine and utilize it as a resource to help with specific case management as well as primary prevention.

10.    Subject the program to continuous quality improvement.

11.    Assurance the information provided to the physician and employee about the company's program and the modified work available in the workplace is, in face, fully operational.

12.    We suggest this role for the patient's primary care physician within timely return to work programs:
 

• the program relies on, and/or strongly effectively encourages, the employee to pursue the early return to work agenda with the doctor. This assumes:

• the program requires the patient's  physician to provide timely well founded, functional limitations (restrictions appropriate to the specific diagnosis) and diagnosis specific capabilities. Diagnostic information may be legitimately required by insurer claims administrators but not by supervisors or other human resources staff of the employer.

• the physician advocates for a quality employee-employer relationship.

• the physician offers the timely application of current concepts in treatment and rehabilitation, the active prevention of long-term iatrogenic disability, and applies outcome-based medical research findings.

• the physician receives clear consent to release of functional limitation information (eg.impairments, medical restrictions). The patient's right to clinical confidentiality includes control over the release of medical information over and above information the patient has agreed to release in the early return to work program.

• the physician requires an environment respectful of the doctor-patient relationship and its role in society.

 
• the physician routinely uses the employee to effect the timely exchange of appropriate information and only has direct contact with non-medical representatives of the employer on medical restrictions and job suitability when communication between employer and employee fails.

• the physician receives employer co-operation with the treatment and medical rehabilitation program recommended by the physician and agreed to by the employee.

    Early return to work programs with the above core values are most likely to effectively and efficiently engage the employee's physician in helping the patient meet health goals through timely return to work. The OMA has general responsibility to help prepare primary care physicians for these responsibilities through medical education initiatives on the requisite new concepts in disability assessment, medical rehabilitation, how such programs facilitate the employees' return to health, and other appropriate information. This work should include an analysis of the determinants of physician behaviour so as to place new educational initiatives on as scientific a foundation as possible. The OMA will explore a standardized training program for physicians and the feasibility of a standardized training program for physicians and the feasibility of a standardized medical reporting format to help determine employability. There may well be a role for guidelines such as have been prepared for physicians to help them assess fitness to drive a motor vehicle (CMA).

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