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TRYING to keep workers at work should be a priority for doctors when completing medical certificates, according to a leading GP and occupational health experts.
New Australian research, published in the MJA, shows the bulk of medical certificates provided by GPs for injured and ill workers recommend complete absence from work, with fewer than a quarter recommending return to work with alternative duties. (1)
In the first study of its kind in Australia, the researchers examined workers compensation data, including medical certificates issued by GPs, for all injured and ill workers with an accepted workers compensation claim in Victoria between 2003 and 2010.
Almost 75% of 124 424 initial medical certificates issued by GPs recommended that workers were unfit for work and about 23% recommended alternative duties. Unfit-for-work certificates were issued to 94.1% of workers with mental health conditions, 81.3% of those with fractures, 79.1% of those with other traumatic injuries, 77.6% of those with back pain and strains, 68.0% of those with musculoskeletal conditions and 53.0% of those with other diseases.
The authors said health professionals were likely to perceive the potential health outcomes of people with mental illness as poorer than they really were.
Their results presented “major challenges in terms of return to work, labour force productivity, the viability of the compensation system, and long-term social and economic development”, they wrote.
Dr Liz Marles, president of the Royal Australian College of General Practitioners, said there were many health benefits from work and the focus with workers compensation patients should be on what they could still do at work rather than what they could not do.
“I think you should always try to see first of all if there is a way of keeping a person at work rather than putting them off”, she said. Trying to find alternative duties was important.
“That does involve the workplace as well and discussion with the patient about why it is good to be able to stay at work”, she said. “That first consultation is critical in terms of setting the expectations of the patient.”
There was a high likelihood of people never getting back to work if they were off for an extended period, Dr Marles said.
Associate Professor James Ross, president of the Royal Australasian College of Physicians’ Australasian Faculty of Occupational and Environmental Medicine (AFOEM), said there needed to be an expectation that the norm was to remain at work on alternative duties, or to have early return to work after as short a period off work as possible.
Professor Ross admitted there were many impediments to certifying fitness for alternative duties, such as finding the time in a busy practice to develop a working diagnosis, understanding the capacity of the worker, addressing their concerns, and understanding the capacity of the workplace to accommodate the injured worker.
“Calling the workplace and talking to a supervisor or manager will greatly help to understand what can be practically certified”, he said.
He suggested GPs have an occupational physician they could call to discuss a patient and potentially refer if needed.
Dr Bruce Hocking, a specialist in occupational medicine in Melbourne, said GPs might well be right if they put people with say, acute back pain, off work initially but kept them mobile at home and then certified them for alternative duties as part of a graded return-to-work program.
“This would be good medical practice”, he said.
However, Dr Hocking criticised the study as lumping all mental health conditions together, when understanding the occupational context of the patient’s symptoms was crucial to proper management.
He said GPs were often aware of the occupational context for patients with mental health problems and would aim to protect the patient from a harmful environment until interpersonal conflict, role ambiguity, or other issues had been resolved or until the patient was strong enough mentally to resume work.
“The GP has very little control over the management of workplaces let alone the time to investigate the rights and wrongs of what is happening there”, he said.
Ms Carolyn Davis, manager of work health, safety and workers compensation policy at the Australian Chamber of Commerce and Industry, said the chamber supported early, safe and sustainable return to work. Consultation between the GP, injured worker, employer, workplace rehabilitation staff and the insurer was important.
“This ongoing consultation can assist the GP to recognise what can be done in the workplace and their role in encouraging an early return to work”, she said.
Excellent ideas – but let us not go weak at the knees as with most common-sensical ideas in this modern age where so much time and energy is consumed in finding excuses/reasons for not proceeding. In all treatment matters doctors must acknowledge that tough love is required – if the doctor knows/believes that a course of action will be most effective, then follow it rather than yield to unnecessary options, or over-cautiousness. As my mother used to say “You’d be better off at work where they could find something useful for you to do than to sit around here feeling sorry for yourself”. A graduated return to work programme can provide a highly satisfactory and productive strategy whether for long-term (or chronic) physical or mental ailments. Short term illnesses are judged on their merits, not on the patient’s desire for a “sickie”