JBJS | Workers' Compensation: Avoiding Work-Related Disability*

The Journal of Bone & Joint Surgery, Volume 82, Issue 10

The Orthopaedic Forum | October 01, 2000

Workers' Compensation: Avoiding Work-Related Disability*

J. Mark Melhorn, M.D.

The Hand Center, 625 North Carriage Parkway, Suite 125, Wichita, Kansas 67208-4510
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

The Journal of Bone & Joint Surgery. 2000; 82:1490-1490

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Introduction

Introduction | References

Musculoskeletal pain is often separated into two categories: work-related and non-work-related. This legal distinction is often considered when outcomes of treatment are reviewed but is commonly overlooked during the treatment phase and can have a substantial impact on the outcome. Musculoskeletal pain in the workplace can be caused by injuries or illnesses. By definition, an occupational injury is one that results from a work-related event or from a single instantaneous exposure in the work environment. Injuries are reportable by the employer on the Occupational Safety and Health Administration (OSHA) 200 log if they result in lost work time or if the worker requires medical treatment (other than first aid), experiences loss of consciousness, has restriction of work activities or motion, or is transferred to another job²³. An occupational illness is any abnormal condition or disorder (other than one resulting from an occupational injury) caused by exposure to a factor or factors associated with employment. Included are acute and chronic illnesses or diseases that may be caused by inhalation, absorption, ingestion, or direct contact²³. In the musculoskeletal category, injuries are often defined as traditional traumatic injuries such as fractures, sprains, strains, dislocations, or lacerations. Musculoskeletal illnesses are commonly called cumulative trauma disorders, repetitive motion injuries, or disorders associated with repeated trauma. These terms are not medical diagnoses but labels for musculoskeletal pain that an individual experiences in the workplace¹⁸. By the OSHA definition, musculoskeletal illnesses may include well defined diagnoses or conditions identified by descriptive labels²³ that are very costly to the economy. In 1997, direct health-care costs for both injuries and illnesses for the nation's workforce were more than $418 billion, with estimated indirect costs of $837 billion². Private industry reported 6.1 million injuries and illnesses, with a case rate of 7.1 cases per 100 equivalent full-time workers²⁴. Reducing the total costs of more than $1.25 trillion has clearly become a priority for the American public and the American business community.

A complicating factor in the cost of work-related injuries and illnesses is the Workers' Compensation system, which represents a compromise for both employers and employees. Although described as a system, it is not; each state, each United States territory, and the federal system have different and separate Workers' Compensation laws and regulations. The Workers' Compensation system is designed to be a no-fault and exclusive remedy. The workers and their dependents are not required to prove fault for personal injuries, diseases, or deaths arising out of and in the course of employment. The employer agrees to provide rapid payment to the worker for lost wages and medical-care costs in exchange for limitation or elimination of the employer's potential liability for said occupational illnesses, injuries, and deaths and, thereby, the possibility of large tort verdicts.

In response to public-health and business concerns, occupational orthopaedics is rapidly evolving as a specialty^15,17. Similarities can be drawn between sports medicine and occupational medicine. For example, examination and treatment of the injury alone are not sufficient. Injuries do not occur in a vacuum. The outcome is affected by motivation; social, psychological, and economic factors; and community values¹⁷. After recovery, an injured player is expected to return to the game and to perform at his or her previous level of athletic ability. Similarly, the injured industrial worker is expected to return to his or her previous level of performance - that is, to accomplish a particular task within a reasonable time-frame. Although the typical treating physician may be well versed in the conditions of the gridiron, he or she may not be as familiar with the requirements and limitations of the industrial playing field. In occupational medicine, it is not only necessary to "fix" the worker; one must have an idea about how to improve the workplace to prevent future injury. As in sports medicine, the management and prevention of workplace injury demand a dedicated and knowledgeable cadre of physicians, surgeons, and therapists who are able to apply modern knowledge and expertise to a successful medical program. In both sports medicine and occupational medicine, prevention is the best approach^19-21.

Occupational medicine presents a number of challenges to the physician. Management of work-related musculoskeletal disorders is often frustrating. Patients may have more symptoms and longer recovery times, may require longer and more frequent office visits, and may be accompanied by the employer or nurse case manager during the office visit. They frequently have more questions about work status and require more telephone calls and paperwork. Many have attorneys, and they commonly require a permanent physical impairment rating with subsequent depositions or mandatory court appearances. Treatment outcomes often shift from good to poor¹². The negative shift in outcome indicates that Workers' Compensation introduces additional factors that influence patients and complicate treatment efforts. Traditional western medical education is heavily weighted toward the scientific study of the biological systems of health and disease, often to the exclusion of such factors²⁶. Physicians who provide care to those with work-related injuries are often inadequately prepared to deal with the biosocial issues - including motivation, social factors, psychological overlays, economic incentives, and legal complications - that influence the outcomes of treatment²¹. Physicians who are adequately prepared are often faced with the difficult task of separating fact from fiction. Occasionally, the patient's symptoms can be disproportional to the findings of the clinical examination. Since an occupationally related OSHA event requires only a complaint of pain, multiple subjective issues must be reviewed. This can make the clinical picture confusing and can require more tests and studies to establish the appropriate medical diagnosis than are necessary for a patient with a similar, nonoccupational condition. Other factors impacting treatment costs might include somatization behavior among patients and medicalization among physicians¹, cost-shifting from commercial insurance to Workers' Compensation insurance³, elimination of compensation for pain and suffering in order to decrease the prevalence and improve the prognosis⁴, and removing disincentives for early return to work¹⁰. The occupational physician must recognize, understand, and address these factors to achieve the more favorable outcomes that are seen after the treatment of injuries and illnesses in patients who are not seeking Workers' Compensation.

Steps for the Physician

Physicians can be a major force in serving the public good and in reducing the costs of work-related disability for a number of reasons. Physicians are patient advocates. As patient advocates and in the best interest of society, physicians should encourage rehabilitation, not disability. Many studies have shown that early return to work results in a better outcome for patients with work-related injuries and improves their quality of life^{5,7-9,13,14,16,17}. Early intervention by the physician and the rehabilitation counselor at the time of the injury can facilitate a positive attitude and empower the worker to resist the negative effect of a system that discourages early return to work²². For instance, the current Social Security disability system discourages potentially disabled workers from even attempting rehabilitation. To be eligible for disability benefits, a claimant must prove that he or she is unable to engage in any substantial gainful employment because of a medical impairment that is anticipated to continue for at least twelve months²⁵. On the other hand, to be eligible for rehabilitation, the claimant must demonstrate both the potential for work and that rehabilitation would be beneficial. Physicians should discourage patients from prolonging disability beyond medical necessity, as this has been shown to have a negative impact on the patient's total health. Patients with extended disability often become depressed and show decreased motivation, and their medical outcomes are usually worse than those of patients who participate in early-return-to-work programs²⁶. Additionally, the individual who has chronic pain suffers less when his or her life has purpose and meaning. Gainful employment frequently serves as a distraction from pain⁶. Individuals with legitimate painful injuries should be appropriately compensated for pain and suffering, but an alternative to the current reimbursement system is needed. The compensation and disability system must be changed so that it encourages early intervention, prevention of chronicity with incentives toward rehabilitation, and early return to work.

Specific steps for the physician seeking to help patients avoid work-related disability include¹¹:

1. Do not commit to a diagnosis that the injury is work-related without reasonable certainty.

2. Do evaluate the physical and emotional components of each patient individually.

3. Do inform the patient of the diagnosis with care.

4. Do put reasonable limits on rest and physical therapy.

5. Do avoid addictive medications.

6. Do treat physical problems with reasonable and structured activities, giving plenty of reassurance and encouragement.

7. Do encourage early return to safe work when reasonable.

8. Do take a positive role in getting the patient back to work and to use rehabilitation specialists and/or case managers.

9. Do intercept the patient on the way to permanent compensation; do not exploit the system.

10. Do remember that emotional illness cannot be cured by surgery and often can be made worse.

11. Do support legislative changes to reward the injured worker for getting well and back on the job, rather than the current system, which encourages disability.

12. Do continue to be the patient's advocate.

Work-related injuries do not occur in a vacuum. The impact of the injury and the outcome of treatment are influenced by the biosocial issues that make each individual unique and each patient's injury different. Taking the standard approach that a privately insured patient's biosocial issues are the same as those of a patient with, for example, carpal tunnel syndrome who is seeking Workers' Compensation will result in a poor outcome for the patient and a discouraged treating physician. If physicians elect to treat patients seeking Workers' Compensation, they need to do it right. Physicians should address all of the critical issues: age, gender, genetics, workplace and non-workplace environment, biosocial issues, work status, impairment, disability, and handicaps. Learning this art of medicine will improve the physician's skills for all patients and make him or her a better all-around physician.

J. Mark Melhorn, M.D.

The Hand Center 625 North Carriage Parkway, Suite 125 Wichita, Kansas 67208-4510

References

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