Archive
By Richard M.D.
Mar. 3, 2002
You’ve visited the clinics and talked with the administrators. You’veheard the promises of prompt service, top-notch medical care, rapid return towork, and good communication. You’ve interviewed the doctors and even had afew out to see your operation.
You’ve finally made the decision and selected the occupational-healthprovider and clinic that will be treating your injured employees. Now you cansit back, knowing that your problems are over.
It should be so simple! Any successful injury-treatment program requiresconstant attention.
As with many other businesses (and there’s no doubt that occupationalmedicine is definitely a business), the promises made are all too often greaterthan what’s actually delivered. Many clinics and providers will promise youthe world. But when it comes down to what’s delivered, it may be a differentstory.
Expectations and Communications
The single most important factor for a good relationship between an employerand an occupational-medicine provider is having similar expectations. If theemployer expects a call after each initial visit and the provider doesn’troutinely do this, then there will be problems. If the provider’s policy is toalways return injured employees to work with appropriate activity restrictions,and the employer doesn’t want employees back until they are ready for full duty,then there will be problems.
The solution to most of the problems that occur between employers andoccupational-medicine providers is to talk about them. The problem often turnsout to be rooted in a misunderstanding by either you or the doctor.
Most occupational-medicine specialists I know and have worked with are happyto speak with employer representatives. It’s just a matter of finding the timeto do it.
The Problems
Let’s look at some of the common problems that arise between employers andoccupational-medicine providers.
The doctor’s activity restrictions don’t match the light-duty jobs wehave available.
This is a common problem that’s really quite easily solved. You know allthe light-duty jobs at your company and all the accommodations that can be made.The doctor doesn’t. The doctor probably works with more than 100 companies.There’s just no way for him or her to have intimate knowledge of all the jobsand job modifications at your workplace.
In most cases, it’s not necessary for the provider to know all about yourmodified-duty positions, light-duty options, and so on. Why? Because suchknowledge may result in unnecessary restrictions. If the employee’s injuriesprevent him from working in one of those jobs, then the doctor might put theemployee out of work.
It’s best for the provider to write activity limitations based on themedical problem and not for a specific job. If the restrictions don’t quitefit the jobs available, then give the provider a call.
Actually, the restrictions should apply to every aspect of the injuredemployee’s life and not just what she does at work. That’s why many doctorsstay away from the term “work restrictions,” preferring “activityrestrictions” or even “life restrictions.”
Here’s a medical secret: most restrictions are somewhat arbitrary. Is therereally a difference between a lifting limit of 10 pounds and 12 pounds? Mostlikely not. But it could be the difference between an injured employee’s workingand not working.
If you find that minor modifications in the activity restrictions are needed,call the doctor. Most often you’ll find that the restrictions can be revisedto meet your needs.
My employees always have to wait a long time to be seen, even when theyhave an appointment.
This is a common problem, particularly in successful clinics. Most clinicsare staffed to handle their average patient flow. Unfortunately, patient flow israrely “average.” The clinic is either busy or quiet.
The first step is to document how long your employees actually do wait. Arethey going directly from work to the clinic and back or, as I have seen, makinga few stops along the way? I have also seen patients who arrive at the clinic,never check in with the receptionist, and just take a seat. It may be a whilebefore anyone notices they are there.
Assuming that these are not the problems, then talk to the clinicadministrator. Find out which days and times are their busiest — and theirquietest. Try to schedule appointments when they are slow.
Many occupational-medicine clinics work on both an appointment and walk-inbasis. Do you make appointments or just send your employees over for routinepurposes with no appointment? Clinics usually take the patients withappointments first, so walk-in patients end up waiting.
Every employee is sent to physical therapy.
Many occupational-medicine specialists have adopted the concept of the “industrialathlete” and treat injured employees the same way an injured athlete istreated.
Athletic trainers have found that the sooner you get an injured athletemoving and into rehab, the quicker he is back to playing form. This also appliesto industrial athletes. One study found that quick entry into physical therapyfor an injured worker actually decreased the number of physical therapy sessionsfrom an average of 6 to 5.5. That’s nearly a 10 percent reduction.
It’s easy to assume that a clinic with its own physical therapy center willtend to use it more often than a clinic without one. And I’m sure that suchoveruse does occur at times. But don’t assume that’s always the case. Mostdoctors are ethical and refer a patient to physical therapy only when theybelieve it will help.
Some of my employees don’t like the physical examinations they receive.
This is a double-edged sword: some employees complain that the exam wasn’tcomplete enough, and others complain that it was too thorough. I’ve heard bothcomplaints.
Before looking into this problem, you have to know both what you wantincluded in any physical examination and what the provider thinks should be init. Here’s a quick list of what I believe should be included:
A complete history, including an occupational history, that’s furnished bythe employee and reviewed by the examiner. The examiner must comment on anysignificant positive answer.
An examination that focuses on the musculoskeletal system but includes theentire body. The employee must change into one of those lovely hospital gowns.It’s just impossible to do a good exam otherwise. The doctor should payspecific attention to — and comment on — anything that the employee hasbrought up in the history.
An opinion letter by the examiner indicating any significant medical problemsthat might interfere with the employee safely performing the tasks of his job orif the employee will need special accommodations.
Once you have defined what you want, find out if this is what the provider isdoing. If so, then you are getting a good exam and your employee complaints arejust that — complaints.
The doctor orders too many/not enough tests.
As you can see from the wording of this complaint, it goes both ways. As Isee it, there’s one medical reason to order a test: the results may change theultimate treatment plan. For example, if a fracture is suspected, an X-ray willhelp the doctor answer the question. A fracture requires one treatment, a spraina different one. If the results won’t change the treatment course, then whyorder the test?
Another reason to order a test is that the patient wants it, and the doctorbelieves that a negative test will remove “roadblocks” to the patient’srecovery. For example, a patient who is convinced he has a fracture may need anX-ray just to relieve his concern and allow him to recover.
This is where the art of medicine comes into play. In some scenarios it’sobvious that an X-ray is required, and in others it’s obvious that no X-ray isneeded. But then there are the many cases in which it’s not quite so simple.In these situations, it’s best to get the test.
The doctor sends too many/not enough patients to see a specialist.
This is similar to the last complaint. There are three reasons to refer apatient to a specialist: the diagnosis is in doubt, the patient requires atreatment that the occupational-medicine provider can’t perform, and thepatient/employer/case manager demands it.
If you believe that the provider is sending too many/not enough patients tosee specialists, you should think about what your expectations are from thespecialists. There aren’t any special tests that only specialists can order.If the patient doesn’t want surgery, then why send her to see a surgeon?
If you believe that too many patients are being referred to specialists, thentalk with the occupational-medicine provider. Sometimes the reason is that thedoctor doesn’t feel comfortable treating certain types of medical problems. Ifthose medical problems make up a large portion of your injuries, then it may betime to look for a new provider.
The doctor’s report doesn’t have the story right.
It’s amazing how many times employers call, saying that the doctor has thehistory of the injury all wrong. Yet the doctor has recorded just what theinjured employee told her — that’s all that the doctor has to go on. Give thedoctor a call if you have additional information. It may be critical.
The Black-Box View of Occupational Medicine
Before wrapping up this article, I want to touch on one other subject — theblack-box model. In this model of treatment, injured employees are put into a”black box,” and the output is healthy employees. It’s called a black boxbecause what happens inside the box is totally hidden to the outside observer.To the observer it makes no difference what happens in the box. What’simportant is how long it takes for the recovery to occur, how complete therecovery is, and what the total cost of the process is.
When evaluating the services you get from your occupational-health provider,as well as the costs, it’s helpful to use the black-box approach. If yourinjured employees are getting back to work quickly and the costs are undercontrol, then what difference does it make what the doctor does for treatment?
In the end, to receive the occupational-medicine services you want, you haveto make sure your expectations are well communicated to the provider. You haveto monitor the program closely and feel comfortable about talking with yourprovider whenever there are problems.
Workforce Online, March 2002
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