Are You an “Employer Friendly” Physician?
Physicians do a disservice to patients with work related injuries by not understanding basic return to work practices. Given the same injury, patients who go back to some type of productive work as early as possible have less long term disability, are more productive, and happier than those who are kept out of work.
In her article “7 Signs Your Injured Worker is Treating with a Physician Who is Not Employer Friendly,” Rebecca Shafer makes some excellent points about physicians treating worker’s comp injuries. Her article is geared towards the payor side, so I’ll add some comments that treating physicians/providers need to consider when treating these patients. (Although this is a huge topic and we can only just touch on some basics here.)
- Placing the patient off duty. As Ms. Shafer states, if a patient is off duty, it means they are totally disabled, as in the hospital, going directly to surgery or absolutely can’t move. This is rarely the case. Often times the patient will tell the provider “there’s no light duty at my job.” I generally explain to the worker that they’ll get better faster if they return to some type of productive work today. I explain that I will first determine what their job duties are, then determine if the injury prevents them from doing the essential elements of the job.If they can return to full duty with only “first aid” level care, the injury may not even be OSHA recordable, which will help your clients (the employer) immensely. If they can not do their regular duties, write specific restrictions on what they can or cannot do in terms of stand, sit, walk, lift, carry, push, pull, climb, crawl, reach, grasp, etc., and how many pounds for what period of time–occasional, frequent or continuous. Any physician providing workers comp services should have some type of form on which you can indicate these restrictions.
- Follow up after the first visit, in my opinion, should be in just 2 or 3 days. Many times the injury will be significantly improved and the patient can be returned to full duty. Other times the patient will complain they are worse. When this happens, you must not “knee-jerk” take them off duty, rather focus on their demonstrated level of functional ability in order to determine work status, not subjective complaints. Always write the restrictions based on examination of their ability to function, and always explaining that it is in their best interests to continue to work to this level of ability. My subsequent follow ups are generally weekly.
- Medications If there is a minor injury with the worker returning to full duty, treat the injury as “first aid”, to avoid an OSHA recordable. Prescribing OTC NSAIDs at OTC strength is generally fine for most minor injuries. Remember if you write Motrin 600 instead of 400 it is going to be recordable. If you are not completely familiar with what is or is not considered first aid regarding OSHA recordability, <<click here for my article on OSHA recordables>>
- Physical Therapy Yes, PT can be easily abused, but also mandatory for injuries showing a functional deficit. If the worker cannot return to full duty within a week or so, or if off duty and not in the hospital, I am aggressive with PT to restore mobility, function, and also importantly, confidence and motivation. I personally like a close working relationship with the therapist so we are a team working to get the patient functional as soon as possible. I did not have a PT department in my last urgent care centers, but would if I had the space. You don’t have to over-prescribe PT to have a successful and effective PT department.
- Specialist Referrals Obviously if there is a surgical problem, the patient needs to be referred right away, and be careful to not allow them to go into “limbo” with no duty prescription or excessive lost time waiting for the specialty appt. If the patient is not progressing, e.g. showing signs of improvement in function, with progressive lightening up of work restrictions within 2-4 weeks, generally a specialist should be consulted.
- Communication Yes, notes, restrictions, meds, PT, diagnostics, referrals and follow up plans, as well as expected date of maximal medical improvement (MMI) or prognosis should be legible and reported at each and every visit.
Treating injured workers effectively requires an understanding of proven return to work practices and strong cooperation and communication among providers, employers, adjusters, payers, and patients.
Lawrence Earl, MD
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Hey Larry: Great overview and comments. We are self-insured at Baystate Health, so we try to make sure we identify red flags, while still encouraging/expecting the MD to provide excellent care. I’ll share this with my colleagues in the Disability Managenent Services department.
Joe
Dr. Earl,
Thanks for the great article. I agree with all of your points and would like to offer the following observations. The physician must truly believe in the concept of early return to work as a best practice or they will quickly succumb to pressure exerted by those patients who are adamant about “needing time off to get better.” In addition, the physician must be willing to cultivate a specialist net work of providers who practice with the same philosophy and to confront those specialists who take workers off the job for indefinite time frames and schedule unending follow-up visits based solely on a patients subjective complaints. Finally, the effective workers compensation physician must understand the difference between a true functional deficit and a subjective complaint of pain. I agree that early physical therapy is essential to restore function and facilitate early return to work.
Dr. Earl,
Thank you for this great post. I’ll be at a very large Work Comp Conference in the next few weeks in Orlando with a client and this gives me a start point for a portion of the practice that I have less experience in.
You’re welcome! I’m glad you found it helpful, let me know if there is anything I can do to help your client.