The focus of my blog has been about changing the system to reduce the risks of a poor health outcome, but is there another facet to solving the problems I have highlighted? Should doctors make a conscious effort to keep people out of the system?
I recently attended a meeting where a senior member of the Hobart judiciary suggested that ‘tough love’ should be applied by doctors to their patients to avoid them becoming entrenched or to extricate them from compensation systems. Perhaps the comments were directed at me personally, I don’t know, but I probably do have a reputation for being supportive of people injured at work.
Recently another doctor has joined my practice to start a career in occupational medicine. My role in mentoring brings into focus the role of doctors generally and particularly those who see patient’s with work-related incapacity. I want to teach optimum practice, in the best interests of health outcomes.
Although the insurers and the judiciary cannot be aware of people who never put in a claim, it is quite a common experience in my practice for patients to ask about whether they should put in a WC claim. Many never put in a claim despite having an eligible condition.
Recently my practice has received an unusually high number of referrals from General Practitioners to help their patients decide whether to pursue a claim for workers compensation, either within the Tasmanian workers compensation system or with Comcare. Over recent weeks two-thirds of the referrals to my practice from General Practitioners, have been in relation to whether the worker has a ‘case’ to pursue a workers’ compensation claim, although one patient had already concluded that claiming compensation was not in their best interests, despite evidence of a work-related disorder.
There were some very complex scenarios amongst these referrals with a mix of constitutional factors, work-related factors (both acute events and task demands that might create a risk), in addition to non-work related recreational and domestic injuries and activities. On top of that, of course, is the psychological makeup of the person that can have an influence. Of those cases, one didn’t have clear evidence of work causation from a medical perspective and the others mostly had a mix of work-related and non-work related factors, but a lawyer would need to advise whether the work-related factors were sufficient for eligibility for compensation.
There is a unique opportunity with workers who come and see a doctor at a point before they decide to put in a claim. There is potential to steer them into or away from the system, before it ‘grabs hold’. Many patients tell me their General Practitioners advise them (or sometimes insist) that they put in a workers compensation claim. I am not sure whether this occurs because the doctor believes it is in the patient’s best interests or whether an accepted claim provides a source of funding for treatment.
My approach is different. It is important that the patient themselves decide about whether to claim, but that needs to be an informed decision. I explain the pros and cons of entering the workers compensation system and some of the factors to consider, apart from the primary issue of evidence of causation from a medical perspective, for example:
How serious is the health problem? Can you manage it with your personal resources? Does the condition risk your work future?
What is your relationship with your employer? Will they support you making a claim? Will a claim damage your employment relationship or jeopardise future employment? What is the reputation of the insurer in respect of their response to a claim?
Are you aware of the potentially stressful processes involved with workers compensation, i.e. loss of personal control, attending IME assessments, providing your personal details to a third-party etc?
Sometimes I might indicate that a legal opinion is required, if I am pressed on eligibility for compensation, but I am conscious that even suggesting legal advice may put them on a path to an adverse outcome.
It is the patient’s choice whether to make a claim, and if that choice is made with an understanding of both the risks and benefits, then I would respect that choice and provide support in relation to medical evidence about work causation, if it exists.
A more difficult situation for a doctor to confront is a patient who is already ‘in the system’, where the doctor is providing ongoing medical certificates to support a claim and there is no progress. In circumstances where enmeshment in a compensation system is working against recovery, how can a certifying doctor address the problem in the best health interest of their patient? I think this was the situation referred to by the senior member of the Hobart judiciary where ‘tough love’ from doctors was needed.
Leaving aside the concern that some doctors might have about upsetting a long-standing patient of the practice, and perhaps losing a whole family as clients of the practice, there are considerable difficulties for a doctor to stop supporting a claim already underway.
Firstly, some patients I have cared for told me at the end of the process, after their claim had settled, how important it was that they had consistent support from a doctor in an otherwise ‘uncaring’ system. To withdraw that support, even with the best intentions, can potentially have serious psychological consequences.
Secondly, to withdraw certification support can mean there is no treatment as the patient would be unable to fund treatment themselves.
Often the best a doctor can do is to discuss the benefits of exiting the system and encourage independence and taking back control, so that certification is no longer required, but that seems to happen relatively rarely in practice. If there is a supervening event, such a further non-work related injury or significant psychological event, there might be an opportunity to stop supporting a claim, but that too is unusual.
There is no easy solution.
It is true that ceasing support for a claim might help that patient exit the system and make a better recovery, but the likely outcome is that the patient will change doctors and continue in the system or suffer from lack of any support and the psychological consequences.
It might be easier if the legal definitions of injury and disease causation were changed to be more in line with medical definitions of causation. Such a change might make it easier for a doctor to explain that their patient is no longer entitled to compensation and that certification cannot continue. At present an injury occurring in the course of employment and any consequences is compensable. A disease where employment has contributed ‘to a substantial degree’ is also compensable.
Perhaps a change to a definition where some sequelae of injury are excluded or an arbitrary time limit is applied may assist, at the risk of incurring the wrath of those concerned about legal rights.
A better solution however is to have a system where the doctor can flag situations where the compensation system is working against recovery and the patient can be directed into a process to finalise the claim as painlessly as possible.