The Great Divide!
Firstly, let me say welcome to a few new followers to my blog following the release of Mark Stipic’s podcast of a second interview with me on RTW Nation about engagement with general practitioners.Thank you Mark.
Here is a link in case you missed it: http://rtwnation.com/34
Peter Sutczak introduced me to the ‘modern’ concept of vocational rehabilitation in the 1980’s. He used posters, similar to the one below, to get across the Teamwork Concept necessary to achieve the desired outcome – recovery and return to work.
The concept was that everyone paddled together (up shit creek, if necessary) to achieve the goal that was best for the individual worker, their employer and society as a whole.
How that all seems to have changed (or perhaps was never achieved).
The two sides of the fence!
The Tasmanian Association of Vocational Rehabilitation Providers (TAVRP) has recently advertised its intention to run a symposium in June 2017 to coincide with Dark MOFO and Tasmania’s Mid-Winter Feast. The title is an ominous “The Dark Side of Rehab – A look at the more complex and controversial aspects of occupational rehabilitation”. I don’t know the details of the programme yet, but I expect it will be interesting.
While TAVRP is aligned with the peak national rehabilitation organisations ASORC and ARPA, there is another group, supported by WorkCover Tasmania called the Injury Management coordinators Association.
Tasmanian legislation makes provision for the role of Injury Management Co-ordinator and once a person has completed a short course they can be accredited in this role and work as independent provider coordinating rehabilitation without the more rigorous accreditation required by organisations to provide the schedule of rehabilitation services defined by legislation.
There appears to be a divide within the world of vocational rehabilitation
Perhaps the same division occurs amongst employers, those that will go the extra mile to support their employees with injury or illness and those who focus seems to be more on workers compensation as a cost of business to be contained. There is probably a third group of employers, those that haven’t even considered the issue!
I am aware of other dichotomies in the world of workers compensation. In the legal world there are plaintiff and defendant lawyers, and that applies very strongly to lawyers who operate in the world of workers compensation. Interestingly, I have heard plaintiff lawyers use the term moving to the “Dark Side” when referring to the world of defendant Law. Perhaps defendant lawyers use the same term for the world of plaintiff law. I am sure the legal profession can enlighten me on this point.
Plaintiff and Defendant Doctors?
Recently an occupational physician colleague asked me why I didn’t immediately object to being labelled a “plaintiff” doctor in discussion at a recent educational meeting about the role of surveillance (another murky issue) in occupational medicine . I answered that I didn’t agree with the label, but am now so used to the categorisation of doctors either on one side or other of the fence (and similar categorisation of every other “player’ in workers compensation) that I hardly notice such labelling any more.
John Quintner, in a recent comment on my recent blog article about an opinion piece from AFOEM President, Dr Peter Connaughton stated as follows in relation to the roles taken by occupational physicians, perhaps referring to the “Dark Side” of occupational medicine.
‘However, many became willing pawns in the adversarial arena, often being on the side of third-party insurers. ‘
It is clear that increasingly doctors who operate in the workers compensation space are being categorised as well, as either plaintiff or defendent doctors. How sad!
Adversarialism as a concept
As illustrated by the diagram below from Culture of Peace Activist, Peter Newton-Evans , adversarialism can become a vicious cycle:
Adversarialism in Workers Compensation
It is becoming clear that over the years there has been a move towards adversarialism in workers compensation, almost certainly to the detriment of health outcomes for injured workers. There are now teams of people whose focus is either on the objective of cost reduction or on achieving health outcomes, but rarely both.
How do we overcome these artificial boundaries and achieve better outcomes all round? Each side of the fence needs to reach out and understand the other’s perspective and try to regain a shared focus on achieving the best outcome for the injured worker. If that goal can be achieved, I expect that costs can be contained.
LET’S GET BACK TO TEAMWORK – USING THE EVIDENCE BASE TO GUIDE US ABOUT WHAT WORKS!
Insult and Injury 
Dwight Dowda provided the insightful comments below. Thanks Dwight.
Hi Peter
Interesting blog and thanks for sharing it.
Occupational medicine has changed over the three + decades during which I have been an OP
When our specialty was spawned in Australia in the early 80s things were really happening…OH&S legislations were new with exciting jurisdictional and regulatory foci on health and wellbeing of workers and this was against the backdrop of Australia still having a strong industrial productivity with manufacturing etc still onshore. This meant that there was ample opportunity to “do our specialty thing” whether as employed company doctors in various areas (e.g. Electricity Commission of NSW which had as many as 13000 employees in NSW) or as consultants to factories/industry etc.
But OH&S legislation spawned more than Occupational Medicine; safety officers, drug and alcohol counsellors, rehabilitation companies, EAPs etc all became burgeoning industries in their own right and with competition for the $ from such groups and the never ending search for reducing costs on the part of factories/companies/organizations there was a dilution of the work available to OPs.
Many OPs who were full time employed were no longer needed where outsourcing became a cheaper alternative.
With further watering down of industry in Australia and companies either shutting down in Australia altogether or going off shore the available true Occupational medicine work became less available.
But the other facet that grew in importance was the increasingly complex and adversarial world of workers compensation which by its very nature was adversarial with employer versus employee and defense lawyer versus plaintiff lawyer.
The work related nature of workers compensation saw OPs dragged (voluntarily) into this murky world. After all, with reduced opportunities in “real” Occupational Medicine here was a ready resource of income. This was enhanced increasingly by the “discovery” by lawyers and insurers that OPs had broad knowledge of the workplace and workplace injury and disease, so they increasingly turned to OPs for opinions on workers compensation cases.
Our specialty then found itself divided into plaintiff oriented or defendant oriented referrals on workers compensation matters.
This has evolved into OP involvement in other jurisdictions (e.g. CTP, DVA etc) that have no bearing on the prime reason for being an OP. Yet the work is there; who is going to pass up the opportunity to make money if such work is offered?
As to the great divide in our specialty, I think that the common intent of our Fellowship as espoused within the earliest pronouncements of competencies of OPs has been severely eroded by the reduction in opportunity for “real Occupational Medicine” work and the gravitation towards assessment work in a medicolegal setting that has thrust OPs into one or another camp, often entailing bitter adversarial contest.
These are a few thoughts on my impression as to why we find ourselves in the situation that you have succinctly discussed in your blog.
The great divide can be lessened by a common goal of seeking (altruistically) truly ethical and unbiased evidenced based opinion as the basis of our specialty. I say altruistically because our Fellowship is just like any other group in medicine or anywhere for that matter..there will always be a moiety that represents the “bad apple”…driven by the lure of the dollar rather than the higher ideals mentioned above.
These are musings from an OP who is near the end of what has been a truly fascinating trip since early 80s to the present time.
Regards
Dwight
Thanks Dwight
I don’t think young occupational physicians coming through realise that there has been a lot of change in the roles undertaken by occupational physicians over the last 30 years!
Peter Sharman
There has always been a tension between those who see themselves on either side of an adversarial system. I would like to do psychiatric assessments for both sides and indeed have done so but the time frames are impossible. On one occasion I saw the same person twice for the insurer and three times for the plaintiff lawyer, all inadvertent. The claimant had used a slightly different name. To my vast relief my opinion was the same. Ihave enjoyed being on the Medical Panel in Victoria because the adversarial process is absent. similarly, more recently the TAC now allows for Joint medical Examinations where my report goes to both parties.
In Victoria I am include the following declaration in every report.
[I have made all the inquiries that I believe are desirable and appropriate and that no matters of significance which I regard as relevant have to my knowledge been withheld. I have prepared my report according to the requirements of the “Expert Witness Code of Conduct” adopted by the Supreme and County Courts of Victoria and confirm that I have read the Code and agree to be bound by it].
I have also prepared my report according to the following:
Civil Procedure Act 2010
Requirements for Expert Witnesses
The Civil Procedure Act 2010 (“the Act”) came into effect on 1 January 2011. Its main purpose is to reform and modernise the laws, practice, procedure and processes in relation to civil proceedings in the Supreme Court, the County Court and the Magistrates’ Court, and to provide for an overarching purpose in relation to the conduct of civil proceedings to facilitate the just, efficient, timely and cost-effective resolution of the real issues in dispute.
To achieve that purpose, the Act outlines a number of overarching obligations. These apply to expert witnesses in a civil proceeding. They are:
(i) to act honestly.
(ii) to cooperate in the conduct of civil proceedings, with the parties and the court.
(iii) not to engage in conduct that is misleading or deceptive or likely to mislead or deceive.
(iv) to narrow the issues in dispute.
(v) to ensure costs are reasonable and proportionate (being proportionate to the complexity or importance of the issues in dispute, and the amount in dispute).
(vi) to use reasonable endeavours to act promptly, and minimise delay.
In addition, each person to whom the overarching obligations apply has a paramount duty to the court to further the administration of justice in relation to any civil proceeding in which that person is involved.
I write reports for the court or tribunal, not for the referring party. When I train people I say that ‘you should be an advocate for your opinion but not for the claimant or the insurer.
Thanks Michael
I agree that Medical Panels can help remove the doctor from the constraints of the adversarial system.
I was recently extensively cross examined in a court about my understanding of my duty to the court as an independent medical examiner. It is important that doctors working in the legal system understand those issues, but even as a doctor working in the legal system, you can still be an advocate for health as well as an advocate for your own opinion, as you suggest. As my occupational medicine training supervisor, Dr Martin Bicevskis, told me when I was training in the 1980’s our role is not to act as a medical ‘policeman’.
Peter Sharman
Adelaide Occupational Physician, Dr Kar Loong Ng posted this comment on LinkedIn:
“Great work as always Peter. Do you think the concept of (good and effective) early intervention which identifies complex injured workers from day 1 and intervening early, would result in a better health outcome and cost reduction? Perhaps it also reduces effect on the great divide ?”
and I responded as follows:
“I have included Dwight Dowda’s comment below. You will see he uses the term “real” occupational medicine. I think taking on an early intervention role and working as a team with the worker’s GP and workplace is “real” occupational medicine and can certainly reduce costs and can bring together occupational medicine practitioners and other doctors into a co-operative working relationship. Unfortunately the legal system, through its inherent adversarialism, can be divisive encouraging doctors to take sides and restricting open and frank communication that might otherwise result in better outcomes.”