NO, I DON’T MEAN AIRLINE PILOTS!

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A patient told me recently that their surgeon had advised that necessary care could not be provided within the workers compensation system. The only option, as far as the surgeon was concerned, was that the recommended surgery be undertaken with funding from private health insurance. Given the necessity for the surgery, the patient felt there was no choice but to proceed on that basis, which they did. No doubt their future management will be complicated, especially if it is confirmed that they do indeed have a work-related condition and rightfully belong within the workers compensation system.

This anecdote is but a pixel within the big picture of doctors becoming increasingly reluctant to manage patients within compensation systems.

A SHIPPING PILOT?

Let’s briefly digress to consider an analogy relevant to patient management within compensation systems. The concept of a “pilot” is a useful one. I picture a ship’s pilot guiding a vessel through treacherous waters with the primary objective of the safety and well-being of the ship. A pilot has specialised knowledge to guide the ship in risky situations.

Using this analogy, the injured worker remains as the captain of the ship, but a pilot is needed to negotiate a passage through a dangerous reef or to navigate a difficult harbour to find a safe berth.The prime objective of the pilot is the safety of the ship.

Taking the analogy further, the pilot’s objective is not the financial well-being of the system that insures against shipping losses, even though an effective pilot will contribute to the financial well-being of those systems. The health interests of an injured worker and the interests of a compensation system are not completely aligned!

PILOTS FOR INJURED WORKERS

Who can most effectively pilot an injured worker within a compensation system?

I would suggest the following attributes are important.

• A trusted continuing relationship with the injured worker
• Awareness of hazards, safe pathways and relevant resources
• Knowledge of the individual’s psychosocial risks
• Experience in team roles with the ability to communicate with other key participants
• Respect for the role by all system participants

In my view, the person with the best overall credentials to take on that role is the worker’s medical practitioner. The most fundamental criterion is a durable trusting relationship between the injured worker and the “pilot”. A worker can usually be assured that the doctor’s interests are aligned to their health and recovery interests with minimal conflict of interest, reinforced by the doctor’s legal duty of care to their patients. This “duty of care” is absent for other participants, except to the extent that an employer has a legal duty of care regarding the worker’s employment. With the right to select their own doctor, an injured worker can change to the care of another, if that trust is undermined for any reason.

Doctors can fall down in their ability to take on that role however for a number of reasons:

• Lack of motivation or incentive to take on the role
• Limited experience of compensation systems, leading to limits on their knowledge of risks, hazards and safe pathways, particularly in relation to workplaces
• Limitations on communication with other key participants due to time and knowledge restraints

Where a patient’s usual GP cannot take on the piloting role, there should be options for a referral to another medical practitioner with a greater capacity for the role, while retaining the benefits of a trusting relationship through the patient’s input regarding the referral. This can be to another GP or a specialist, such as an occupational physician, with relevant expertise.

There are alternatives for the “pilot” role. While in an environment where an employer has a positive relationship with its employees, an employer might be able to take on a piloting role, the sad truth is that many workplaces remain adversarial and employer/employee trust is often the first casualty after a claim for compensation. The advantage that an employer has is knowledge of the workplace issues and the worker’s workplace history, but in some cases a compensation claim is just another step in the deterioration of the already suboptimal employer/employee relationship.

While a positive role by the pre-injury employer is essential to a return to work outcome with the original employer, it is the complex cases that require a trusting relationship that continues beyond the loss of the original employee/employer relationship. A worker’s doctor has scope for a continuing relationship irrespective of the situation following injury, along with some knowledge of the worker’s medical and psychological history relevant to understanding the response to injury and incapacity.

Another contender for the “pilot” role is the rehabilitation professional. Again, while in many circumstances, an independent and professional practitioner can develop a trusting relationship with the injured worker, there are potential conflicts of loyalty given the mechanism for appointment and funding of rehabilitation professionals. These conflicts have potential to undermine that relationship. The continuation of the relationship is contingent on funding from a third-party i.e. the insurer or the employer itself. If the third party funder interprets a trusting relationship as ‘hand holding’ or advocacy on behalf of the worker, there is the option to terminate the relationship by withdrawal of funding.

While union representatives and lawyers can sometime provide guidance on specific legal or employment issues, I do not see there is scope for these people to take on a routine “pilot” role. Indeed, involvement of unions and lawyers is seen by other parties as evidence of a breakdown in the usual workplace and health care relationships and the start of a process that will inevitably lead to a poor outcome.

Occupational Physicians (OP’s) are arguably the most important medical specialty in the piloting field, given their expertise in work-related health issues and rehabilitation. In my view OP’s should also play a leading role as mentors and guides to other medical practitioners managing patients in compensation systems with a role in direct management of more complex or potentially poor-prognosis cases.

Other important specialties include rehabilitation physicians, pain physicians, psychiatrists, rheumatologists, musculoskeletal / sports physicians and various surgical specialists, particularly orthopaedic surgeons and neurosurgeons, but probably not in a  “pilot” role.

A looming crisis?

My concern is that there are barriers to the development of effective piloting provided by doctors because of a diminishing pool of doctors willing and suitably equipped to take on such roles.

Discussions I have with GP’s suggests many of them don’t want to take on compensation cases (particularly complex ones) any more. It has become all too hard with a complex poorly understood system, need to constantly seek approvals for treatment, disempowerment caused by the role of the insurer and their medico-legal advisors and relatively poor remuneration considering the complexity and input of time necessary.

Despite WorkCover Tasmania’s recent trial of a support and mentoring system for GP’s, known as MAMS, the scheme was abandoned leaving GP’s and specialists without any additional resources to help them manage compensation cases.

The inceasing reluctance of doctors to become involved in compensation systems is also reflected in research undertaken in Victoria. I suspect if such research was undertaken locally, there would be the same findings. See link below.

Is clinician refusal to treat an emerging problem in injury compensation systems?

Perhaps of even greater concern (certainly to me as an occupational physician) is a developing crisis in the local Tasmanian OP workforce with the impending retirement of 80% of the current workforce that has been in practice since the 1980’s.

The 2016 Australian Government Factsheet on the OP workforce provides some sobering statistics. The OP workforce nationally is ageing with well over 50% of practitioners over the age of 60 (myself included)!

Tasmania already has amongst the lowest numbers of OP clinicians per 100,000 population (close behind Queensland) as illustrated by the following charts.

The situation with an OP shortage is compounded by differential remuneration that preferentially rewards OP’s (and other specialist doctors too) to undertake independent medical assessment (IME) work over actual patient treatment and management i.e. involvement in “pilot” roles.

Other medical specialists are also increasingly reluctant to get involved in compensation cases as illustrated by my opening anecdote. With the recent retirement of Hobart’s only rheumatologist willing to take on compensation cases, there are no longer any rheumatologists that seem interested to work in this field. Tasmania’s only rehabilitation physician in private practice advertises on the Tasmanian Health Directory Site: “no workers compensation cases”. Most surgeons I deal with seem reluctant to take on compensation cases.

CONCLUSIONS

I believe we confront:

a deficiency of medical practitioners who could become “pilots” for injured workers

and, it seems

the situation is deteriorating, rather than improving, with time

I draw the above conclusion from observing interactions in my local compensation schemes  i.e. Tasmania’s Workers Compensation Scheme (WorkCover Tasmania) and Motor Accident Scheme (MAIB) and Comcare, but what I do see from interstate jurisdictions suggests that this is a national phenomenon. Formal research confirms this trend.

This phenomenon is also suggested by SafeWork Australia’s initiative to sponsor a committee considering measures to improve GP engagement. Their Annual Report refers to initiatives in this area (page 65):

SafeWork Australia Annual Report 2016/17

The legal and insurance systems are also recognising lack of GP’s engagement and expressing frustration with slowness in provision of medical information to resolve legal issues.

Human Resource Practitioners have identified 6 “mega trends”:

These trends will further challenge our existing compensation systems. See my earlier article Degenerative Disease – Too Heavy a Burden on our Compensation Systems. Already it has been estimated that half the work-related injuries that currently occur are managed outside of the workers compensation systems “designed” for that purpose.

WHERE TO FROM HERE?

There needs to be a fundamental rethink of approaches to successfully engage medical practitioners, both GP’s and specialists, in our compensation systems.

Doctors need to be encouraged by a variety of means to develop the skills and relevant career paths, so that there enough “pilots” for our injured workers. This involves both identifying the barriers to engagement and providing incentives and training for those doctors prepared to become involved in this important aspect of medicine – reducing disability following work injury.

What is needed is a co-operative effort between various medical organisations, government, regulators and consumer groups to explore these issues and develop strategies to promote GP and specialist involvement in compensation case management.

Equally important are strategies to promote the specialty of occupational and environmental medicine in Tasmania so that we have enough OP’s to serve our future needs. There is a clear need from a local training programme for OP’s, before the specialty in Tasmania disappears entirely.