Disputes on the rise and claimants walk away!

Walk away

The 2013/14 annual report from the Tasmanian Workers Rehabilitation and Compensation Tribunal provides data about the number of disputes and the percentage of claimants who do not contest what is known as a ‘reasonably arguable case’ finding.

Link to article

There is a low threshold for a reasonably arguable case finding by the Tribunal, as acknowledged by practitioners on both sides of the liability ‘fence’. An insurer can often readily obtain an independent medical report that might question work causation. In my experience, in many cases lawyers advise their clients that it is best to consent to such a finding and put their efforts into the next step in the legal process to establish liability. The figures suggest that relatively few, however, go on to the next step.

Also, the reality, as indicated by the Tribunal figures, is that the number of disputes are rising both in absolute terms and as a percentage of claims.

The question is why is this occurring.

My medical colleagues tell me that their patients say that often the reason is that to pursue a claim there is a $30K risk. Legal firms quote such a figure as the potential cost if they take on the case, and if there is potential to lose (as there always is) the worker might need to cover that cost.

Understandably many claimants ‘walk away’ from a claim when in other respects they might have a valid claim.

It does seem likely that this jeopardy for claimant workers is an important factor, but there are other potential reasons, for example:

Legal advice that the likelihood of success is poor

The claimant might have returned to work in a short period with nothing to gain by pursuing the claim

It is of concern that many claimants who might be eligible for compensation if their case was properly considered might be prevented from receiving due consideration by the cost barriers imposed by the current system.

While I think it is important that claimants make an informed decision about whether to enter the workers compensation system, it is important that there is equitable access for those that choose this option. See my earlier blog posts – Tough Love and the Update on Tough Love

It would be interesting to obtain accurate information about why claimants ‘walk away’ by surveying those claimants who do and see whether the trend of increasing disputes continues when the next annual Tribunal report is released.

I am interested to know what is happening in other jurisdictions. Comments would be welcomed, particularly to get an insurers perspective on this issue.

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Surveillance Again!

images-3

Personal Injury Lawyer, Brian Hilliard with Slater & Gordon in Hobart has raised issues about excessive use of surveillance for both workers compensation and motor accident claimants. The following article appears in today’s Hobart Mercury newspaper.

http://m.themercury.com.au/news/tasmania/spying-out-of-control/story-fnj4f7k1-1227359463049

I have previously raised concerns about this issue:

Surveillance – Sharp Focus or Blunt Instrument?

With increasing use of technology the scope for intrusion into personal space has increased dramatically. I am yet to see surveillance of a workers compensation claimant from a drone, but it’s probably not far off!

There needs to be a public debate about what is acceptable, so that the law can catch up with technology.

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Update on “Tough Love”

I attended a meeting last night of medical practitioners with an interest in Workers Compensation. Some of them had read my blog article “Tough Love”. There was almost universal agreement that doctors do have a role in explaining to potential claimants the risks and benefits of entering the workers compensation system, as well as providing some indication as to whether they do have a work-related condition, or at least a condition that is consistent with the “stated cause”. While there were some differences in the extent to which the doctors would try to dissuade patients from making a claim there was consensus that doctor’s do have an important role in this area. Interestingly there was one doctor who seemed to disagree. The doctor raised concern from the perspective of a medical indemnity insurer that a doctor might be unfairly using the unequal power of the doctor patient relationship to deny a worker their legal entitlement by being seen to influence a decision about a claim. It was suggested the doctor should complete the certificate in all cases, but annotate the certificate accordingly if there were any doubts in their mind. In Tasmania, there is a box on the certificate where there is the option to indicate that the claimed condition is inconsistent with the stated cause. I think it is fundamentally important that it is the patient’s choice about submitting a claim or otherwise. While a doctor can influence the decision to submit a claim, it is important that, if the worker makes an informed decision to request a workers compensation certificate, that the doctor complies with that request, honestly completing that certificate to the best of their ability and, if necessary, raising any concerns about inconsistency on the issued certificate. It is a nonsense to suggest that doctor’s have no role in informing a worker about the potential negative consequences to their health from our compensations systems. I am interested in comments.

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No coverage by ACC in New Zealand for ‘RSI’ type disorders!

ACC

 Dr John Quintner has asked that I post his article on this site. I welcome the opportunity to facilitate constructive discussion and debate on this issue!

See also references to Dr Quintner’s work on  thetipssite

Here is the article:

FIBROMYALGIA AND NEW ZEALAND’S ACCIDENT COMPENSATION SCHEME

Since 1974 the New Zealand Accident Compensation scheme has provided the only form of workers’ compensation available. It replaced the separate workers’ compensation legislation and the common law right to sue for personal injury.

Despite its name, the Accident Compensation Act provides cover for personal injury resulting from work-related accidents and work-related gradual process conditions.

In 2003, the Accident Compensation Corporation (ACC) obtained a High Court decision (Teen v ARCIC, unreported, High Court, Wellington CIV 2003-485-1478, Wild J) that a pain syndrome developed by an office worker whose tasks included intensive data entry did not constitute personal injury and was therefore excluded from ACC cover.

Varying medical opinions were offered for the appellant’s symptoms: that the claimant had developed fibromyalgia syndrome, implying pain without tissue injury as a result of prolonged repetitive mouse and keyboard use “with the adoption of constrained statically loaded postures inducing tension and lactic acid overload in the muscles”; “regional pain syndrome” of the upper body related to psychosocial risk factors including “fear avoidance behaviour” and “catastrophising” beliefs about pain; and a chronic pain syndrome that could probably be subclassified as fibromyalgia [“FMS”].

The Teen case involved a telecommunications worker. Her symptoms were extensively canvassed in an earlier District Court decision (Teen v ACC and Telecom NZ Ltd [2002] NZACC 244 3 September 2002) which defined fibromyalgia as “abnormal pain and tenderness of normal tissue involving abnormal pain perception in the central nervous system, a condition in which treatment directed at (non-existent) tissue damage in the arms, such as physiotherapy, rest and anti-inflammatory medication, failed to effect a cure; recovery did not occur in the expected time-frame as there was no damaged tissue to recover”.

The case-law following the Teen decision has therefore followed the view that a pain syndrome which developed in the context of repetitive work under stress in an office situation may occur without a discrete physical injury, and is not covered by the ACC. The term “fibromyalgia” is no longer used to describe the constellation of symptoms developed by office workers using computers. The current term is “regional pain syndrome”. 

The Courts of Law in Teen and similar cases involving telecommunications workers were not advised of the extensive debate that had occurred in Australia in the 1980s over the so-called “RSI epidemic”. Nor were they advised that the view put forward by the ACC was based on conjectures promulgated by Dr Geoffrey Littlejohn, an Australian rheumatologist. Interestingly, Dr Littlejohn had given a keynote presentation at a consensus meeting of ACC officials and medical professionals held in February 1998 [1].

Perhaps even more significantly, the New Zealand courts were not advised that NIOSH investigators in the United States had published their findings on telecommunications workers in terms of discrete musculoskeletal conditions [2]. There was a striking similarity between the types of symptoms described in the 2002 District Court decision in Teen and the physical findings described by Hales et al [2], namely “rotator cuff tendinitis, bicipital tendinitis, epicondylitis, proximal tendinitis, distal tendinitis, deQuervain’s disease, trigger finger, cervical root syndrome, thoracic outlet syndrome, radial tunnel syndrome, carpal tunnel syndrome, Guyon tunnel syndrome, ganglion cysts, probable joint-related, muscle-related (tension neck syndrome and neck trigger points).” 

In a Viewpoint article [3], Professor Des Gorman, a New Zealand occupational physician, stated that there were “no objective data to show that mechanical work process alone can cause any of the chronic pain syndromes. Current epidemiological data show that while keyboard workers have an increased prevalence of neck, shoulder and elbow pain, there is no dose relationship between this pain and their work process and they do not have an increased prevalence of any discrete musculoskeletal disorder. The end result is a group of patients who will be “in limbo” – neither acceptable to the ACC as a domestic, recreational, or motor vehicle accident, nor able to prove to the insurance company concerned that a mechanical work process has caused their problem.”

Again Gorman made no reference to the report by Hales et al, or to NIOSH’s collection of epidemiological literature relating to video display terminals (NIOSH 99-135 at www.cdc.gov), or even to NIOSH’s publications on ergonomics (NIOSH 97-117 at www.cdc.gov). Nor did he make any mention of other epidemiological reviews concluding that there was indeed a relationship between musculoskeletal disorders and computer use.

In my opinion, the views expressed by Drs Littlejohn and Gorman reflected their limited understanding of the “RSI” phenomenon in Australia [4,5]. There were indeed competing hypotheses, a fact that may not have been made known to the ACC, nor to the New Zealand Courts of Law.

The end result of this tragic omission has been that New Zealand workers who are diagnosed with “fibromyalgia” or “regional pain syndrome” or similar nebulous types of pain syndrome have no legal entitlement to any other compensation if their claims are declined by ACC.

If they are unable to work, they may or may not be able to qualify for subsistence-type social welfare benefits, but they do not have access to ACC-provided medical investigations, treatments, rehabilitation, retraining, or earnings-related compensation. Finally, if the symptoms do happen to be work-related, there is no means of identifying, minimising or preventing hazardous workplace factors to protect future workers from the relative risk of developing these conditions.

 References

  1. Rankin DB. Viewpoint: The Fibromyalgia Syndrome: A Consensus Report, Accident, Rehabilitation and Compensation Corporation, Wellington. NZ Med J 1999; 112: 18-19.
  2. Hales et al, Musculoskeletal disorders among visual display terminal users in a telecommunications company, Ergonomics 1994, Vol. 37 No. 10, 1603-1621.
  3. Gorman D. Viewpoint: The Accident Insurance Act – a desirable reform or market madness? NZ Med J 2000; 113: 62-63.
  4. Quintner JL, Elvey RL. The neurogenic hypothesis of RSI. In: Bammer G, ed. Working Paper No. 24. Canberra: Australian National University, 1991.
  5. Cohen ML, Arroyo JF, Champion CD, Browne CD. In search of the pathogenesis of refractory cervicobrachial pain syndrome. Med J Aust 1992; 156: 432-436.

 

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Ethics 101 for IME’s – You Cannot Treat Too!

Ethics 101

I had a recent experience worth blogging about.

A Human Resources adviser to an employer recommended that I undertake a  ‘Fitness for Work’ assessment as an independent medical examiner (IME). Apparently there were  concerns about the worker’s rehabilitation progress. The insurer objected, but there are differing accounts as to the basis of the objection. I was not present at the meeting where this proposal was discussed to know first hand what was actually said.

One objection apparently raised was that I might take on a treatment role. The alternative objections were that, as an occupational physician I am not qualified to assess psychological cases, that the insurer saw no reason to revisit liability or the costs of the assessment would be too great.

I want to focus on the issue of IME examiners taking on a treatment role. It is a basic  issue where I would have thought the ethics were clear.

An IME shouldn’t take on treatment – but are there exceptions?

In what circumstances can a doctor engaged to conduct an independent medical assessment take on a treatment or management role? What constitutes treatment? Does a recommendation to undertake an exercise programme constitute treatment?

Here is an excerpt from the AMA document on this subject.

5.1 A doctor conducting an independent medical assessment should not provide routine treatment for the examinee. Emergency treatment should only be provided where no reasonable alternative exists and immediate referral is then made to a treating agency or treating doctor for ongoing care.

Here is a link to complete document:

AMA Guidelines for Independent Medical Assessment

Kim Uildriks,  Contract Psychologist to ADF/Medibank Health Solutions recently posted an article on a related topic:

Should IME Examiners assist distressed injured workers?

The thrust of the article is that IME assessors should assist workers acutely distressed during an IME assessment. I am surprised there would be any debate about that.

Kim quite reasonably concluded:

To me, as a treatment psychologist, the prospect of not offering support to a client when they are obviously in need seems preposterous. But, could I be wrong? How would you as an IME treat someone in this situation? Would offering assistance really compromise your neutrality?

Apart from emergency treatment, I believe the only acceptable circumstance for an independent doctor to progress to a role to direct or manage treatment (or any of the other functions of a treater such as certification or prescription of medication) would be in a situation where the worker (or their own doctor) specifically requested such a course of action and there were no other practicable options to provide the necessary treatment or management expertise through another practitioner (and then only with consultation with the party that had requested the independent assessment).

While I have conducted thousands of Independent Medical Examinations over my working career, I can recall only handful of cases where I later took on a management or treatment role for the worker. A few years ago I did take on management of a worker who had suffered serious injuries in a fall from a height. I had seen the worker for independent assessments at the request of the worker’s solicitor. The rehabilitation physician managing his case withdrew from practice and asked that I take on a management role as there were no other suitable rehabilitation physicians available in Hobart. I agreed to take on that role after discussion (and informed agreement) with the worker and advising the solicitor about the change in role – explaining that I could no longer be considered ‘independent’ in any later legal proceedings.

In my experience this set of circumstances is very unusual, even in Tasmania where there are limited numbers of specialists.

I am aware that in Tasmania other doctors sometimes take on a management or treatment role after an insurer, lawyer or employer has arranged the appointment. Sometimes the role taken on is only to the extent of making a referral for an exercise programme thought necessary, but in other cases extensive and ongoing treatment has been initiated. I am not aware of what request might have been made of the doctor, but it is clear from discussions I have had with some of these patients I have subsequently seen, in some cases at least, that the doctors involved did not explain to the worker their right to choose any doctor who provides treatment.

 I believe it is IME ethics ‘101’ that an IME assessor doesn’t take on treatment except in unusual circumstances, but I am not sure that is universally accepted. Is it an issue in other states? Tasmania is a small jurisdiction with limited medical resources that might be an exception.

I am interested to hear what happens in other states.

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Degenerative Disease – too heavy a burden on our compensation systems?

Degenspinaldisease

I have been critical of arguments used in Independent Medical Examiner (IME) reports to justify opinions that a work injury (or an activity at work) is no longer the “cause” of an ongoing disabling condition.  My criticism is based on the faulty logic of those opinions under our current legal system, not because I have no sympathy or concern for the employer found to be liable when those arguments fail.

One of the most common opinions expressed in defendant IME reports  is that the effects of a work injury have ceased and that any ongoing symptoms are due to an underlying degenerative condition.

The spurious argument

There is an underlying asymptomatic degenerative disease, usually evident as imaging changes. No argument with that! Although there is an acceptance by the IME that an injury, event or a work activity triggered the claimed condition, the opinion is, that despite continuing symptoms, the effects of the injury or work activity have ceased (or will cease at some future time). Therefore any continuing symptoms (and associated disability, work incapacity or need for treatment) are solely due to the underlying condition which is unrelated to work. It is argued that the effects of the claimed injury can only continue for a finite period of time, often on the basis that the inciting injury was minor.

It is the latter arguments that fail the test of logic. I know of no evidence to support the idea that the duration of symptoms following an injury in a compensation system can be accurately predicted, nor evidence about the likely timing of onset of symptoms from an asymptomatic degenerative disorder. Certainly the IME’s who use these arguments do not present any evidence in support. There are however well accepted mechanisms for persistent pain that can  explain chronicity of symptoms irrespective of the severity of any initial tissue damage.

What is fair?

I do have sympathy for the insurer or employer where a claim is made for a seemingly minor incident at work on a background of gross reportedly asymptomatic degenerative disease and the claimant develops long-term incapacity. The employer has to cover treatment, including expensive surgical procedures and income support costs and perhaps a significant payment for permanent impairment.

From a medical perspective, the most significant cause of the claimed condition might well be the worker’s genetic makeup and their life-time of wear and tear activity. The ‘straw’ that breaks the proverbial ‘camel’s back’ (or in the situation being discussed here, the ‘insurer’s purse’) is often a fairly inconsequential injury or event at work, or even onset of symptoms in the course of normal work activity.

Workers compensation liability determination however works within a legal framework. In most jurisdictions, an ‘injury’ arising in the course of employment is all that is required for liability to be placed on the employer for treatment, lost income and permanent impairment. It doesn’t matter much how significant the injury was, or whether there were predisposing factors, if the person was previously asymptomatic, there is a good chance that the employer will be found liable.

Furthermore there is the principle of benevolent interpretation, especially when it comes to impairment assessment. For example, in the current version of the Tasmanian WorkCover Guides to the Assessment of Impairment, the following appears:

‘If there is objective evidence of a pre-existing symptomatic permanent impairment in the same region at the time of the work-related injury, then its value should be calculated and subtracted from the current whole person impairment value. If there is no objective evidence of pre-existing symptomatic permanent impairment, then its possible presence should be ignored.’

The reference to ‘symptomatic’ in the final sentence above is true benevolence, because for a pre-existing condition to be considered significant and taken out of consideration it has to symptomatic, in addition to the requirement for objective evidence of its existence.

Presuming that the worker is telling the truth (and that is not always correct) there are adequate medical explanations for persistent pain following injury i.e. the mechanisms of neural sensitisation and the influence of psychological factors on those processes. It is perhaps wishful thinking that a doctor can arbitrarily state that the effects of the injury have ceased and that the persistent pain and disability has somehow reverted to being due to the underlying condition even if the process had previously been asymptomatic. The ‘but for’ test comes into play from a legal perspective i.e. ‘but for’ the injury/event/work activity, is it likely that the worker would have the current symptomatic condition?

In reality, in most cases, the only logical answer  is that without the work injury/event/work activity the worker would not have the symptomatic condition and therefore the employer is legally liable. It is a separate question as to whether that is fair. As our workforce ages with the expectation from our politicians that we will all work longer and longer these issues will become more and more common.

In my opinion it is usually a nonsense when an IME assessor uses the argument that the effects of a precipitating event has passed and that a previously asymptomatic condition has now taken over as the cause. It doesn’t make medical sense, nor is it ‘common sense’.

The real question?

What is needed to avoid employers becoming unfairly liable for degenerative disease resulting from genetic predisposition and a lifetime of wear and tear?

While it will be a difficult task to change currently well-accepted definitions of causation established by statute and common law, such changes are essential to ensure the burden of occupational injury and disease is fairly borne by employers. Maybe any change will open up a whole new opportunity for legal argument! I certainly hope not.

There are many conditions where work is the cause, but no claim is lodged, or claims are legislatively excluded, particularly burgeoning workplace psychological ill-health issues. If the system is to fairly deal with these conditions, which it does not at present, measures need to taken to reduce the burden on employers from unfair liability for degenerative musculoskeletal disorders.

The answer

A change to the legal definition of injury such that medically recognised contributing factors can be taken into account in determining liability, even for previously asymptomatic conditions.

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Occupational Medicine – “Why do I do it”

An unashamed promotion of the specialty of Occupational Medicine – based on my own experience and biased perspective of the specialty !

Professor David Ferguson - Australia's 'Father' of Occupational Medicine

Professor David Ferguson – Australia’s ‘Father’ of Occupational Medicine

Anyone who has spent time in Hobart and watched TV will have heard the used car commercial that says “WHY DO I DO IT'” when the business owner offers an enticing trade-in offer. I am certainly not suggesting that occupational physicians are in any way like used car salesmen, but I do get the impression that other doctors wonder about the attraction of working in this field of medicine.

A new doctor has joined my practice. This has led me to reflect about the specialty of Occupational Medicine as a career choice for a doctor embarking on a medical career. I hope he reads this!

I recently discharged a patient with great satisfaction. The patient had been referred late in the course of the claim, at the suggestion of the insurer. A somewhat unusual situation as most referrals come from other doctors and perhaps earlier in the course of a claim. The patient was severely depressed with very high pain levels from an orthopaedic injury and had contemplated suicide. The previous specialist involved in the care hadn’t been listening and only proposed medication or further surgery as the solution. The care had become disjointed. The patient was very frustrated to say the least. My practice was able to provide coordinated care including pain management and allied health care, as well as provide information to both the patient’s own lawyer and the insurer about residual impairment and future medical needs (in addition to a lot of information to the patient). The claim was settled without too much angst. I think even the insurer was satisfied with the outcome. While the patient wasn’t able to go back to work, on discharge was coping much better, pain levels had settled markedly and advice was given about future work options. Cynics would say this was because the claim settled, but the improvement was evident well before settlement. The patient thought there was now a future and hinted that a life had been saved. Perhaps it had!  I do think we helped the patient negotiate the system and get out in the best shape possible. Any speciality other than occupational medicine would have had difficulty in that role.

Perhaps occupational medicine does have something unique to offer!

How has the specialty of Occupational Medicine been viewed?

Recent social media posts from the Faculty of Occupational Medicine (FOM) in the United Kingdom have encouraged doctors to become occupational physicians by extolling the attractions of the specialty. As a part of a recruitment drive in February of this year, FOM tweeted – ‘Choose a speciality with wide clinical variety where no 2 days are ever the same’ and ‘Interested in a medical speciality that trains you to be a leader?’ Perhaps the recruitment drive reflects continuing problems with the status of Occupational Medicine in the UK.

Social Media and contact with a German-trained colleague have illustrated the German approach to occupational medicine. Each business has a legal requirement to appoint an occupational physician, but the reality is that there are too few occupational physicians and many businesses in Germany are apparently in contravention of this law. I am told though that in Germany Occupational Medicine is relatively low in the ‘pecking order’ of medical specialties.

There has also been some negativity about occupational physicians expressed on the websites of Injured Workers support groups, suggesting that their opinions don’t carry the same weight as the opinion of other specialists.

Within the field of medicine, Occupational Medicine has been seen as a ‘poor cousin’ to the high-profile specialities, like Neurosurgery. This is rarely openly stated, but it is clear that there has been a lack of respect from other specialists towards occupational physicians, at least in the past. This is probably because it is a relatively new speciality, the areas of expertise are misunderstood or that the training programme has been seen as insufficiently rigorous. Most medical specialities entail an in-depth understanding of the diseases of a particular body system and their treatment, whereas Occupational Medicine covers the relationship between work and health across the entire spectrum of health disorders, both physical and psychological. Some occupational physicians have gained the reputation of supporting insurers and employers to deny treatment, providing further fuel to the concerns of other doctors whose focus is on their patient’s needs.

The status and recognition of Occupational Medicine as a medical specialty has been mentioned in recent informal discussions I have had in a variety of settings – medico-political, medical, insurance and legal. The value of specialist qualifications in occupational medicine and the role of a specialist occupational physician in the workers compensation field is, I think, becoming increasingly recognised.

Acceptance by the Courts?

In recent weeks, I have been asked to give evidence in three different courts – the Commonwealth Administrative Appeals Tribunal, the Tasmanian Supreme Court and the local Workers Rehabilitation and Compensation Tribunal.  One of the matters settled before my evidence was required, however the relatively unusual experience of being asked to appear in court as an expert witness on three occasions in such a short space of time emphasised the growing recognition of the role of an occupational physician as an expert witness. Other occupational physicians also figured prominently in those giving evidence. I have observed over the years that if opinions don’t carry weight in court the practitioner very quickly stops being asked to appear in court.

Does this reflect increasing recognition by the legal fraternity that occupational physician’s opinions have value in higher level legal processes? I think so.

My Own Career Experience

I will digress to provide some background about my own career in occupational medicine.

I undertook my undergraduate medical training at the University of Adelaide completing my training in 1979. I hadn’t grown up in Adelaide nor did I belong to a family of doctors. Initially I wanted to gain entry into the surgical training programme. I am not sure why now, but it seemed like the right thing to do at the time. Certainly to be a surgeon had Kudos, the potential to help people and good income. I became frustrated as it seemed that those who gained entry were those who were already part of the Adelaide medical establishment and I didn’t have a ‘look in’, or perhaps I just wasn’t good enough.

In 1981 a job with the Hydro-Electric Commission (known as the Hydro) as the general practitioner in the construction town of Tullah on Tasmania’s rugged West Coast was brought to my attention. As I was born in Hobart there was an attraction to working in the state of my birth for a year or two, while I decided on a career direction. I took the job (there were probably no other applicants) and was given enormous responsibility as a newly graduated doctor with responsibility for a Medical Centre servicing a remote community of over 2000 people, a nursing staff of 5 and the state’s second biggest ambulance service (more than 6 ambulances, I recall).

This environment was a great introduction to the ‘coal-face’ of workplace health and safety. The Hydro workforce undertook hazardous dam construction activities, including underground tunnelling operations and workshop maintenance, not to mention the road hazards with wet, windy and slippery roads and what was known as the “Tullah 500” as workers escaped each weekend from the West Coast to return to their families on the NW Coast or other parts of the state. During this period there were a number of industrial and road fatalities which brought home to me the ultimate consequence of workplace hazards.

The Tullah Medical Centre had responsibility for workforce health programmes, such as the relatively new concept of hearing conservation. I duly took my part in conducting audiometric programmes for the workforce along with the nurses, often starting early and travelling to the work site to conduct tests before work began. Alcohol and drug issues were also evident.

Professor Niki Ellis

Professor Niki Ellis

Dr Niki Ellis (now a professor with international standing as an Occupational Medicine Academic) was a young occupational physician employed by the Tasmanian Health Department along with Dr Martin Bicevskis (later my training preceptor). She visited Tullah and impressed me with her enthusiasm for occupational medicine. Her visit was my first real awareness of the specialty, having never had any exposure as an undergraduate or newly trained doctor. She later developed a video about the newly identified risks of RSI, a radical approach for the time!

Dr Martin Bicevskis

Dr Martin Bicevskis

I applied to do the 3 month course in Occupational Medicine at the University of Sydney in 1984 and was very lucky to have the support of my employer to attend the course. I had the fortune to meet Professor David Ferguson, Australia’s father of Occupational Medicine and other notable figures in the field. I think the Hydro were prepared to do almost anything to keep a doctor for their West Coast construction operations. Before me they had employed a doctor who had become notorious as one of the first doctors convicted of Medicare fraud!

I had the interesting experience of being the Hydro’s doctor at a very interesting time in Tasmanian politics when there was controversy about the building of the Gordon below Franklin Dam, when Bob Hawke intervened to prevent its construction. At the time ‘Greenies’ as they were known travelled to the West Coast to protest and one night camped at the Tullah Oval – a very provocative move, but I don’t remember any serious injuries from clashes with the Hydro workforce.

I completed the Sydney Course, and again with the support of the Hydro, I was offered the opportunity to set up one of the state’s first occupational health units, based at Head Office in Hobart. The position was recognised as a training position towards specialist qualifications in Occupational Medicine, with Martin Bicevskis as my preceptor. All I had to do was to recruit a doctor to replace me on the West Coast. Not an easy feat, but I achieved that with Dr Alfonso Messieh from Sydney who took over my role in Tullah. I understand is still working in Tasmania to this day, although he didn’t stay long at Tullah.

In Tasmania at the time Occupational Physicians only existed within organisations. I worked with the Hydro, Dr Tim Stewart worked at the ZincWorks, Dr Andreas Ernst worked at Comalco. In the Public Sector there was Dr Helen McArdle and Dr Martin Bicevskis. How that has changed! There are now no privately employed Occupational Physicians in Tasmania.

In Hydro Head Office, I started to realise the power of Occupational Medicine. We brought in one of the state’s first Smoke Free Workplace Policies to a workforce of over 5,000. I realised that such a policy had the power to assist hundreds of employees quit smoking. This is much more powerful than working 1 on 1 with patients! We had initiatives to deal with ‘RSI’, developed strategies for rehabilitation for both work-related and non-work related conditions, health promotion programmes as well as dealing with specific occupational hazards, e.g. the carcinogen creosote that was still being used to preserve very old ‘wood stave’ pipelines.

I also had experience in dealing with health and industrial relations aspects of asbestos, most notably at the Bell Bay Power Station in the state’s north. A wealth of ‘hands on’ experience. I am indebted to Peter Sutczak, staff counsellor and Heather Scott, occupational health nurse who worked with me at that time and opened my eyes to gender equality and the psychological consequences of injury and many other aspects of workplace health and safety. It was during this period that I met Phil Dening, a doyen in the field of vocational rehabilitation who went on the take an important role in Injury Management with various insurers.

I was involved in controversy too, not always over occupational issues, but in my role as manager of the Hydro’s medical services. A senior nurse employed as the Hydro township of Tarraleah in the central highlands of Tasmania used her sick leave to attend a school camp. Hydro Human Resources made an example of her and she was duly sacked for abuse of her entitlements. The Tarrleah community responded. A strike by the power unions followed  and I was embroiled in an industrial dispute than nearly ‘switched off the lights’ in the state. It was interesting to observe first hand the interaction between the Premier and the Hydro General manager in response to this situation, at a time when some people thought the Hydro was more powerful than the government. The upshot however from an occupational medicine perspective was my interest in what came to be called ‘absence management’. I realised the workplace culture in some areas was of acceptance of use of the annual entitlement of sick leave for other purposes. As a result of initiatives I helped develop, the Hydro put in place policies and procedures to address absenteeism and change the cultural attitude towards use of sick leave.  The leave entitlement system was changed to what became known as ‘No-debit sick leave’ where employees did not receive an annual entitlement to sick-leave. Other organisations, like Forestry Tasmania later followed with similar changes.

After I presented a paper at the national occupational physicians conference in Hobart, the College of Occupational Medicine (as it was then known) developed a guideline on Managing Absenteeism (a joint effort between SA occupational physician Peter Jezukaitis and myself). While this work has now been superseded by publications such as Realising the Health Benefits of Work this involvement demonstrated the potential for occupational medicine to have a broader impact on health issues in the workforce, in addition to  productivity and industrial relations issues.

I had another brush with notoriety that lead to my loss of confidence in the main stream media. I have detailed that experience in an earlier blog article. Why Insult & Injury?

I have had continuing contact with another occupational physician, Dr Helen McArdle during most of my professional career. Helen was working with the State Electricity Commission in Victoria when I first had contact, but has worked with the Tasmanian Health Department now for many years. We worked together in the early years setting up an occupational health service for the Royal Hobart Hospital, that replaced the earlier general practice clinic for hospital staff.

I left the Hydro in the early 1990’s to join a newly formed private vocational rehabilitation business. It was here I started to understand the dynamics of private workers compensation insurance, having been shielded from the ‘cut and thrust’ of private insurers with the Hydro as a ‘self-insurer’ for much of the time I worked there.

I had involvement with FAI Insurance’s Doug Smith and Colin Fagen and developed a respectful relationship with that organisation, providing rehabilitation services, that were recognised at the time as making a significant impact by reducing their claims costs. Colin went on to take a very senior role with QBE insurance. Later on FAI helped bring down HIH insurance after their two businesses merged, but I take no responsibility for that! I also met Peter Easther (now retired) who worked with TGIO, GIO and Vero Insurance. His approach seemed to exemplify an even-handed approach providing claimants with the opportunity to recover from their injuries.

During this period I developed an understanding of the rehabilitation industry and had the pleasure of interacting with some of the leading Tasmanian practitioners in the field. Maureen Rudge was a true pioneer, I recall hearing about her initial forays into the field of vocational rehabilitation while I was still working on the West Coast. Maree Webber is another practitioner who stands out along with Phil Dening and more recent people in the industry like Peter Wheatley.

During this period I also undertook OH&S audits across a variety of Tasmanian industries, which assisted my understanding of the dynamics within small and medium-sized businesses including Tasmanian icons like Blundstones, Hazell Bros and Gunns Timber. I was particularly impressed by the culture of the Underground Mining Equipment Manufacturer, Dale B Elphinestone, based in Burnie, later bought out by the multinational Caterpillar. Again, organisational culture could be seen as having an enormous influence of workplace health and safety performance. In the case of Elphinstone’s you could see the culture started right at the top with Dale Elphinstone himself, but the enthusiasm of WHS practitioners like Terry Clarke who made it all work.

During the period when I worked with the Hydro and while operating a rehabilitation and OH&S business, I was relatively isolated from mainstream medicine. Coming back into more contact with other doctors when I changed career tack to become a Consultant Occupational Physician in my own private Hobart Practice in the late 1990’s made me more aware of the culture within the field of medicine, that is difficult to identify from within. This topic might be the subject of a future article.

I had the opportunity to host Dr David Fitzgerald as a trainee occupational physician at my practice. David has gone on to set up an Occupational Medicine unit with Emirates airlines, based in the Middle East, but continues in a training role for ‘Remote area’ occupational physician trainees in Australia.

Dr David Fitzgerald

Dr David Fitzgerald

Most recently I have become involved in a medico-political processes. I was involved in the committee that helped develop the WorkCover Tasmania guidelines for the assessment of impairment. Another controversial area! I had the pleasure of working with occupational physician, Dr Dwight Dowda, Australia’s leading figure in impairment assessment during that process.

Dr Dwight Dowda in Fiji

Dr Dwight Dowda in Fiji

 

I was involved as the medical board member with Asbestos Free Tasmania Foundation and worked with Simon Cocker former Secretary of Unions Tasmania in that role to enhance awareness about community risks from asbestos. Most recently I have worked with the AMA where there has been the opportunity to interact with general practitioners and other specialists. Involvement with the AMA WC Reform Committee and the AMA – Insurer Forum has illustrated to me that the training and experience of occupational physicians has a lot to offer. Most doctors do not have the benefit of an overview of how compensation processes work. This work has brought me into contact with interstate occupational physicians, like Dr Kevin Sleigh in Victoria who has a role with the Victorian WorkCover Authority. This contact has provided a perspective on initiatives in Victoria such as their well established Medical Panel system and new approaches such as auditing of IME reports and jointly appointed IME’s.

It is only in recent years that I have had the opportunity for involvement in research and publication. Although I had input into the Absenteeism Guideline produced by AFOM in the early 1990’s, it was not until 2 years ago that I had an article published in a peer-reviewed journal – a case study of a new cause of interstitial lung disease identified at a Tasmanian Fish Farm. Last year I become involved with a University of Tasmania study about attitudes to our Workers Compensation System. Shivon Prakesh is the post-graduate student co-ordinating the research. I am at present trying to get another publication in a peer-reviewed journal, this time about the current status as what is colloquially known as ‘RSI’.

There have truly been ups and downs in my career spanning the last 30 years, but I remain content with my choice of career, especially looking back on what can be achieved in the field of medicine and more broadly by contributing to the protection of health in the workforce through work as an occupational physician.

Has Occupational Medicine come of age?

It is evident that there is growing respect for Occupational Medicine as a specialty from other medical specialists, in addition to the recognition already received from employers, insurers and lawyers.

I now routinely see recommendations from other specialists to obtain the opinion of an occupational physician on matters such as fitness to work for the patients under their care. There are increasing referrals from general practitioners asking for assistance with care for their patients within compensation systems. Hopefully this is not just because the general practitioner finds it too frustrating to deal with the system (although that no doubt is part of it), but because there is recognition of benefit from involvement of an occupational physician in terms of health outcomes.

Occupational physicians have medical knowledge across a range of medical and psychological domains, in addition to an understanding of the workplace and insurance systems that interact with our health systems to assist or retard recovery. No other specialty has that scope.

In Tasmania at least there is still a way to go for acceptance at a Government level. There is currently no real acceptance by WorkCover Tasmania of any special role for Occupational Physicians in our compensation systems, although there has been some discussion about that possibility with the proposed Medical Advisory & Mentoring Service. It is ironic that the Australasian Faculty of Occupational and Environmental Medicine (AFOEM) publication Realising the Health Benefits of Work is promoted by WorkCover, but not the speciality of Occupational Medicine itself.

Some might see the development of Occupational Medicine as a another example of specialists taking over more and more of the traditional territory of general practice. It seems clear to me that the management of complex work-related health issues should be the domain of specialist occupational physicians providing guidance to other medical practitioners, as well as the other parties in our compensation systems.

Occupational Medicine is also the specialty best equipped to provide advice at a government and strategic level about the medical aspects of workers compensation systems.

While the current occupational medicine training programme might be more academically rigorous than in the past, I don’t think it can substitute for the cut and thrust of the variety of experience that I had the privilege of having over my career. It is crucial that Occupational Medicine trainees continue to have a breadth of experience  in different settings, and with a variety mentors to get the experience that can’t be gained from work in a single clinic or workplace or from research and classroom learning.

Occupational Medicine is a great specialty!

It gets you out and about into the real world of business, making a contribution to the economy and community.

You can make a difference to people’s lives, at an individual level, an organisational level and, in the right circumstances, at a societal level.

For those doctors contemplating a career in Occupational Medicine, the speciality allows work-lifestyle balance. It is a family friendly specialty where there is usually no on-call or shift work.

True, there is a lot of paperwork and reports, and at times involvement in conflict, but the intellectual challenge of providing care for patients in a complex environment, explaining and interpreting health information to suit the audience (from illiterate worker through to business executive and the judiciary) and the satisfaction of success as a doctor helping a worker recover, outweighs any negative aspects.

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‘Tough Love’ – Do doctor’s have a role in keeping people out of the WC system?

Tough Love

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.

 Treating doctors have an important role in assisting their patients to make an informed choice about initiating a claim for compensation. Risks and benefits need to be weighed up, but it is ultimately the patient’s choice. Already many choose to avoid the system.

Extricating workers with an existing claim from a damaging system is a more difficult task for a treating doctor. Unless there are changes to existing legal definitions of injury, the only realistic option is to alter the system so that doctors can flag such situations so that system processes can take over and provide a way out.

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Strange Bedfellows! The AMA Insurer Forum in Tasmania

Strange Bedfellows

Before the weekend can start in earnest (I have made a commitment to clean out my car and wash the dog), I thought I should share some commentary about a process that has been underway in Tasmania over the last six months or so.

In my earlier post, Let Me Explain I mentioned my roles as the Convenor of the AMA Tasmania Workers Compensation Reform Committee and as convenor of meetings between the AMA and representatives of the insurance industry, known as the AMA Insurer Forum (AIF).

It is not possible to provide independent commentary about a process where you are directly involved, but the process is certainly worthy of mention. My involvement declares my personal support for such initiatives.

The impetus to the process was the growing frustration by doctors about poor outcomes for a relatively small proportion of workers injured (or claiming to be injured) at work. The AMA agreed to set up a committee of concerned members, and following liaison with representatives of the private insurers, and later the self-insurers, a process was set up to facilitate dialogue. It was an opportune time as the new Tasmanian Liberal government was due to review the workers compensation legislation and had also expressed an interest in ‘Red-Tape’ reduction.

It emerged that there was common ground between the insurers and doctors in some areas. The WorkCover Board in Tasmania which oversees the system has voting representation for workers and employers, but doctors and insurers as key ‘players’ have no voting representation, only practitioners nominated by the Minister with expertise in their respective fields, not true representation or voting rights.

There was also commonality of concern about lack of communication and understanding between doctors and insurers that was contributing to the poor outcomes for injured workers and the costs of the scheme. There was also agreement that impairment assessment methodology where spinal surgery had been undertaken required review, although the issues for doctors and insurers were somewhat different.

As a result of the process the AIF was able to produce a joint submission to Minister Peter Gutwein. The submission included recommendations for immediate priorities that fitted within the Government’s ‘Red-Tape’ reduction priority over the next six months and recommendations for more fundamental changes to be considered in the long-term.

The AMA, in particular, was keen to explore what has been called a ‘Complex Case Management Model’ where  the doctor involved in the “early” stages of management of a work injury is empowered to consider prognostic factors and identify “complex” cases. The AMA recommended that cases flagged as “complex” could be streamed into an alternative management pathway managed by a medical practitioner with enhanced skilled in “complex case management”.

In addition, the AMA expressed concern that workers compensation processes had been dominated by a legal adversarial approach to the detriment of optimum health and rehabilitation management. Higher level input by the medical profession was seen as necessary to balance the system more in favour of health outcomes.

I previously expressed concern about lack of research data about compensation systems.

How Big is the Elephant in the Research Room?

However more research is being done. Just yesterday the ISCRR’s Alex Collie has publicised relevant research on the importance of health professional interactions with insurers.

Healing or Harming? Healthcare Provider Interactions with Injured Workers and Insurers in Workers’ Compensation Systems

It seems clear that processes such as the dialogue between insurers and doctors occurring in Tasmania can be more productive with the increasing evidence base about factors that affect outcomes for those injured at work. Discussion no longer need to rely entirely on personal perspectives and opinions, but on some more solid, if incomplete, data.

The AIF Joint Submission has now been widely circulated to interested parties in Tasmania and is available for those interested to read the detail.

Here is a link: AMA Insurer Joint Submission

The preamble provides some perspective:

‘AIF’s key initiative is the need to achieve better health outcomes for workers in the Tasmanian Workers Compensation system through mechanisms such as balanced decision-making models incorporating medical and injury management input at a case and strategic level. This can be achieved by:

 * initiating alternative injury management pathways,

* early identification of complex/long-term injury cases, and

* establishing mechanisms to monitor the quality of medical input

 AIF also identified that communication between doctors and the insurance industry will need to be further enhanced to ensure more collaborative working relationships are established to achieve our key initiatives.

 Enhancements in the way injuries are managed in accordance with these principles has potential to expedite recovery time, lower the risk of secondary conditions and improve return to work outcomes. These measures will ultimately reduce the direct and indirect cost of work related injuries, including employer premiums.   The community as a whole will also benefit from a reduction in the impact of chronic ill-health and disability.

 AIF agree that ‘simple’ injuries that account for up to 90% of all work related injuries are well catered for in the current system. The focus of attention of the AIF has been to consider measures to enhance the management of the more serious or ‘complex’ cases that the statistics indicate account for the majority of financial and human costs.

 The challenge is to identify these cases as early as possible after injury/ disease onset so that medical and rehabilitation resources can be used more effectively to improve outcomes.’

 Dialogue between key ‘players’ in workers compensation is key to mutual understanding and improvements in the system!

 

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AHPRA and IME’s

The WorkCover Victim’s Diary and Civil Forensic Psychiatry blogs have recently made commentary on issues with IME assessors and complaints processes.

I have previously blogged about issues with IME assessors.

IME’s – The Good, The Bad and the Ugly Pt 3

Dr Epstein has raised concern about undue impact on doctors from the AHPRA complaints investigation process while WorkCover Victim (I wish she would publicise her name) raises the issue of widespread bias and unprofessional conduct by IME assessors.

Dr Epstein states:

…….our concern is that a significant number of complaints about independent medical examinations are from disgruntled people who want to lash out at the IME if the opinion provided is not acceptable.

Doctors are frustrated by the trivial nature of many of the complaints, they are frustrated by the time and emotional energy expended in responding to these and by the economic cost.

APHRA – our enemy or our friend?

I have had concerns that the WorkCover Victim site doesn’t put forward solutions and tars all IME assessors with the same brush, but in the most recent post the following statement appears:

I am NOT saying all doctors in our workcover system are horrible creatures; many have indeed left the industry for private practice (rather, it is said that some have ‘retired into’ workcover examinations/assessments…), we believe better guidelines for IME (and the like) designations, along with rigid ethics requirements, stringent quality control and recordings of examinations/assessments of all injured workers must be seriously considered in order to save lives and indict criminals.

http://aworkcovervictimsdiary.com/2015/02/something-is-rotten-in-the-workcover-system/

While I think recording of examinations/assessments is impractical and would introduce a whole new set of problems, the other recommendations by WorkCover Victim are logical.

I have had my own recent experiences of doctors whose behaviour does not accord with my  understanding about what is professional, safe and reasonable. Concerns arise both with practitioners treating workers and IME assessors, but the latter issue is far more common.

I work in Tasmania and it is possible that the Tasmanian workers compensation and motor accident jurisdictions have more than their fair share of unprofessional or biased IME assessors (or assessors working outside their area of competence). In the absence of any enforceable professional standards for IME assessors and tightening of standards in interstate jurisdictions, it is likely that those assessors who cannot work elsewhere are flying in to Tasmania. Indeed the term ‘fly-in’ in the context of IME assessors has a negative connotation here amongst injured workers and treating practitioners.

Generally the worst IME offenders are only ‘weeded’ out of the system when the insurers realise that their opinions cause too many complaints and problems, or when they realise that their opinions do not ‘stand up in court‘. Unfortunately this realisation by the insurers can take a while (sometimes many years), to the detriment of fairness for the workers assessed while that process takes place. I understand (hearsay only) that one of the medico-legal provider organisations is bemoaning the problems they are having in recruiting quality practitioners to provide IME opinions. Perhaps the insurers too have the same concerns.

While Dr Epstein raises concerns about the frequency of  trivial complaints, the experience with patients I am treating is that they are perhaps too reluctant to complain. Patients who have suffered from what appear to be biased or unprofessional assessments are generally unwilling to raise any official complaint, be it with the local WorkCover authority or AHPRA. The Health Complaints Commissioner locally no longer accepts complaints about IME assessors, only complaints about practitioners involved in their treatment. I understand that a complaint about an opinion I expressed about a prospective worker’s unfitness to work in a particular role was the last formal complaint considered by that organisation!

My experience also is that doctors are also very unwilling to complain about other members of their profession, even when there are clear problems or they are doctors who fly in from another state. Doctor’s medical defence organisations advise extreme caution in raising complaints about ‘colleagues’ for fear of counter claims and other unintended consequences.

AHPRA does have an important role in dealing with complaints about doctors. I agree that process should be fair for the doctors and the complainants. Measures do need to be in place to screen out frivolous or trivial complaints, but in a jurisdiction like Tasmania where there are no standards for IME assessment issued by WorkCover and no auditing of IME reports, there should be no additional barriers in place for injured workers aggrieved by an IME assessor. There should also be a better mechanism for doctors to raise concerns about other doctors. Often it is the doctors who can most easily recognise the deficiencies in other doctors in terms of bias, unprofessional practice or lack of competence. While I recognise complaints from other doctors might be seen as an expression of professional jealousy or ‘turf wars’ there is still an important role for doctors . I don’t have all the answers about the best processes, but injured workers cannot be expected to know what is reasonable professionally, only recognise when they are treated rudely, roughly or accorded insufficient time to explain properly.

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