EXPERIENCES OF MEDICAL ADVISORS IN THE WORKERS’ COMPENSATION SYSTEM IN BRITISH COLUMBIA by Lydia Amold-Smith RN, Royal Columbian Hospital, New Westminster, 1978 BScN, University o f Northern British Columbia, 1999 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in DISABILITY MANAGEMENT THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA May 2006 © Lydia Amold-Smith, 2006 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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Conformement a la loi canadienne sur la protection de la vie privee, quelques formulaires secondaires ont ete enleves de cette these. While these forms may be included in the document page count, their removal does not represent any loss of content from the thesis. Bien que ces formulaires aient inclus dans la pagination, il n'y aura aucun contenu manquant. i*i Canada Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPROVAL Name: Lydia Amold-Smith Degree: Master of Arts Thesis Title: EXPERIENCES OF MEDICAL ADVISORS IN THE WORKERS’ COMPENSATION SYSTEM IN BRITISH COLUMBIA Examining Committee: Chair: Dr. Robert Tait Dean of Graduate Studies University of Northern British Columbia Sup w visoi^ Dr/fe^iry Harder Associate Profpssor, Disability Management Program University o f Northern British Columbia C o p r ^ tte ^ M m ^ r D r . Shannon Wagner Assistant Professor, Disability Management Program University of Northern British Columbia Committee Member: Dr. Lantana Usman Assistant Professor, Education Program University of Northern British Columbia External Examiner: Dr. Penelope Barrett Associate Professor, Nursing Program University o f Northern British Columbia Date Approved: Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Abstract Attending physicians and medical advisors, physicians contracting their services to the Workers’ Compensation Board, have key roles in assisting injured workers to return to work. A literature review of the role o f the physician in the compensable return to work process reveals a lack o f information regarding the experiences o f medical advisors. This descriptive phenomenological study was undertaken to explore the lived experiences of four medical advisors in a northern rural service delivery location. The purpose o f the research was to gain an understanding o f the medical advisors’ experiences in the compensable return to work process and in the compensation system. Analysis o f the interview data revealed a central theme of commitment to quality medical care for injured workers, along with three major themes and several minor themes subsumed within the major concepts: providing medical opinions - requiring factual information, clarifying the diagnosis, no previous relationship with worker, categories o f injuries; working with attending physicians and specialists - building relationships, evidence based treatment plans, role of the attending physician, role of the medical advisor; and, working within the workers’ compensation environment - structure and policies, expedited services, and case management/team environment. This research report presents the central theme as the foundation through which the major themes are interconnected. This study does not generalize to all medical advisors, but relays stories that contain the essence of a lived experience. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Acknowledgements I attribute the completion of my graduate studies and this thesis to people who have offered support along the way. Special thanks to my supervisor, Dr. Henry Harder, committee members, Dr. Shannon Wagner and Dr. Lantana Usman, and external examiner, Dr. Penelope Barrett, for their direction, support, and guidance. As well, many thanks to my classmates, Maria and Kim, whose friendship and support have been invaluable. Lastly, and most importantly, thank you to my husband, Lorrie, and my children, Marisa and Brett, for your unremitting love, devotion, and support. Completing this thesis would not have been possible without you. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS Abstract ii Table o f Contents iii Chapter 1 Introduction to the Study Significance of the Study Purpose of the Study Research Question 1 3 5 6 Chapter 2 Literature Review Introduction Concepts Common to Compensable Return to Work Disability Disability Management Disability Prevention Workers Compensation British Columbia Medical Association Role o f the Attending/Primary Care Physician Historical Prospective In Canada Physician Responsibilities Assess Diagnose Treat Return to Work/Functional Plan Monitor Report Ethics Communication Prevention Physician Education/Training Role o f the Occupational Physician Role o f the Medical Advisor Conclusion 8 8 8 8 10 12 15 15 17 17 20 22 24 25 31 37 41 41 42 45 46 48 50 53 Chapter 3 Research Methodology Orientation o f the Study Study Participants and Sites Data Collection Technique and Practice Data Analysis Ethical Considerations O f Method 54 54 56 58 59 61 Chapter 4 Findings and Discussion Introduction Findings 63 63 64 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 5 Appendix A Appendix B Appendix C Appendix D References Choosing to Contract Services to the WCB Medical Advisor Training Central Theme Major Themes and Sub-Themes Providing Medical Opinions Requiring Factual Information Clarifying the Diagnosis No Previous Relationship with Worker Categories of Injuries Working with Attending Physicians and Specialists Building Relationships Evidence Based Treatment Plans Role o f the Attending Physician Role of the Medical Advisor Working Within the Workers’ Compensation Environment Structure and Policies Expedited Services Case Management/Tearn Environment 64 65 67 67 67 67 72 73 77 81 81 89 93 98 106 106 108 110 Summary, Conclusion, and Recommendations Summary Conclusion Recommendations Limitations o f the Study Implications for Practice and Future Research Personal Reflections on the Research Consent to Access Site Form Medical Advisor Interview Guide Transcriber Confidentiality Agreement Agreement o f Participation Forms 115 115 122 123 123 124 124 127 129 132 133 137 iv Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 1 INTRODUCTION TO THE STUDY Physicians play an extremely important role in the process o f assisting injured workers to return to work (Shrey, 1995; Wyman, 1999). They are trained and certified to determine the diagnosis, order investigations, and prescribe therapy for clinical conditions (Cowell, 1997). Workers’ compensation boards across Canada rely upon attending physicians to provide ongoing clinical care to assist injured workers in their recovery and to facilitate the return to work process (Guzman, Yassi, Cooper, & Khokhar, 2002; Russell, Brown, & Stewart, 2005). Medical advisors, physician members o f the clinical services team of WorkSafeBC, the Workers’ Compensation Board (WCB) o f British Columbia (BC), also play key roles in the return to work effort (WCB, 1999). Work is identified as a key determinant o f health. Work is the primary activity for normal adults and is an essential part o f human life (Harder & Scott, 2005; Loeser & Sullivan, 1997). Unemployment has a detrimental impact on an individual’s mental, physical, and social well being (Guirguis, 1999; Health Canada, 2003). According to Janlert (1997), there is a causal link between unemployment and the deterioration in health status. In 1998, Canadian workers lost a total of 72 million workdays to illness or injury (Dyck, 2000). The direct health care costs of workers aged 15 to 64 was calculated at $37.4 billion. Indirect costs are much more difficult to measure and include a decrease in productivity caused by the loss o f an experienced worker, the loss to the tax system as a disabled worker is placed on disability pension, and the increased demand on social services as the unemployed cope with reduced economic circumstances (Shrey, 1997). 1 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The primary goal of managing disability is safe and early return to work (Williams & Westmorland, 2002). The longer an injured worker is off work, the less likely it is that he/she will ever return to productive employment (Dyck, 2000). Disability management is a proactive, employer based approach aimed at preventing and limiting disability, providing early intervention for health and disability factors, and fostering rehabilitative strategies to promote cost effective restoration and return to work (Franche & Krause, 2002; Harder & Scott, 2005; Williams & Westmorland, 2002). The Canadian Medical Association (CMA) recognizes that prolonged absence from work is detrimental to physical and social well being (CMA, 2000). According to the CMA (2000) policy, the role o f the physician is: to diagnose and treat the illness or injury, to advise and support the patient, to provide and communicate appropriate information to the patient and the employer, and to work closely with other involved health care professionals to facilitate the safe and timely return to the most productive employment possible, (p. 1) A physician is responsible for understanding his/her patient’s role in the workplace, recognizing and supporting the employer-employee relationship in return to work, and facilitating the injured worker’s return to function and return to work. Medical advisors emphasize the goal o f return to work within the framework o f the Workers’ Compensation Act (WCB, 1999). While the attending physician is able to . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2 provide information regarding non-compensable factors that may impact an employee’s return to work, the medical advisor focuses on the injured worker’s compensable injury and the worksite. Together the attending physician and medical advisor collaborate to prepare a clinical care or treatment plan to assist the injured employee with a safe return to work in order to enhance his/her recovery. Significance of the Study As a nurse advisor and member o f WorkSafeBC, the WCB, Worker and Employer Services division, my role involves the application of my professional skills and knowledge to prepare and monitor return to work plans while using the principles o f disability management. This entails working closely with the injured worker, employer, attending physician, and WCB case management team, including medical advisors. Having worked in the nursing profession my entire adult life, I have interacted with many attending physicians and medical advisors. As a nurse advisor for the past six years, I have been witness to the multiple different approaches general practitioners have undertaken in the management o f injured workers in the compensable return to work process. As a member of the case management team, I also work with medical advisors within a scheduled team meeting format, at worksite visits and teleconferences, and informally on a claim by claim basis as necessary, to assist injured workers return to work. As a registered nurse, I have seen my practice evolve from one o f taking care of patients in the acute care setting to one with an increased focus on health promotion and teaching individuals in the community to take care o f themselves. My current population of interest is workers who have been injured at work. To assist injured employees with achieving the goal of return to work, I work alongside attending physicians and medical advisors. 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Although I work closely with medical advisors and have been an eyewitness to their practice with objective medical opinions and skills in occupational medicine, I do not have a clear understanding o f their specific experiences. I chose to undertake this research in order to gain a deeper understanding of the lived experiences of medical advisors in the performance of their job duties as they contract their services to the WCB o f BC. I hoped to discover if it was possible for me as a nurse advisor to gain a clear understanding of this essential lived human experience in order to enhance my practice and professional relationships with medical advisors, and indirectly, with attending physicians with whom I collaborate to prepare return to work plans for injured workers. My experiences with medical advisors have been extremely positive. I had previously met or worked with the majority of the physicians recruited for this study prior to working with them in my position as nurse advisor. As members of the case management team, nurse and medical advisors interact on a continuous basis. I have read their opinions on claim files, listened to their advice and informal education sessions in team meetings, and attended both worksite visits and formal workshops or in-service sessions with them. I believed I had a solid foundation of knowledge concerning the services medical advisors provide. However, each medical advisor has a unique style and approach to practice. Medical advisors document and discuss with WCB team members the results of their numerous conversations with general practitioners and specialists. Nevertheless, I was curious as to how they approached other physicians, how their calls were received, and what those experiences meant to the medical advisors. I was also puzzled as to why, in my opinion, many attending physicians do not understand their role in the compensable return to work process, and if they do, why they do not practice the appropriate management. My work is much more 4 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. challenging and, at times, an injured worker’s recovery is prolonged if attending physicians do not practice the principles o f disability management. Perhaps medical advisors had some insight as a result of their ongoing contact with general practitioners and specialists. I wondered if attending physicians viewed calls from medical advisors as interference or assistance. My belief was that attending physicians would be amenable to discussing cases with medical advisors, physician colleagues, because of their respective medical backgrounds. I was also interested in learning how medical advisors felt working within a structured compensation system and a team environment as opposed to general or private practice where the physician often works in comparative isolation. Lastly, knowing the many questions medical advisors are posed with, I was curious as to how they wade through the information in a file in order to provide medical answers. Research is required to shed light upon the experiences of medical advisors in the workers’ compensation system and bridge a gap in the research literature. Although the study is preliminary, in my view, it adds to a knowledge base on how to better work and communicate with medical advisors, as well as attending physicians, considering the influential role they play in the return to work process. This research provides a better understanding o f the experiences of medical advisors and may also prove useful in terms o f medical advisor training. Because o f the scope of the study, it is my assumption that it may motivate further research and additional investigations with similar designs to extend findings. Purpose o f the Study The purpose of this study was to gain an understanding o f the experiences o f medical advisors in the workers’ compensation system. It is my hope that the information gathered from this research will impact practice within the case management team by reflecting the lived 5 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. experiences and voices o f medical advisors in the performance of their duties, as well as provide insight into collaboration with attending physicians in order to achieve improved return to work outcomes for injured workers. There is substantial literature regarding the role o f the physician in compensable return to work, with most o f the literature regarding return to work surrounding low back pain. However, no research exits with the context o f medical advisors and their experiences assisting the case management team in managing clients in the workers’ compensation system. The goals o f this research study were to obtain an in-depth understanding of the experiences of medical advisors in the compensable return to work process and the experiences of medical advisors in the workers’ compensation system. My goals were to explore each participant’s experience in relation to their duties at answering questions posed by the case management team, in relation to their interactions with attending physicians and specialists, and in relation to working within the environment o f the workers’ compensation board. My research explored these experiences through conversational interviews with four medical advisors who contracted their services to the WCB in a northern rural service delivery location. Research Question As common with qualitative inquiries, research questions are postulated to provide a guide to the study, as well as to ensure that the central phenomenon is investigated (Creswell, 1998). The study research questions are grounded on a central research question: What are the experiences of medical advisors as they assist in the management of injured workers in the workers’ compensation system? Based on the literature review and my past experience as a nurse advisor in the workers’ compensation system, sub-questions (Creswell, 1998) included the following: 6 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. (a) What motivates medical advisors in their choice to contract services to the WCB? (b) What are the perceptions o f medical advisors regarding skills and training required for their work as they contract services to the WCB? (c) How do medical advisors feel when they provide or state their opinions on files for injured workers they have not seen or examined? (d) What types o f injuries or cases do they consider the most challenging to work on and why? (e) How do medical advisors describe their working relationships with attending physicians and specialists? (f) What are the work experiences of medical advisors working within the workers’ compensation environment? (g) What are the experiences of medical advisors working within the case management model? These questions were reframed to serve as samples of the semi-structured interview questions for the four medical advisors as the purposeful sample for the study. The process is permissible in the qualitative process o f data collection as stated in most qualitative research literature (Creswell, 1998; Denzin & Lincoln, 1994). 7 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 2 LITERATURE REVIEW Introduction In recent years, the literature relating to physicians and the return to work of injured workers has increased in abundance. It has been recognized that prolonged absence from one’s normal roles, including absence from the workplace, is detrimental to a person’s mental, physical, and social well being (American College o f Occupational & Environmental Medicine [ACOEM], 2002; CMA, 2000). This literature review o f the role of the attending/primary care physician, the occupational physician, and the WCB of BC medical advisor in compensable return to work commences with the introduction of the concepts of disability, disability management, disability prevention, and workers’ compensation. Concepts Common to Compensable Return to Work Disability An impairment is defined as any loss or abnormality o f psychological, physiological, or anatomical structure or function (Shrey, 1995). An impairment may be temporary, persisting during active pathology, or may be permanent, continuing even after the active pathology is resolved. The World Health Organization defines disability as the loss or reduction o f functional ability and activity consequent to impairment (Cantor, 1996; Dyck, 2000). This is the reduction o f the ability to perform normal activities and tasks, including job duties in the workplace. Sheer (1995) asserts that “physicians involved in determination o f work capacity need to appreciate the difference between a pathologic process (disease or impairment), its functional ramifications (disability), and the handicapping environment o f the disabled individual” (p. 178). 8 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Disability brings with it sizable human and financial costs to the employee, family, work group, organization, and society in general. An average o f 9.5 days per employee per year is lost due to disability in Canada (Brooker, Sinclair, Clarke, Pennick, & Hogg-Johnson, 2000). Unplanned absences cost Canadian employers about $15 billion and stress related disorders cost the Canadian economy approximately $13 billion per year in lowered productivity, lost work days, and medical costs (Dyck, 2000). In 1998, Canadian workers lost 72 million workdays to illness or injury (Dyck, 2000). The direct health care costs of workers aged 15 to 64 was $37.4 billion. According to the National Work Injuries Statistics Program (as cited in Brooker et al., 2000), in 1996 there were 380,000 eligible workers’ compensation claims in Canada requiring time off from the workplace. Approximately one third o f all injuries in the United States are occupational in nature (Wyman, 1999). In 1995,6.6 million workplace injuries were reported, with nearly 50% resulting in lost work days. The cost of these injuries and illnesses was estimated by the National Safety Council to be $119.4 billion. A 1996 census found that persons with disabilities are only half as likely to be employed as those without disabilities (Human Resources Development Canada, 2002). Thirty-three percent of the working population will become disabled and unable to work for six months at some point in their lives (Dyck, 2000). The longer an injured employee is off work, the less likely it is that he/she will ever return to productive employment. An injured employee who is off work for six to twelve months has only a 50% chance of returning to work (Texas Workers’ Compensation Commission [TWCC], 2003). The longer an injured employee is disabled and off work, the greater the chance for depression, chemical dependence, passivity, and dependence on the health care system. By encouraging the employee to engage in normal Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. activity, a physician can help shift the employee’s focus away from the injury and toward functional recovery and return to work. The longer an injured employee remains off work, the more detrimental it is to thenpersonal and vocational lives, and to their overall economic well-being (TWCC, 2003). Lengthy and unnecessary time away from work allows the injured employee to focus on the injury, which tends to increase the perception o f pain and discomfort, and often leads to depression; encourages the injured employee to become sedentary, leading to de-conditioning; causes the injured employee to lose contact with co-workers, to become disconnected from work, and to lose job skills; changes the injured employee’s routine and family dynamics; causes the injured employee to lose the habit of working, and decreases the injured employee’s lifetime earning potential (Harder, 2003). Productive return to work strategies are needed to minimize the consequences of occupational injuries and illnesses. Physicians who fail to provide information required for the rapid processing o f workers’ compensation claims or who take a passive role in the return to work process directly contribute to poor health outcomes (Pransky, Wasiak, & Himmelstein, 2001). Disability Management Disabling injuries and illness have enormous personal, social, and economic effects that are rarely fully recognized or understood (Shrey, 1997). Direct costs can be measured by healthcare or rehabilitation costs, lost time from work, the cost of assistive devices, and insurance premiums. Indirect costs are more difficult to measure and include the decrease in productivity caused by the loss o f an experienced worker, the loss to the tax system as a disabled 10 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. worker is placed on disability pension, and the increased demand on social services as unemployed persons struggle to cope with reduced economic circumstances. The primary goal o f managing disability is safe and early return to work (Williams & Westmorland, 2002). Disability management is a proactive, employer based approach aimed at preventing and limiting disability, providing early intervention for health and disability factors, and fostering coordinated disability management administrative and rehabilitative strategies to promote cost effective restoration and return to work (Franche & Krause, 2002; Williams & Westmorland, 2002). Dyck (2000) defines disability management as “a systematic, goal oriented process of actively minimizing the impact o f an impairment on the individual’s capacity to participate competitively in the work environment, and maximizing the health of employees to prevent disability, or further deterioration when a disability exists” (p.7). Disability management emphasizes treatment and rehabilitation of the individual as well as changes to the work environment that enable the worker to be productive (Dyck, 2000; Rankin, 2001). Every province and territory o f Canada has a human rights statute which prohibits discrimination in employment based on disability (Molloy, 1992). Both human rights and workers’ compensation board legislation require all employers to take all reasonable steps to accommodate the needs of disabled employees to the point of undue hardship. In Ontario, the Workplace Safety and Insurance Act mandates employers take a leadership role in returning disabled employees to work (Gilbert & Liversidge, 2001). A safe and timely return to work benefits the patient and his/her family by enhancing recovery and reducing disability (CMA, 2000; Dyck, 2000). The Canadian human rights legislation has a major impact on the way employers treat employees, and in particular, disability management processes (Dyck, 2000). To comply with 11 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. legislation, disability management programs must evaluate employees on their capabilities and not disabilities, assess persons as individuals, avoid making generalizations about disabilities, define specific employment needs according to business priorities, clearly state the essential components of the job, and establish reasonable standards for evaluating job performance. Successful disability management programs have shown that employees, families, and work groups can be supported through periods o f illness or injury, that effective return to work outcomes can be achieved, that illness or injury prevention can be accomplished, and that costavoidance in terms of disability costs can be realized (Dyck, 2000; Leckie, 1998). The attending physician is an important link between the employee, the employer, and the workers’ compensation board (Dyck, 2000). Ongoing communication between the treating physician and the disability management service provider is essential in order to prevent misunderstanding among stakeholders and to avoid prolonged employee absences. Disability Prevention Work, whether in or outside of the home, is the primary activity for normal adults (Harder & Scott, 2005; Loeser & Sullivan, 1997). Brown (as cited in Loeser & Sullivan, 1997) argues that the value of work far exceeds the financial benefits that accrue since it defines one’s skills, accomplishments, identity, and social interactions. When an individual is removed from the workplace, not only are there are economic effects for the worker and his/her family, but psychologic, physiologic, and social changes are likely to occur. Unemployment has far reaching and detrimental impacts on an individual’s mental, physical and social well being (Guirguis, 1999; Health Canada, 2003). The Determinants of Health Working Group Synthesis Report (2003) documents that individuals who have been unemployed for any significant length o f time tend to die prematurely and have higher rates of 12 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. suicide and cardiovascular disease; spouses of unemployed workers experience increased emotional problems; children, particularly teens, whose parents are unemployed are at higher risk o f emotional and behavioural problems; and recovery o f physical and mental health after unemployment is neither immediate nor complete. Work is therefore identified as a key determinant of health. Guirguis (1999) states the physician approach to medical care of the injured/ill person with employment problems should focus on return to work as goal of treatment. According to Ross (1995), being unemployed rates as the equivalent of smoking ten packages o f cigarettes per day. Jin, Shah, and Svoboda (1995) performed a systematic review of the literature on the impact o f unemployment on health and concluded the evidence strongly supports an association between unemployment and a greater risk o f morbidity (physical or mental illness or use of health care services), both at the population and individual levels, and a greater risk o f mortality at the population level. They recommend primary prevention strategies involving the prevention or reduction o f unemployment, as well as secondary and tertiary prevention of recurrent or permanent adverse health consequences, and suggest that physicians and other health care providers can play an important role in collective actions against unemployment by advocating for health. In a Swedish Medline data base review, Janlert (1997) found “there is a causal link between unemployment and the deterioration in health status.. .Losing, or gaining, employment has clear effects on psychiatric symptoms and on well-being. The death rate is increased among unemployed persons” (p. 79). 13 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Social Development Canada (2002), in its paper, Defining Disability, states that disability is difficult to define because it is a multi-dimensional concept with both objective and subjective characteristics. When interpreted as an illness or impairment, disability is seen as established in an individual’s body or mind. When interpreted as a social construct, “disability is seen in terms o f the socio-economic, cultural and political disadvantages resulting from an individual’s exclusion” (Social Development Canada, p. 1). Doupe (2004) reports that, over the past 10 to 15 years, there has been a move from a medical model o f disability to a social model, and currently to the model which encompasses bio-psycho-social elements. The bio-psycho-social model synthesizes elements of the medical model and includes the physical, psychological, and social models without reducing the concept o f disability to either medical or social. In his research on preventing disability in the workplace, Dr. Patrick Loisel, an orthopedic surgeon at the University of Sherbrooke in Quebec, found that workplace disability is a multi-factorial problem resulting from interactions among four stakeholders - the worker, the workplace or employer, the insurer or the workers’ compensation board, and the health care system (Doupe, 2004; Loisel et al., 2001). Disability prevention encompasses patient reassurance and interventions linked to the workplace rather than using a medical model of treatment. In a population based randomized clinical trial between September 1,1991 and December 31,1993, Loisel showed that a model of subacute back pain management (the Sherbrooke model), linked with a rehabilitation intervention and a workplace intervention including job modifications, hastened the return to work by a factor of 2.4 (p=0.01) (Loisel et al., 1997; Loisel et al., 2001). The occupational interventions included visits to an occupational 14 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. physician and ergonomic interventions involving an ergonomist, the injured worker, the supervisor, and management and union representatives. In order to practice principles of disability prevention, a physician must be able to distinguish between impairment and disability (McGrail, Lohman, & Gorman, 2001). Unfortunately, most physicians have not received sufficient training regarding disability prevention practices as a method o f secondary prevention or the therapeutic benefit o f early return to work. In order to meet the needs of the growing pressures in North America caused by an aging workforce, rising disability costs, and lengthening periods o f disability, Christian et al. (2005) suggest adoption of a disability prevention model since “legislators, regulators, policymakers, and benefits program designers should address the reality that much work disability is preventable” (p. 1). They suggest investing in system and infrastructure improvements, training physicians on how and why to prevent disability, and “paying doctors for disability prevention work in order to increase their commitment to it” (Christian et al., 2005, p. 2). (The issue o f physician education in rehabilitation and return to work will be further addressed later in this paper.) Workers’ Compensation and British Columbia Medical Association The primary purpose of workers’ compensation is to assist employees who sustain work related injuries or diseases to recover and return to work and/or be compensated by any resulting permanent disability (Franche & Krause, 2002). Workers’ compensation is a no-fault insurance system, funded entirely by employers, designed to provide injured workers with medical care and wage replacement benefits without delay, expense, and uncertainty of civil litigation (Dyck, 2000; Rischitelli, 1999). 15 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Each Canadian province/territory has a workers’ compensation board mandated by provincial legislation (Dyck, 2000). An employee is legally bound to report a work-related injury to the employer and submit a worker’s report of injury to the provincial workers’ compensation board. The employer is also obligated to submit an employer’s report o f injury to the WCB. An employee must consult his/her physician regarding the work-related illness or injury (Dyck, 2000). The worker’s physician is legally required to submit an initial medical report to the WCB, as well as subsequent progress reports as a means o f monitoring the ill or injured employee’s recovery. The British Columbia Medical Association (BCMA) has an agreement with the WCB of BC entitled Physician’s Role in Facilitating a Return to Work (BCMA, 2002). The agreement states that the BCMA will encourage physicians to assist injured workers in receiving benefits entitled under the Workers’ Compensation Act; physicians will provide care to injured workers and support the principles o f disability management to optimize recovery and facilitate a safe, early return to work; physicians will provide appropriate support and encouragement to injured workers in order to facilitate their participation in rehabilitation programs directed at early recovery and return to work; physicians will encourage workers, with the assistance of employers, to recognize the evidence based principle that early return to work offers the most effective route to recovery from many injuries, in particular soft tissue injuries; physicians will endeavour to communicate effectively through established reporting mechanisms, and contact with WCB staff and rehabilitation providers, to facilitate exchange of claim related information which is directed at achieving early return to work; and physicians will take into account any detailed fitness assessment and job evaluation information and recognize that, in order of 16 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. effectiveness : 1) return to original work with original employer, 2) return to modified work with original employer, 3) return to similar work with another employer, 4) return to modified work within the same industry, are all options which should be beneficially explored before formal retraining to a new occupation is considered. The BCMA (2002) agreement also indicates the WCB is to provide educational programs in disability management to physicians throughout BC. However, the BCMA states it will strongly encourage members to participate in the training for a maximum of one hour per year. According to Campolieti and Lavis (2000), many of Canada’s WCBs have implemented reforms in response to increased expenditures. In an attempt to reduce the frequency and duration o f claims, the WCBs have also made changes to their rehabilitation programs, with efforts including improving communication with injured workers’ physicians and placing more emphasis on prevention and returning injured employees to work. The authors further suggest the return to work component of the WCB rehabilitation strategies will have the greatest impact on the largest number o f physicians. The strategies will lead to a larger role for physicians in facilitating return to work through increased interactions with both WCB case managers and the workplace. Role of the Attending/Primary Care Physician Historical Perspective in Canada The CMA holds that it is the community’s expectation that physicians participate actively in reducing the burden of illness on society and on the health care system (CMA, 2000). In the late 1980’s, the Ontario Medical Association (OMA) began receiving complaints from physicians, patients, employers, and insurers (Doupe, 2004). Employers, concerned with the rising cost of absenteeism due to illness and injury, were frustrated with physicians who advised 17 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. employees to take time off on disability without medical necessity or accountability. Insurers from various sectors - life, health, auto, public, and workers’ compensation - were also frustrated by the way in which physicians were managing disability claims. Doupe (2004) states that physicians were also confused about their role and discouraged by the lack of standardized disability forms, definitions, and fees. The OMA responded with a five point position statement in 1994 outlining the role o f the primary care physician and return to work (Doupe, 2004). Medical associations in Alberta, Manitoba, British Columbia, and the Yukon followed and endorsed or passed similar policies. The OMA position paper of 1994 recommends the introduction o f timely return to work programs and a coordinated move away from the ‘full recovery’ model of disability management. The OMA position states: 1. When the patient is o ff work due to sickness or injury, he/she would bring an employer’s proposed return to work program to his/her physician. 2. Physician provides objective reports on impairment, medical restrictions, and other supporting evidence to the employee. 3. Employer offers the employee a plan for returning to suitable work in a timely fashion. 4. Employee and management have a primary responsibility to initiate a timely return to work which incorporates input from the physician. 5. Management control o f ‘sick leave’ abuse is through the workplace ‘culture’ and timely return to work programs, not medical certification, (p. 1) 18 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In 1997, the CMA adopted a national policy entitled The Physician’s Role in Helping Patients Return to Work After an Injury or Illness (Doupe, 2004). According to the policy, it is the physician’s responsibility to understand his/her patient’s role in the workplace and to support their return to a quality o f life comparable to their pre-injury state. Physicians are also required to recognize and support the employer-employee relationship in return to work. The policy essentially redefines the role o f the physician from one of simply diagnosing and treating illness or injury, to one that includes facilitating their patients’ return to function and return to work (Doupe, 2003). The role of the physician has expanded from the clinic to the workplace and the occupational health position was acknowledged. The CMA policy (2000) recognizes that prolonged absence from work is detrimental to physical and social well being. Determinants such as the effect of poverty and work status on health also need to be considered. For example, the Whitehall studies in England have demonstrated that even a person’s position within an organization can impact his/her health (Marmot, Feeney, Shipley, North, & Syme, 1995). A strong inverse relationship between the grade o f employment (measure of socioeconomic status) and sickness absence was observed. Whether or not physicians are amenable to a role in disability-related issues, this responsibility has been delegated to them (Pransky et al., 2001). With the appropriate intervention, training, and experience, doctors can be effective partners in disability management (Intraspectives, 2002). After the OMA policy on return to work was passed, the Physician Education Project in Work and Health (PEPWH) was formed in 1994 to assist in the implementation process (Doupe, 2004). In 2000, PEPWH developed and published a practical guide on the role o f the physician in injury/illness and return to work/function. 19 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A fundamental purpose o f medical care is to restore health, to optimize functional capacity, and to minimize the destructive impact o f injury or illness on a patient’s life (ACOEM, 2002). Physicians are to encourage a patient’s return to function and work as soon as possible after illness or injury, provided that return to work does not endanger the patient, his/her co­ workers, or society (ACOEM, 2002; CMA, 2000). Doctors treating occupational illness and injury face the challenge of providing high quality yet cost-effective patient care (TWCC, 2003). Physician Responsibilities The physician, having trained within the medical model, often finds it difficult to become actively involved in the return to work process (Lacerte & Wright, 1992). The medical model is based on management of disease, whereas the return to work process is based on taking advantage of residual functional abilities. The physician’s lack of awareness of the rehabilitation role often leads to a passive or protective attitude that may hinder the entire return to work process. Returning injured employees to work in a safe, timely, medically appropriate way is a central goal of the entire workers’ compensation system (TWCC, 2003). The goal o f disability management is to protect the employability of the worker while preserving the financial interests of the employer (Shrey & Lacerte, 1995). All physicians practicing adult clinical medicine will, at some point in their professional experience, be required to make a decision concerning a patient’s fitness to work (Cowell, 1997). Currently there is little or no curriculum time devoted to rehabilitation and return to work in medical training for either work related or non-work related disability or compensation (PEPWH, 2000). In a recent study o f primary care physicians, less than 15% reported receiving any training at all in managing disability (Christian, 2000). By the time they graduate, many medical students entering residencies have not received training in mobility, self-care, and home 20 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. safety, (Scheer, 1995). There is also insufficient training during these early formative years in such vocational issues as workplace hazards, protective measures against toxic exposures, or effects o f medical problems on work performance. A common question posed by many primary care physicians is why disability decisions and related issues should be part of medical practices (Pransky et al., 2001). Since the focus of medical education is the relief of pain and suffering, completing disability forms is often viewed as an annoyance and distraction from the main purpose o f the medical visit. However, a direct relationship exists between physician performance in addressing disability issues and a patient’s quality o f life (PEPWH, 2000). In Western societies, prolonged disability is associated with poor health (Pransky et al., 2001). Successful employment provides income, health care, social structure, physical exercise, and a sense o f well being. Physicians have the training and certification to determine the diagnosis, order investigations, and prescribe therapy for clinical conditions (Cowell, 1997). It is therefore imperative that physicians understand their role in the disability management process. It is also o f critical importance that workers, employers, and unions understand the purpose and limitations of the physician’s evaluation and fitness to work decision. The physician’s role when treating an injured worker is to promote, preserve, and protect the health o f the patient, and to act as an advocate for policies to benefit his/her health (CMA, 2000; PEPWH, 2000). According to PEPWH (2000), the responsibility o f the attending physician is to assess, diagnose, treat, develop a return to work/function plan, monitor, report, communicate appropriate information to the patient and employer, work closely with other involved health care professionals to facilitate the patient’s safe and timely return to the most productive employment possible, and prevent recurrence of the condition. This includes the use 21 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. of an evidence based treatment or care plan that identifies the best sequence and timing of interventions for the patient. Elapsed time away from normal daily routines, including work, is to be minimized (ACOEM, 2002). Thus, rehabilitation begins and is planned at the patient’s first visit (PEPWH, 2000). The CMA policy (2000) acknowledges that successful return to work involves primarily the employee and his/her employer and requires the assistance o f the attending physician to provide detailed recommendations for graded work and activity resumption. The policy also recognizes that patient care and outcomes may be improved through a multidisciplinary approach involving other health professionals, including other physicians, rehabilitation specialists, nurses, physiotherapists, occupational therapists, psychologists, case managers, vocational rehabilitation consultants, and personnel o f employee assistance programs. Assess Doupe (2004) believes that prior to a patient entering the physician’s office with an injury/illness that prevents him/her from working, the medical files should include a work history as well as identification o f physical, chemical, biological, mechanical, ergonomic, and psychosocial hazards. Doupe (2004) also advocates use of WHACS, a mnemonic developed by the Environmental Medicine Curriculum Committee o f the South Carolina Statewide Family Practice Residency Program. The objective o f the WHACS is to provide physicians with essential questions on occupational and environmental exposures that should be included on the patient’s chart (Medical University o f South Carolina, 1994). These questions include: What do you do? How do you do it? Are you concerned about any o f your exposures on or off the job? Co-workers or others with similar symptoms? Satisfied with your job? 22 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Many employed individuals spend more hours at work than with spouses and children (Lees, 1996). In a family clinic of 311 consecutive employed patients aged 20 to 65 years presenting for treatment, 29% claimed that their current illness was caused or affected by the workplace. However, Lees (1996) reports that only 34 o f 160 randomly selected charts documented an individual’s occupation. In addition, none described the person’s work adequately to identity actual or potential occupational hazards. PEPWH (2000) reports the physician’s initial intervention consists o f obtaining an appropriate history with medical-occupational-social components, including daily activities and functional abilities and/or limitations. Both the CMA (2000) and PEPWH (2000) advise physicians who see a patient for the first time concerning a long-standing condition to obtain and consult medical records or previous care prior to offering advice on a safe and timely return to work. According to Scheer, Robinson, Rondinelli and Weinstein (1997), when a worker is seen by the evaluating physician immediately after injury, the prognosis for recovery is better than that for an individual with a delayed presentation. The authors present a case study of a 45 year old male truck driver with non-radiating low back pain that developed the previous day while unloading an oil drum from the company truck. Scheer et al. (1997) suggest “the history given by this truck driver is the single most useful source o f information for diagnosis, prognosis for work return, and management” (p. S-10). History o f previous injuries on the job and their associated recovery periods are all critical information in the initial stage o f assessment. PEPWH (2000) recommends physicians order appropriate investigations after conducting a physical examination. In most cases, a determination o f the injured employee’s functional abilities does not require a formal functional capacity evaluation. Bruckman and Harris (1998) 23 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. assert that most common complaints seen under workers’ compensation do no require testing in the first four weeks since the diagnosis can be made reliably by physical examination. Diagnose PEPWH (2000) advises physicians to reach a diagnosis of the medical condition and perform a functional assessment. Misdiagnosis or failure to properly investigate or identify slow recovery could prolong disability. Both the Alberta (1994) and Manitoba Medical Association (1995) position statements, as well as the TWCC (2003), do not discuss physician diagnosis, rather the focus is on function and the capabilities o f the worker. When an injured worker comes to a physician with symptoms, he/she expects to receive a diagnosis. Loeser and Sullivan (1997) state that physicians are frequently confronted by patients who have symptoms without apparent pathology. Kroenke and Manglesdorf (as cited in Loeser & Sullivan, 1997) observed 1000 patients for three years to determine how often an organic cause was found for 14 o f the most common symptoms presented to primary care physicians. On average, an organic cause was found in less than 15% o f the patients. According to Loeser and Sullivan (1997), patients and third party payors expect physicians to identify damage or disease as the cause o f pain and disability, when often there is no damage or disease that can be identified. Loeser and Sullivan (1997) suggest physicians require more education on human behaviour and the variable relationships among disease, distress, and disability since “the process of disability determination requires physicians to make determinations that cannot be based on medical science and for which they have no specialized training” (p. 61). The authors add that because every patient must be given a diagnosis to conform with accepted billing processes, most patients with low back pain or repetitive strain injury are labeled in the absence o f any known pathology. 24 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Abenhaim et al. (1994) reviewed the medical files o f a cohort o f 1,848 workers in Quebec, representative o f all sectors o f industry, who were compensated for a low back injury in 1988, but not in the previous two years, to determine the prognostic value o f the physician’s initial diagnosis o f back problems. Medical charts were reviewed at the Quebec Workers’ Compensation Board in order to obtain the exact diagnosis made by the treating physicians within seven days of the first day of absence from work. Diagnoses were categorized as specific (lesions o f the vertebrae or discs) and nonspecific (pain, sprains, strains). The history of compensated work absence for low back pain in the following 24 months was obtained. Abenhaim et al. (1994) concluded the physician’s initial unaltered diagnosis was highly predictive o f chronic disability from back pain, particularly in older workers. The authors report the explanation for the result is complex, involving the nature of the underlying lesion as well as the impact o f the diagnosis ‘label’ on the worker and on the physician-patient relationship. Abenhaim et al. (1994) assert the initial ‘specific’ diagnosis at the beginning o f a compensable episode could carry a message to the worker that the condition is serious and requires ‘specific’ clinical management. This emphasizes the importance o f the physician’s role in setting positive, realistic goals and planning early strategies toward functional recovery. Treat Expectations for the employee’s recovery and return to work are clearly stated early in the course of treatment, ideally during the initial assessment, and reinforced with each subsequent visit (TWCC, 2003). The natural history/clinical course o f the condition is discussed as are expected healing and recovery times, and the positive role o f an early, graduated increase in activity on physical and psychological healing (ACOEM, 2002; CMA, 2000). The manner in which the condition is communicated to the worker could affect the eventual outcome (PEPWH, 25 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2000). For instance, using words such as ‘ruptured disc’ indiscriminately in a soft tissue injury o f the back could give the worker an impression o f permanency, poor prognosis, and unnecessary fear related to return to work. The role o f return to work as part of treatment is reinforced (TWCC, 2003). Patients are encouraged to focus on function and capabilities rather than limitations (PEPWH, 2000). Lotters, Hogg-Johnson, and Burdorf (2005) performed a prospective cohort study, with one year follow-up, of participants who had been on sick leave resulting from nonspecific musculoskeletal complaints for two to six weeks, as registered by an occupational health physician. The purpose of the study was to describe the improvement in several health outcomes during sick leave due to musculoskeletal disorders and in the first few months after return to work, and to evaluate the personal and work-related factors associated with the health outcomes in order to provide insight into timing o f return to work. Lotters et al. concluded that being fully recovered is not a stipulation for regaining work activities and hypothesized that workers with musculoskeletal disorders may need additional medical guidance shortly after return to work, particularly those with a history o f sick leave. The CMA (2000) and PEPWH (2000) advocate use o f an evidence based treatment or care plan that identifies the best sequence and timing o f interventions. The BCMA (2002) agreement with the WCB o f BC documents that physicians recognize the evidenced based principle that early return to work is therapeutic. The OMA (1994) suggests physicians offer the timely application of current concepts in treatment and rehabilitation, however the Alberta (1994) and Manitoba Medical Association (1995) position statements do not explicitly document use of evidence based treatment guidelines. The TWCC (2003) recommends use o f evidenced base medicine in order to assist injured employees to return to work. 26 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. More than 900 articles appear yearly in databases of the English language medical literature exploring the purpose and effectiveness o f clinical practice guidelines (Bruckman & Harris, 1998). A guideline is generally used to define the evidence base, norms, or consensus for medical practice. Benchmarks can be derived from guidelines to provide a gauge of reasonableness for resource use and for managing disability that meets the medical needs of patients with a certain diagnosis. Effective return to work efforts require that expectations o f physicians, employers, patients, and payors be addressed simultaneously (Bruckman & Harris, 1998). In most data sets, time lost from work, particularly soft tissue complaints, far exceeds best practices or consensus guidelines. For example, in certain work environments all employees with a simple back ache may expect the same time off from work. As such, physicians may grant a patient’s request for more time off following a complaint o f this nature, since return to work is not the emphasis. Disability duration guidelines can be effective (Bruckman & Harris, 1998). By defining an acceptable optimal standard, physicians are empowered to suggest earlier return to work under a graded modified work program as compatible with the employee’s injuries. Physicians and employers use disability durations to guide expectations concerning absence from work with or without modified duties (Dyck, 2000). Clinical practice guidelines are systematically developed statements to assist the physician and patient with decisions regarding appropriate health care for specific clinical circumstances (Cabana et al., 1999). Theses guidelines represent the ‘gold standard’ o f health care and have the potential to dramatically improve the quality o f health care through the delivery o f the most appropriate interventions and by acting as a standard to evaluate existing treatment programs (Bishop & Wing, 2003). 27 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Despite wide circulation, guidelines have had limited effect on changing physician behaviour. In their systematic review o f the literature, Cabana et al. (1999) found that barriers to physician adherence include knowledge - lack o f awareness or lack of familiarity, volume o f information, time needed to stay informed, guideline accessibility; attitudes - lack o f agreement with guidelines, challenge to autonomy, lack of self-efficacy, physician believes he/she cannot perform guideline recommendation, lack of outcome expectancy, lack o f motivation or the inertia of previous practice; and behaviour - inability to reconcile patient preference with guideline recommendations, presence o f contradictory guidelines, lack of time and resources, lack o f reimbursement, and perceived increase in malpractice liability. Most of the literature regarding return to work surrounds low back pain. Clinical practice guidelines have been applied inconsistently, or not at all, in workers with low back pain. Sixty to eighty percent o f the population will experience low back pain symptoms at some point in their lives (Tacci, Webster, Hashemi, & Christiani, 1999). It has been estimated there is a 28% cumulative incidence o f low back disability over the working lifetime for the industrial population. Low back pain is also a very costly problem in the workplace, with an estimated total workers’ compensation direct cost o f $11.4 billion in the United States in 1989. Low back pain is the costliest o f workers’ compensation claims and represents a failure o f the current medical model for low back management (Derebery, Giang, Saracino, & Fogarty, 2002). Of major concern is the 5 to 10% who are disabled for more than three months and who account for 75 to 90% o f the cost (Indahl, Velund, & Reikeraas, 1995). Abenhaim and Suissa (1987) studied a stratified random sample o f 2,523 files of occupational back pain from the 1981 Workmen’s Compensation Board o f Quebec database and found that 7.4% o f cases who were absent from work for more than six months were responsible 28 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. for 73.2% of the medical costs and 76% of compensation and indemnity payments. In other words, 0.1% of the workforce or approximately 2,700 workers account for more than $125 million o f expenses yearly for occupational back pain in Quebec. Physicians and employers alike must bear such statistics in mind with respect to prevention strategies and return to work programs. In a randomly selected sample o f new onset, uncomplicated, low back workers’ compensation disability cases, Tacci et al. (1999) found an apparent overuse o f diagnostic and treatment modalities. Diagnostic imaging was over utilized in terms o f the number o f studies done (65% had plain films, 22% magnetic resonance imaging [MRI] scans) and also in the time frame in which they were performed (38% had plain films on the first visit). Ninety percent received at least one medication and 38% received more than one prescription for opioid analgesics. Expensive non-steroidal anti-inflammatory drugs were prescribed more often than acetaminophen (61% versus 6%, respectively). Sixty-two percent received physical therapy that often included modalities with as yet unproven efficacy. Tacci et al. (1999) concluded that over utilization of either diagnostic or treatment procedures increases the likelihood of iatrogenic complications, is not cost-effective, and may adversely impact clinical and occupational outcomes. Since World War II the development of chronic low back pain has reached alarming proportions, and is described by some as a Western epidemic (Indahl et al., 1995). It has been suggested that the more seriously the problem has been treated, the worse it has become. In a randomized clinical trial, Indahl et al. (1995) found that low back pain treated as a benign, self limiting condition recommended to light mobilization gave superior results as compared to treatment with a conventional medical system. 29 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Mahmud et al. (2000) sought to determine whether health care utilization and the physician’s initial management o f work-related low back pain are associated with disability duration. Clinical management information for the study was obtained for 98 randomly selected workers’ compensation claimants with acute, uncomplicated, disabling work-related low back pain. Over the course o f the one year study period, Mahmud et al. (2000) found that disability was significantly associated with increased utilization o f specialty referral and provider visits, use o f MRI, and use o f opioids for more than seven days. Workers whose treatment did not involve extended opioid use and early diagnostic testing were 3.78 times more likely to be off disability status by the end of the study. According to Derebery et al. (2002), there is high variability in diagnostic work-ups, in the amount and type o f treatments given by physicians, and the amount of disabling lost or restricted duty prescribed by physicians for low back pain. The more appropriate strategy for low back pain is to de-medicalize the condition and focus on functional restoration and early activation. Physicians practice largely by dogma and tradition, with some estimates that only 10 to 20% o f diagnostic and therapeutic actions are based on scientific evidence (Derebery et al., 2002). While physicians understand the scientific rationale for encouraging patients with low back pain to resume normal activity, the expectations of workers and employers have made it difficult to avoid prescribing relative rest and physical restrictions. Additionally, there are realistic concerns that many patients will choose to seek care from other physicians if they are not prescribed restrictions or time off work. Bishop and Wing (2003) performed an observational study o f 139 family physicians in British Columbia to determine the degree of guideline compliance of family physicians 30 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. managing patients with workers’ compensation claims and acute mechanical lower back pain. The WCB in BC has compiled, published, and distributed clinical practice guidelines for the management of acute mechanical lower back pain to all family physicians in the province. According to Bishop and Wing (2003), the guidelines “are derived exclusively from the best available scientific evidence or expert panel consensus and are independent o f any bias associated with worker/employer special interest issues” (p. 442). The study concluded that physicians demonstrated a high degree o f compliance with the guideline recommended history, examination procedures and medications, but low compliance with recommended imaging as well as many treatment recommendations. Return to Work/Functional Plan Successful return to work involves primarily the employee and his/her employer and requires the assistance of the attending physician providing details of recommendations for graded work and activity resumption (ACOEM, 2002; CMA, 2000). Return to work requires that the employee’s capabilities match or exceed the physical, psychological, and cognitive requirements of the work offered (CMA, 2000; OMA, 1994). A written job description, including available work modifications can be requested from the employer. Return to work programs are based on the philosophy that many employees can safely perform productive work during the process of recovery (WCB, 2002). Since disability interventions, programs, and services are most effective when provided at the worksite (Shrey, 1995), this concept must be reinforced in physician education. When the physician believes the patient has recovered sufficiently and can return safely to some form of productive work, the worker should be clearly informed o f this judgement and advised that despite continuing symptoms, resuming normal activities is an important part o f the 31 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. rehabilitation process (ACOEM, 2002). In cases o f employers with occupational medicine departments, the attending physician may contact the occupational physician or nurse to understand the specific workplace policies, supportive in-house resources, essential job demands, and possible health and safety hazards in the employee’s workplace (CMA, 2000). When requested by the employer, the physician, with the worker’s consent, is to be as specific as possible in describing capabilities and any work accommodations required (CMA, 2000). In more complex cases, the physician is to consider referral to medical specialists and other appropriate health care professionals for a comprehensive, objective assessment of the worker’s functional abilities, limitations, and their relation to the demands o f the employee’s job. The employer and employee have a responsibility to provide the physician with adequate employment-related information to enable him/her to offer appropriate medical advice and support (ACOEM, 2002). While disability benefits are approved based on an employee’s restrictions, the employer and employee should be focusing on work abilities (Dyck, 2000). When participating in developing a modified return to work plan, physicians are to consider and make recommendations related to physical/functional limitations and restrictions (ACOEM, 2002). The rehabilitation plan is to be job relevant and directed at the work place. With respect to limitations, any existing constraints in the employee’s physical or mental capability to perform tasks, the ACOEM (2002) advises physicians to rely on objectively determinable findings to the maximum intent possible. A mild increase in symptoms with increased activity is appropriately viewed as a non-medical issue. Worker-imposed limitations may be based on subjective perception or secondary gain. Restrictions, protective measures required to prevent injury or foster recovery, are to be specific and time limited (ACOEM, 2002; CMA, 2000), for example, no above shoulder 32 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. reaching with the right arm, alternating positions between sitting and standing or walking, and maximum lifting of 10 kg from floor level or 20 kg from waist level. Excessive or unnecessary restrictions actually impede recovery, contribute to disability and increase the possibility of adverse impact on the worker psychologically and financially far more frequently than does the risk o f recurrent injury (TWCC, 2003). Physicians are to state whether restrictions are permanent or temporary, give an estimate of recovery time, and document when the employee is to progress and work restrictions are to be reassessed (CMA, 2000). Recommendations regarding environmental restrictions or medical aids are also to be included, for instance, avoidance of cold environments, no solo work in remote areas, or use of a chair with adjustable height and lumbar support. Effective return to work programs use temporary transitional work as a key tool (Bruckman & Harris, 1998). Employers and physicians use such jobs to maintain social support at the worksite and to gradually increase conditioning until the employee can return to his/her regular duties. The use o f modified duty or transitional jobs assumes the employee will gradually transition to more strenuous or demanding work until he/she is able to return to regular job duties. A review o f low back pain intervention studies suggests that medical management in the first three to four weeks after the onset o f pain should be generally conservative (Frank et al., 1998). Studies o f interventions focusing on return to work implemented in the subacute stage, three or four weeks to 12 weeks after the onset of pain, have shown important reductions, by 30 to 50%, in time lost from work. There was substantial evidence indicating that employers who promptly offer appropriate modified duties can reduce time lost per episode of back pain by at least 30%, with spin off effects on the incidence of new back pain claims as well. For instance, 33 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. workers with less severe injuries voluntarily chose modified duties immediately rather than incur time loss due to workplace culture brought about by accommodation responses to reports o f health problems. Lastly, Frank et al. (1998) report newer studies document reductions o f up to 50% in both time lost from work and health care costs from guidelines-based approaches to clinical diagnosis and treatment of low back pain and other soft tissue injuries. Durand and Loisel (2001) reported an observational study that showed a work rehabilitation program closely linked to the workplace was efficient in returning workers with back pain to stable work at their pre-injury level. At a two year follow-up, 93% of participants in the Therapeutic Return to Work Program were working. Durand and Loisel (2001) document this represents the highest published rate of return to work to date following a rehabilitation program for chronic back patients. They add that although the study was limited by its normreferenced evaluation design, the results indicate the importance of placing the worksite in the centre of the return to work process. A two year prospective inception cohort study o f back injury in nurses in Manitoba concluded that focusing on reducing the perception of disability at the time of injury is critical to preventing time loss (Tate, Yassi, & Cooper, 1999). However, once time loss occurred, participation in a return to work program reduced further time away form the workplace. Tate et al. (1999) also concluded the findings add to the evidence that workplace interventions can be effective in reducing the morbidity from back injury. In a longitudinal cohort study of 148 randomly selected workers who had not returned to work in three months following compensable musculoskeletal soft tissue injuries, Crook, Moldofsky, and Shannon (1998) found the rate of return to work for those provided with modified jobs was two times higher than those with no accommodation in employment. A 34 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. systematic review o f the scientific literature on modified work published since 1975 also found that injured workers who are offered modified work will return to work about twice as often as those who are not (Krause, Dasinger, & Neuhauser, 1998). Similarly, modified work programs decrease the number o f lost work days by 50%. Since work is where both patients and physicians spend the majority o f their waking hours, it is reasonable that the solution to some health problems lies within the work domain (Doupe, 2004). Hall, McIntosh, Melles, Holowachuk, and Wai (1994) believe that many return to work restrictions are not based on clinical findings, but rather reflect the injured worker’s report of pain and the therapist’s fear that an unrestricted return to work will result in further physical harm. Catchlove and Cohen (1982) assert that individuals will view themselves as incapable of full recovery if a return to work is not stressed. In a prospective study of 1,438 workers with compensable low back claims attending an early intervention program at 12 Canadian Back Institutes in Ontario, Hall et al. (1994) found that individuals recommended to return to work unrestricted had a higher success rate than those recommended to work with restrictions. In the study group, the success rate for the return to work unrestricted group was 84% compared with only 47% for the return to work restricted group. Hall et al. (1994) believe unrestricted return to work must be emphasized since “an unwarranted restriction implies disability and may become a self-fulfilling prophecy” (p. 2036). Bemacki, Guidera, Schaefer, and Tsai (2000) reported on an early return to work program initiated at The Johns Hopkins Hospital and Associated Schools of Medicine, Hygiene and Nursing in Baltimore, Maryland, in April 1992 as part of a comprehensive effort to control the incidence and costs of work-related illnesses and injuries. The program incorporated employee and supervisory training and job accommodation, however also included an industrial 35 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. hygienist trained in ergonomics to facilitate the placement of individuals with restrictions. Over a ten year study period, a 55% decrease in the rate o f lost workday cases was observed before versus after the return to work program (Bemacki et al., 2000). Furthermore, the number of lost workdays decreased from an average of 26.3 per 100 employees prior, to 12.0 per 100 employees after the return to work initiative, while the number of restricted duty days went from an average of 0.63 per 100 employees to 13.4 per 100 employees, a 20 fold increase. Bemacki et al. (2000) concluded: The study suggests that a well-structured early return to work program is an integral part o f a comprehensive effort to control the duration o f disability associated with occupational injuries and illness. It also indicates that to be most effective, an early return to work program must include participation by medical providers, safety professionals, injured employees, and supervisors, (p. 1172) If the employer and employee cannot agree on a return to work plan, the employer is to contact the physician and employee to identify the minimum level of capability that can be accommodated in the workplace (CMA, 2000). When conflict occurs between employer and employee, the attending physician may use the skills of an occupational physician. The CMA (2000) recommends that conflict-resolution processes be put in place to address the participants’ concerns. 36 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Monitor Physicians are to monitor the worker’s progress throughout the recovery and following his/her return to work (PEPWH, 2000; TWCC, 2003). A fundamental scale can be used to mark progress, for example, asking the worker to state in terms o f percentage, the proportion o f his/her pre-injury activities he/she is performing both at work and away from the job (TWCC, 2003). These numbers are recorded and tracked with each physician’s visit. Physicians are to identify and address potential obstacles to the recovery o f function and return to work as soon as possible (ACOEM, 2002: CMA, 2000). During each patient evaluation, physicians must gather information to make medical decisions and to identify any psychological issues that need to be addressed (TWCC, 2003). A patient’s length o f recovery can be influenced by such factors as the individual’s motivation, social support system, work attitude, family dynamics, and workers’ compensation. Risk factors for delayed recovery include personal or family history of prolonged disability, symptoms or disability out of proportion to diagnosis, perceived exaggeration pain behaviour, dysfunctional family dynamics, history of physical or other abuse, chemical dependency, depression, job dissatisfaction, workplace friction, economic or legal factors, underlying medical conditions, and involvement in the workers’ compensation system (Derebery & Tullis, 1983; Harder, 2003; McGrail et al., 2001). Returning to work in a modified duty position during the healing period is a critical element in the recovery process and in managing the impact o f non-medical factors (TWCC, 2003). Welter (1994) believes that, in some instances, a worker whose physical recovery is delayed may view a physician’s recommendations to promote the recovery as a threat to their 37 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. image as a disabled individual. However, he advises the physician to respond with compassion and firm therapeutic goals: The patient whose physical recovery is delayed, for whatever reason, learns to be psychologically disabled as well, and the physician who offers to speed the recovery is sometimes seen by the patient as a threat, since the physician is challenging the patient’s image o f himself as a disabled person. Bearing this in mind, it is important that the physician respond with compassion, understanding, and firm therapeutic goals rather than returning the patient’s hostility. (Welter, 1994, p. 17) In another dimension, Derebery and Tullis (1983) posit that, under certain circumstances, patients who are receiving compensation for an injury will have a disproportionate disability and delayed recovery because of reinforcers provided by the accident. In order to maximize recovery, physicians are advised to take a thorough psychosocial history and recommend return to work as soon as possible. According to the Australasian Faculty of Occupational Medicine (2001), “there is good evidence to suggest that people who are injured and claim compensation for that injury have poorer health outcomes than people who suffer similar injuries but are not involved in the compensation process” (p. 2). The ACOEM Occupational Medicine Practice Guidelines (2004) surmise that participation in the disability benefit system can be counterproductive for patients with such participation often defeating what would otherwise be a successful medical result. 38 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Engelberg (1994) believes injuries that are caused by, or arise out of, employment should be treated no differently than those arising from some other circumstance. He also argues that sudden low back pain “should receive a work-up that is tailored to .how the patient presents clinically and not one that is driven by where the back pain allegedly occurred or by how the diagnosis or treatment will be paid for” (p. 284). Rischitelli (1999) points out that physicians should remember compensability is a legal, not a medical determination. The attending physician should not become a benefit, disability, or employment rights advocate for the injured worker. With regard to physician opinions of medical causation, Rischitelli (1999) concludes that “biased, illogical, scientifically unsupported, or even incompletely explained conclusions damage the credibility of physicians in the community and undermine the purposes of the workers’ compensation system itself’ (p. 614). McIntosh, Frank, Hogg-Johnson, Bombardier, and Hall (1999) performed a prospective prognosis study of 2,007 Ontario Workers’ Safety and Insurance Board claimants with the objective of developing a prognostic model that predicts time receiving workers’ compensation benefits for low back claimants. The study revealed five significant predictors associated with increased time receiving benefits compared with reference groups: working in the construction industry, older age, lag time from injury to treatment, pain referred into the leg, and three or more Waddell non-organic signs, while three predictors were associated with reduced time receiving benefits: higher values on a low back questionnaire (the greater the score, the greater the perceived level o f function), intermittent pain, and a previous episode o f back pain. Physicians should be aware o f and identify factors that differentiate claimants who become chronically disabled from those who do not (McIntosh et al., 1999). 39 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Guzman, Yassi, Cooper, & Khokar (2002) surveyed Manitoba general practitioners, family physicians, and emergency physicians who saw at least 10 workers with injury claims in 1998 to determine physicians’ views about facilitating factors for and barriers to assisting workers recover after occupational soft tissue injuries, and to ascertain physicians’ knowledge and attitudinal barriers to their involvement in return to work. Respondents felt the main facilitating factors were the physicians’ ability to explain the nature and prognosis o f injuries to workers and the willingness of workplaces to accommodate injured workers. The physicians identified the main barriers as workers’ misunderstandings and fears about their injuries and nonsupportive supervisors and co-workers. Guzman et al. (2002) concluded that most physicians seemed aware of their role in the return to work process and the effect of occupational factors, however their advice on activity after injury differed from practice guidelines. In another study aimed at understanding the treating physician’s perspective with regard to barriers their patients face when returning to work from injury and illness, Schweigert, McNeil, and Doupe (2004) conducted physician focus groups in Southern Ontario. Schweigert et al. (2004) concluded that treating physicians believe the most significant barriers for the timely return to work for their patients exist in the workplace, specifically related to lack of knowledge concerning modified work. Physicians also identified themselves as potential barriers citing that their role in the return to work process is not clear and is demanding due to insufficient time to deal with return to work issues, that they have a lack o f occupational health training, and “that they possess a lack o f knowledge o f specific work issues or that they are overwhelmed with too much or inappropriate information at times” (Schweigert et al., 2004, p. 427). 40 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Return to work function is a cooperative effort (PEPWH, 2000). O f all the factors that contribute to a return to work following injury, the physician’s care and the worker-employer relationship are potentially strong determinants of the outcome. If there are workplace problems, Doupe (2004) recommends asking the worker the obstacle question, “what are the specific obstacles preventing you from working today?” (p. 12). The author also teaches and counsels workers to cultivate what is in their control, such as resiliency and mechanisms to deal with stress. Prompt diagnosis, timely and appropriate treatment and guidance, and ongoing liaison with the workplace increase the likelihood of return to work (OMA, 1994). Report PEPWH (2000) recommends physicians report on worker progress initially and at periodic intervals during treatment and rehabilitation. Medical records are confidential (ACOEM, 2002; CMA, 2000). A physician’s report concerning the patient’s ability to return to work is tailored to the intended audience (CMA, 2000). A report directed to an employer contains only information that the employer requires to assist the employee in his/her return to work, for example, the ability of the worker to perform pre-injury duties or the employee’s capabilities and limitations. Medical information regarding the worker’s diagnosis and prescriptions is not submitted to the employer without the patient’s authorization. However, in some cases, provincial or territorial legislation may require physicians to provide information to workers’ compensation boards without prior patient approval (CMA, 2000). Physicians need to be aware of legal requirements in the province or territory in which they practice. Ethics The CMA Code o f Ethics states that physicians must respect the patient’s right to confidentiality except when this right conflicts with the physician’s responsibility to the law, or 41 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. when the maintenance o f confidentiality would result in a significant risk o f substantial harm to others or to the patient if the patient is incompetent (CMA, 2000). The patient has the right to examine and obtain a copy o f his/her medical reports. Although the CMA (2000) discusses a patient’s right to confidentiality, no mention is made of a physician’s ethical responsibility or accountability in ensuring an injured worker returns to work. Physicians who do not focus on functional abilities or who prescribe inappropriate time away from the workplace are, in effect, harming the worker and impacting his/her well being and economic and vocational future. In addition, when using the term patient rather than worker with an injury, the CMA focuses on the sick role rather than rehabilitation. Communication Timely and effective communication with the patient and other stakeholders is critical to the success of any return to work plan (PEPWH, 2000). The physician facilitates the return to work process by encouraging communication between the patient and his/her employer early in treatment and rehabilitation (CMA, 2000). By encouraging the injured employee to take an active role in his/her recovery, the dialogue enables the worker to participate in the return to work process and decision making (TWCC, 2003). This facilitates employee ownership of the return to work plan since the worker is central to the process. Although communication with the employers largely takes place through the worker, direct communication with employers (with the patient’s consent) may be required in more complex cases (Doupe, 2004) and is often the key to successful reintroduction of the recovering worker to the workplace (Welter, 1994). Employers and workers’ compensation boards are also more willing to pay the physician for his/her time (Doupe, 2004; WCB, 2002). 42 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Christian (2000) argues that during an office visit, the physician has only a 10 to 15 minute interval scheduled to speak with the patient, perform an examination, make a diagnosis and treatment plan, answer questions, dictate the chart, then start again with another patient. There is no incentive for physicians to produce results. However, Engelberg (1994) points out that although primary care physicians are busy professionals who may balk at the thought of communicating with employers in the return to work process, “by not spending this time, physicians may make decisions about employability that they should not make and may give inadequate or wrong advice to both the employee/patient and the employer” (p. 286). Since full recovery is not necessary for return to work (Doupe, 2004), physician communication with injured workers is crucial throughout the entire return to work process. Doupe (2004) asserts the role of the physician involves a careful meld o f clinical expertise, sound judgement, and administrative ability combined with highly developed communication and counseling skills. She suggests the employee with an injury should hear the following statements from his/her physician at the first visit: I believe work is important to your health. As long as you are capable o f working and there are no significant reasons why you can’t, you will do more harm by staying home. Let’s talk about why you feel you can’t work and figure this out together, (p. 13) Christian (2000) writes that physicians have remarkable personal power to influence outcomes by building patient trust, naming the problem, recommending treatment, and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. forecasting the eventual outcome. She believes recovery times are hastened when patients hear their physicians predict that they will be shorter. In a literature review on disability management practices, Williams and Westmorland (2002) found open and positive communication among the worker, the union, the supervisor, and the health care provider to be a necessary ingredient of successful return to work, citing “open communication is more likely to enhance the worker’s motivation to return to work” (p. 91). Pranksy, Shaw, Franche, and Clarke (2004) also performed a review o f selected articles to examine prevailing models of disability management and prevention and concluded that improvements in communication may be responsible for successes across a variety of interventions. Communication-based interventions may further improve disability outcomes, reduce adversarial relationships, and prove cost effective, however control trials were recommended. Walker (1992) proposes the learned helplessness model may be an appropriate paradigm for explaining evident problems o f motivating the workers’ compensation claimant toward occupational recovery. WCB claimants can be encompassed by a complex system o f medical, legal, financial, and work dynamics that can create a sense of uncontrollability, setting the stage for learned helplessness. Walker (1992) suggests injured worker helplessness can be reduced by increased physician communication with respect to diagnosis and prognosis, and by stakeholders’ support o f disability management and prevention. In a qualitative study aimed at understanding family physicians’ experiences in managing injured workers within the compensation system, Russell et al. (2005) interviewed ten physicians in southwestern Ontario and found that few participants enjoyed dealing with workers’ compensation problems. The physicians felt challenged by lack of time, were wary when 44 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. dealing with employers, and were particularly concerned with patient confidentiality. As a result, workplace communication seldom extended beyond standard WCB forms. Russell et al. (2005) also reported that although family practitioners were appreciative o f the input o f other professionals within the workers’ compensation system, they were suspicious o f external influences on decision making and perceived their commitment to patients conflicted with insurer requirements to guidelines and pathways of care. Russell et al. (2005) concluded that their findings suggest workers’ compensation authorities can benefit from a better understanding of the dynamics o f contemporary family practice, particularly o f time and cost barriers to workplace liaison. The premise that physicians’ primary loyalty is to their patients is a basic ideology of medical ethics (Rosenstock & Hagopian, 1987). Although primary physicians face challenges when integrating the field o f occupational medicine into their practice, “occasionally, this may mean making medical decisions that do not agree with the worker-patient’s immediate desires” (p. 577). Prevention PEPWH (2000) reports physicians are to prevent a recurrence of the condition in the same worker or an occurrence of the same condition in other workers. Doupe (2004) believes primary care physicians are in a pivotal position to determine the underlying causes o f workplace related injury/illness and to notify the workplace parties, or if necessary, the workers’ compensation board. Enabling disability among patients should be avoided at all costs since “good disability prevention does not compromise our [the physician’s] role as patient advocate” (Doupe, 2004, p. 13). 45 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Physician Education/Training Traditionally, the teaching o f occupational health has been neglected in the medical school curriculum and in the practice of clinical medicine (Cullen & Rosenstock, 1988; Levy, 1985; Uzych, 1989). There is a need for continuing medical education in order for positive physician participation in the return to work process (Guirguis, 1999). In his survey o f undergraduate programs in Canadian medical schools, Marchant (as cited in Lees, 1996) found the time devoted to occupational medicine ranged from 0 to 36 hours. Similar inadequacies were also found in family medicine residency programs. Physicians play a key role in evaluating and certifying the work implications o f illness, recommending appropriate length o f time off work, and assisting injured employees in returning to work and maintaining employment (Pranksy, Katz, Benjamin, & Himmelstein, 2002). A validated survey was mailed to a random sample o f 423 Massachusetts primary care physicians. The response rate was 43%. The objectives o f the study were to explore the practices and perspectives o f primary care physicians in relation to disability and return to work concerns that are common in general practice. Pransky et al. (2002) found that respondents ranked a lack of light duty availability as the most important barrier to improved return to work outcomes. Results also showed that primary care physicians infrequently communicate directly with their patient’s employers and usually do not write specific orders with respect to job tasks during recovery. Although the primary care physicians recognized the importance o f disability prevention, Pransky et al. (2002) state their practices in managing time off from work, reporting work restrictions, and communicating with employers could lead to suboptimal return to work outcomes. Less than 25% o f the respondents had any training in this area and ranked physician education as a highly desirable intervention. 46 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Hainer (as cited in Lessenger & Giebel, 1992) also suggests that occupational medicine is a neglected aspect of family medicine. In addition to treating on-the-job illness and injury, the discipline also includes pre-employment and periodic screening, site visits, and prevention measures. Hainer proposes a family medicine resident curriculum that includes job site visits, elective rotations in clinical occupational medicine, and topic conferences, and also advocates for an understanding o f workers’ compensation and of the physician’s role in it in order to improve communication with patients, insurance companies, and employers. Lessenger & Giebel (1992) analyzed 2,846 industrial illnesses and injuries in 2,430 patients seen in a family practice with a large occupational medicine component over a three and a half year period. Of the 268 medical diagnoses made, back injuries and cumulative trauma disorders o f the upper extremities were the most prevalent. Lessenger & Giebel (1992) recommend family practice residents are trained in workers’ compensation procedures and laws and in specific occupational health problems, with the principal goal being primary prevention of injuries. Neither the CMA (2000) policy nor the PEPWH (2000) guide advocate for physician training in WCB procedures or recommend attendance at job site visits. In a literature review relating to the effectiveness o f education strategies designed to change physician performance and health care outcomes, effective change strategies included reminders, patient-mediated interventions such as patient education materials, outreach visits (visits by physician educators such as pharmacists), opinion leaders or educational influentials, and multifaceted activities (Davis, Thomson, Oxman, & Haynes, 1995). Audit feedback and educational materials including non-interactive printed audiovisual and computer produced information were less effective, and formal continuing medical education conferences, seminars 47 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. or workshops without enabling practice reinforcing strategies, had relatively little impact on improving professional practice. Derebery et al. (2002) designed a case control study to evaluate the effects o f an educational intervention on physicians’ management o f low back patients. Physicians were given a two hour didactic presentation, a low back manual promoting evidence based treatment, a post test (eight hours continuing medical education), and periodic (usually two to three times per year) distribution of provider practice management reports that showed their individual practice data analysis. Physicians were encouraged to use a bio-psycho-social model of management. A low back pain management change strategy was developed (Derebery et al., 2002). The strategy included three steps for stimulating behaviour changes; providing disconfirmation, emphasizing that change was necessary, and providing specifics on how to accomplish change. Results showed the intervention group reduced the percentage of restricted work cases, reduced the percentage o f lost-time cases for male patients and female patients less than 40 years old, and shortened restricted work day duration and total case duration for female patients. Role of the Occupational Physician Occupational medicine is a preventative medical discipline that deals both clinically and administratively with the health care needs of workers, individually and in groups, with respect to their work environment (Doupe, 2004). Since occupational medicine focuses on health and the impact of work on health, it involves the recognition, evaluation, control, management, prevention, and rehabilitation of occupationally related diseases and injuries. According to the ACOEM (2004), Occupational Medicine Practice Guidelines, “primary prevention, early 48 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. detection, and secondary prevention o f delayed recovery are key parts o f the occupational health practitioner’s role” (p. 83). The policies and statements of the American College o f Occupational and Environmental Medicine (ACOEM, 2002) regarding the attending physician’s role in helping patients return to work after injury has been adapted from the CMA (2000) policy. The ACOEM (2002) concludes that physicians who follow the principles outlined in the policy will improve care for their patients, families, communities, employers, and society in general. Physicians who are board-certified in occupational and environmental medicine often have formal training in toxicology, epidemiology, and industrial hygiene, and are well suited to be team members in the various phases of risk assessment, communication, and management (Sparks & Cooper, 1993). The American College of Emergency Physicians (1986) recognizes the role of emergency physicians in occupational medicine in its policy statement which documents “the emergency physician with additional qualifications and/or special competencies frequently may engage in ... the provision o f initial care and continuing occupational medicine services, including illness and injury prevention, case management, and patient rehabilitation” (p. 1240). Tsutsui, Horie, and Kaji (2002) performed a literature search to determine the role o f the occupational physician in the return to work process of workers with acquired disability. They found studies indicating the occupational physician should commence cooperation with the treating physician immediately after appearance of the disability and exchange medical and occupational health information. The occupational physician also evaluates the disabled worker’s abilities and fitness for work (Tsutsui et al., 2002). 49 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Role of the Medical Advisor As a member of the British Columbia Workers’ Compensation Board clinical team, the medical advisor provides medical consultation for the division and for pertinent external members/stakeholders (WCB, 1999). The medical advisor offers medical opinions and recommendations on issues such as causation, diagnosis, prognosis, treatment, pre-existing conditions, and activity. The medical advisor’s primary internal working relationships are with the case managers, vocational rehabilitation consultants, entitlement officers, nurse advisors, and the clinical services team members. Outside the Board, the medical advisor’s interaction is ongoing with external providers such as attending physicians, surgeons, and program providers. The medical advisor plays a key role in the early return to work effort, offers guidance and assistance, and provides formal and informal medical education pertaining to treatment and prevention regarding medical issues within the framework of the Workers’ Compensation Act (WCB, 1999). The medical advisor facilitates medical recovery by intervening when recovery is not anticipated, collaborating in the development of a recovery plan, conducting medical examinations to clarify the most likely medical condition, discussing treatment options, and intervening when rehabilitation fails for medical reasons. Medical advisors emphasize the goal of return to work at all stages and advise on the viability of vocational options from a medical perspective, visit the worksite to observe tasks associated with the job function, and assess to determine if medical treatment and physical rehabilitation needs have been met. Medical advisors educate internal and external participants and also engage in self­ development by participating in continuing education, sharing information through community outreach, and providing informal and formal ongoing education to adjudicative staff (WCB, 1999). A primary responsibility of the medical advisor is to develop a working relationship with 50 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. attending physicians. This involves networking via telephone consultations and face-to-face communication on an individual basis or in small groups and workshops. Medical advisors educate community physicians on the principles o f occupational medicine, rehabilitation and disability management, and provide basic information regarding workers’ compensation practices (WCB, 1999). The worker is not entitled to care for the medical problems which existed prior to the work-related condition (Shrey, 1995). If the worker is left with a permanent impairment, a pension is in order. Physicians are directed to case managers and vocational rehabilitation consultants with respect to specific policies and entitlement. Medical advisors collaborate with attending physicians to prepare clinical care or treatment plans with specific recovery time lines (WCB, 1999). Physicians are advised to use the return to work process as a tool in their treatment plan. The return to work process ensures that physicians make medical decisions while employers make employment decisions. An attending physician is not expected to identify tasks or design work duties for a return to work plan, rather the plan is a collaborative effort with the worker, employer, physician, and WCB staff. The medical advisor, in conjunction with the nurse advisor, can educate the attending physician with regard to the worker’s critical job demands. The attending physician, using a bio-psycho-social model, has a holistic view o f the injured worker, while the medical advisor recognizes and focuses on the compensable injury accepted on the claim (WCB, 1999). The attending physician is able to provide information regarding non-compensable factors that may impact an employee’s return to work, while the medical advisor is better able to offer information specific to the worksite and job duties. The medical advisor is guided by the principles that exemplary medical care to injured workers and 51 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the safe, early return to meaningful work to enhance the recovery process are in the best interests o f both the worker and the employer. This not only supports the attending physician and injured worker in the disability management process, but also assists with resolution of the claim. The WCB medical advisor communicates with physicians who are inconsistent with clinical practice guidelines/disability duration guidelines (WCB, 1999). Evidence based clinical information and outreach visits are provided, and independent medical examinations and/or rehabilitation programs offered in order to obtain objective medical findings and assist with appropriate treatment. However, when a worker is required to be evaluated by an impartial physician, the employee may be resentful and mistrusting of the doctor’s motives and opinions (Scheer, 1995). Through consultation and education initiatives, medical advisors assist attending physicians to understand that the longer a worker remains off work with a compensable injury, the greater the likelihood the relationship with the employer will be jeopardized. The need for early intervention and prompt treatment with a functional approach that ensures return to work as a goal o f treatment is an important concept for physicians to grasp (Dyck, 2000; Scheer, 1995). Medical advisors also alert attending physicians to the fact that labour management conflict and/or job satisfaction can be obstacles to return to work planning. For their cooperative efforts in discussing return to work planning with a medical or nurse advisor, arranging return to work planning with the employer, or participating in meetings and site visits, attending physicians are advised as to the appropriate billing fees (WCB, 2002). Christian (2000) believes medical reports are undervalued and suggests increasing remuneration for physicians who provide prompt and complete information regarding return to work planning. 52 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Conclusion Ineffective disability management by doctors is an obstacle for return to work (Van Der Giezen, Buijs, & Van Mechelen, 2002). Physician involvement with injured workers should be objective, expeditious, and considerate (Scheer, 1995). The physician plays an important role in workplace disability management by providing critical medical information and recommendations that can positively impact an injured worker’s ability to safely return to work (Cowell, 1997). The need for treatment focusing on function and return to work is an important concept for physicians to understand. A successful return to work involves the employee and the employer with the assistance o f the attending physician. The literature review o f the role o f the physician in compensable return to work has shown that, together with employees and employers, physicians and medical advisors play a key role in the return to work effort. However, the literature also reveals a lack of information regarding the experiences of medical advisors assisting in the management of clients in the workers’ compensation system. Although a prior qualitative study (Russell et al., 2005) examined the experiences o f family physicians managing patients in the workers’ compensation system, this review justifies the need for an in-depth descriptive study of the experiences of medical advisors using a phenomenological approach. Physicians can be gate openers or gate slammers (Scheer, 1995). The challenge is to discover the most efficacious methods o f working with, not against physicians, in order to assist injured employees in a safe, timely return to work. 53 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 3 RESEARCH METHODOLOGY The research orientation for this study is based on qualitative methods. Creswell (1998) defines qualitative research as an inquiry process o f understanding based on distinct methodological traditions o f investigation that explore a social or human problem. The qualitative researcher constructs a complex, holistic picture, analyzes words, reports detailed views o f informants, and conducts the study in a natural setting. This study employs a qualitative design using a phenomenological approach to understand the experiences o f medical advisors in the workers’ compensation system. Orientation o f the Study Phenomenology as a philosophy and a research orientation describes the lived experience of study participants in relation to a concept or phenomenon (Creswell, 1998; Giorgi & Giorgi, 2003; McMillan & Schumacher, 2001; Moustakas, 1994). It is considered the search for essences and answers to the question, “what is it like to have a certain experience?” (Miller & Crabtree, 1998, p. 28). Van Manen (1990) states that “lived experience is the starting point and end point o f phenomenological research” (p. 36). This discovery oriented research adopted a phenomenological approach to investigating the phenomenon of medical advisors’ experiences in the workers’ compensation system. The choice o f the research orientation considered the various advantages o f the method. Phenomenologists explore the structures o f consciousness in human experiences by using inductive data collection tools o f qualitative methods such as interviews, discussions, and participant observations (Creswell, 1998; Lester, 1999). The goal is to capture, as closely as possible, the way in which the phenomenon is experienced within the context in which the 54 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. experience takes place (Giorgi & Giorgi, 2003; Van Manen, 1990). In addition, phenomenologists search for the essence or central underlying meaning o f the participant’s experience and “emphasize the intentionality o f consciousness where experiences contain both the outward appearance and inward consciousness based on memory, image, and meaning” (Creswell, 1998, p. 52). This phenomenological study allows an understanding of the experiences o f medical advisors from the “participants’ perspectives” (Bogdan & Biklen, 1998, p. 24). The emphasis is on the subjective aspect of the medical advisors’ behaviour. A theoretical framework is not employed since the nature o f this research is that of a descriptive study seeking to understand medical advisors’ experiences in the workers’ compensation system. I chose a research orientation that would best permit the voices and experiences of medical advisors to be heard and supported. A qualitative study design using a descriptive phenomenological approach afforded me the opportunity to facilitate this research by investigating the lived experiences of medical advisors. Other factors in the choice o f this methodology included using an approach rooted in the social sciences and humanities with a clear, sound framework that ultimately assists in providing a better understanding of a phenomenon about which there is little information. Lastly, this methodology is participant centered and well suited to my personal and professional values and ethics. As a nurse advisor whose colleagues are medical advisors, I approached this study with an open-mind and endeavoured to minimize and acknowledge my prejudgements or biases from previous experience, acquaintance, and familiarity with WCB medical advisors to permit their experiences to be heard. This research orientation is reinforced by Moustakas (1994) on his views of the nature and meaning o f epoche as not only a preparation for acquiring new 55 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. knowledge, “but also as an experience in itself, a process of setting aside predilections, prejudices, predispositions, and allowing things, events, and people to enter anew into consciousness, and to look and see them again, as if for the first time” (p. 85). Study Participants and Sites This research was undertaken in order to gain a deeper understanding of the experiences of medical advisors in the workers’ compensation system. My reasons for studying physicians are two fold. Firstly, I am interested in the medical field as a result of my nursing background, and secondly, I ultimately hoped that this research may provide meaningful information that may improve my practice and that of my colleagues. The dominant sampling procedure in qualitative research is that o f purposeful sampling which searches for information rich cases that can be studied in depth (Creswell, 1998; Hoepfl, 1997; Kuzel, 1999). Of the 16 strategies for purposeful sampling (Miles & Huberman, 1994), criterion sampling was used for this study. Criterion sampling, useful when doing small exploratory studies, is appropriate for a phenomenological study as all the individuals studied represent people who have experienced the phenomenon (Creswell, 1998; Kuzel, 1999). The sample size, four medical advisors, meets this criterion. According to McMillan and Schumacher (2001), “the power and logic o f purposeful sampling is that a few cases studied in depth yield many insights about the topic” (p. 401). The population sample for this study consisted o f all four physicians who contract their services to the WCB o f BC in a northern rural service delivery location. The term ‘medical advisor’ is used since the participant is a physician who provides clinical advice within the scope o f the Workers’ Compensation Act. 56 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Two of the four medical advisors reside outside the service delivery location office. As such, medical advisor duties are performed via computer, telephone, and video conference, with face to face attendance occurring approximately every one to three months for three to five day sessions. The dispersion o f individual participants in the study may provide important contextual information useful for the data validation and accuracy analysis phase common with qualitative research (Creswell, 1998). The participants were recruited by me, the sole researcher for the study, through association at the worksite, the WCB area office. All four voluntarily consented to participate in the study several months before the interviews took place. Considering my personal and professional access as an insider on the research site and to the participants, this study was most suitable to me as the researcher. Of the four medical advisors invited to participate in the study, two are females and two are males. Three o f the physicians received their medical training in Canada while the fourth was trained abroad. All participants are experienced physicians who graduated from medical school between 20 and 35 years ago. Experience as a medical advisor in the group ranged from four to twelve years. Three o f the medical advisors work primarily with the case management team while the fourth provides opinions for files earlier in the claims and adjudication process. Only one o f the physicians had previously contracted his/her medical services to other insurance companies in the past. Over the past two years, distribution of WCB claims changed from a geographical allocation to a province wide distribution based on industry segmentation. The northern rural service delivery location is responsible for claims in the forest and transportation industries, the health care and hospitality sectors, and for a variety of other employers. Written consent to 57 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. perform the interviews at the WCB office was received from WCB management in December 2005. Please see Appendix A for Consent to Access Site Form. Data Collection Technique & Practice The study data collection technique engaged the phenomenological orientation o f indepth interviews (Creswell, 1998) which involved an informal, interactive process that utilized open-ended comments and questions (Moustakas, 1994). The phenomenological interviews investigated what was experienced, how it was experienced, and lastly, the meanings the participants designated to the experience (McMillan & Schumacher, 2001). The study employed the semi-structured interview data collection technique. Each medical advisor was interviewed individually within the month of January 2006. Three o f the interviews were conducted in the northern rural WCB office, while the fourth was conducted in a lower mainland WCB office. The face to face conversational interviews lasted from 50 to 90 minutes in length and were audio-taped with the medical advisors’ consent. An in-depth interview can be characterized as a conversation with a goal (McMillan & Schumacher, 2001). As recommended by Creswell (1998), each conversation stemmed from an interview protocol o f five pre-determined open-ended questions that enabled participants to best voice their experiences unconstrained by any perspectives of the researcher. However, question sequencing was flexible which allowed the interviews to be participant directed. Please see Appendix B for Medical Advisor Interview Guide. Although I was acquainted with each medical advisor as an insider in the workplace, I was somewhat apprehensive at the commencement of the first interview. However, once we began, any feelings of tension dissipated and I had no apprehension with subsequent participants. 58 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I approached the conversations with professionalism and created an atmosphere of comfort and respect by acknowledging the participants as experts in their fields and work experiences. All four medical advisors were candid and articulate as they described their experiences in the workers’ compensation system. Participants provided subjective accounts o f personal experiences as opposed to objective information they as medical advisors submit in their work. I felt very fortunate and privileged that the participants were able to grant their time and attention for this study to enable me to pursue this research. Data Analysis Qualitative data analysis is a cyclical process integrated into all phases o f the research process (McMillan & Schumacher, 2001). The data analysis process involves data reduction, the analysis o f specific statements as codes and the generation of themes in a search for all possible meanings (Creswell, 1998; Lester, 1999; McMillan & Schumacher, 2001). A phenomenological study seeks to understand the lived experience o f individuals and “their intentions within their lifeworld” (Miller & Crabtree, 1998, p. 28). According to Van Manen (1990), “a good phenomenological description is collected by lived experience, recollects lived experience, is validated by lived experience, and validates lived experience” (p. 27). This research reflects these premises as the voices and lived experiences of the research participants provide validity to the entire study. Typically, qualitative researchers use as many strategies as possible to ensure validity in design (McMillan & Schumacher, 2001). The verification strategies that were employed in this study included data triangulation, a process o f corroborating evidence with the four key informants with regard to their experiences as medical advisors, with comparisons made to the literature; data was mechanically recorded with use of tape recorders; peer review was 59 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. undertaken as a graduate student provided an external check of the research process and verified the themes in the data; and, member checks were performed to review collected data with participants as individual summaries of the interviews were submitted to each medical advisor to ensure accuracy o f findings (Creswell, 1998; Creswell, 2005; McMillan & Schumacher, 2001; Miles & Huberman, 1994). The qualitative format o f report writing used is the descriptive and thematic approach that allows the reader to make decisions about transferability as well as better understand major ideas that emerged. Since participant identifiers were removed prior to data analysis, confidentiality was not breached during peer review. Qualitative researchers tend to use inductive data analysis meaning that categories and patterns emerge from the data rather than being imposed on the data prior to data collection (McMillan & Schumacher, 2001). As common to phenomenological data analysis (Miles & Huberman, 1994), I listened to the audio-tapes several times to better acquaint m yself with the data and become familiar with each participant’s story. The second phase o f analysis engaged the service of a qualified transcriber familiar with academic qualitative research data who transcribed the audio-tapes verbatim. Prior to submission o f the audio-tapes for transcription, the transcriber signed a confidentiality agreement. Please see Appendix C for Transcriber Confidentiality Agreement. Upon completion of the transcription, I listened to the audio-tapes and reviewed the transcripts for accuracy. All participant identifiers were removed from the transcribed documents and each audiotape was labeled. Spoken mannerisms or props such as ‘uhmm’ or ‘uh’ were excluded in this manuscript unless relevant to the quotation. As I listened to the audio-tapes again, I identified changes in tone and voice modulation, and gaps or silences in the conversations between the participants and myself. I read the transcripts several times and made more sense o f the data (Creswell, 2005). I immersed myself 60 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. into the data. As I read the transcripts, I reflected on the data and made notes and memos in the margins, and underlined interesting and meaningful text. I continued cycling through the data, comparing and contrasting information between the interviews. The more I read and immersed m yself into the participants’ stories, the more I developed a deeper, richer understanding of the data. I also reflected on my role and how my previous working relationships with medical advisors may have influenced the analysis process. In essence, prolonged engagement with the transcripts caused an illumination of the data that enabled me to recognize and identify the emerging themes. Ethical Considerations o f Method Qualitative researchers face ethical issues regardless of the choice o f study design (Creswell, 1998; McMillan & Schumacher, 2001). Despite the choice of research method, all studies require permission from a human subjects review board (Creswell, 1998). After choosing a qualitative research study design using a phenomenological approach to investigate the lived experience of medical advisors, a research proposal was developed. In December 2005 the proposal was submitted to the University o f Northern British Columbia (UNBC) Research Ethics Committee where it was approved. McMillan & Schumacher (2001) posit that “criteria for a research design involve not only the selection o f information rich informants and efficient research strategies, but also adherence to research ethics” (p. 420). A researcher protects the anonymity of the participants, explains the purpose o f the study and does not engage in deception about the nature o f the study, and develops case studies o f individuals that represent a composite rather than an individual picture (Creswell, 1998; McMillan & Schumacher, 2001). 61 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Prior to the commencement of each interview in January 2006, the agreement of participation and research participant informed consent forms were discussed in detail. I informed each medical advisor of the purpose o f the study, the data collection procedure and protection o f confidentiality and anonymity. Each participant was advised of his/her right to withdraw from the study at any time without prejudice. Medical advisors were given an opportunity to ask questions and were also provided with a copy of the consent forms. Please see Appendix D for Information Sheet and Informed Consent Forms. There were no known risks or benefits associated with the medical advisors’ participation in the study. The principle o f beneficence, a duty to benefit others and maximize net benefits in research ethics (Canadian Psychiatric Association, 2000; Interagency Advisory Panel on Research Ethics, n.d.; Nuhfer, 2001), was applied in this study as the research is intended for the advancement o f knowledge and for the benefit o f physicians and medical advisors as a whole. The principle o f non-maleficence, the duty to do no harm to the research participants, was also applied in this study through the maintenance o f confidentiality, anonymity, honesty, and professional conduct. The participants were told that the data from this study will remain in locked storage at the UNBC for one year following completion of this thesis, after which time it will be destroyed. 62 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 4 FINDINGS AND DISCUSSION Introduction Qualitative research is intrinsically multimethod in focus reflecting an attempt to acquire an in-depth understanding o f the phenomenon in question (Denzin & Lincoln, 1994). As there are no statistical tests for significance in qualitative studies, researchers bear the responsibility of discovering and interpreting the importance o f the derived data to establish conclusions o f the study (Hoepfl, 1997). This chapter presents the analyzed data findings as revealed in the study. This process engaged the phenomenological research method by transcribing the oral interview data to textual data. Since phenomenological studies emphasize “what happened and how the phenomenon was experienced” (McMillan & Schumacher, 2001, p. 490), data presentation includes structural descriptions of participants’ experiences, synthesis o f meanings, and the essence o f the experience (Creswell, 1998; Moustakas, 1994). To better understand the participants’ experiences, I read the transcripts several times as required of the phenomenological process of analysis (Miles & Huberman, 1994). Through such engaging research activity, I was able to immerse m yself within the data and arrive at the central theme, medical advisors are committed to providing quality medical care for injured workers, and three major themes with several minor themes subsumed within the major concepts: providing medical opinions - requiring factual information, clarifying the diagnosis, no previous relationship with worker, categories of injuries; working with attending physicians and specialists - building relationships, evidence based treatment plans, role o f the attending physician, role o f the medical advisor; and, working within the workers’ compensation 63 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. environment - structure and policies, expedited services, and case management/team environment. The themes are identified as sub-titles and discussed in a descriptive narrative approach by citing participants’ quotes verbatim to enable a better understanding (Bogdan & Biklen, 1998) of the work lived experiences of the medical advisors. This data sheds light upon the phenomenon of the experiences of medical advisors in the workers’ compensation system through the voices and stories of the participants, commencing with decisions to contract services to the WCB and medical advisor training. Findings Choosing to contract services to the WCB Three o f the medical advisors reported that choosing to contract their services to the WCB assisted them in achieving a work-life balance. One chose work as a medical advisor as his/her physician partner in private practice was “working here [WCB] already, he enjoyed the work. We shared a practice and we decided to also share this part o f the job as well.” Another physician viewed work as a medical advisor as “an opportunity to have a change of practice style and a better lifestyle.” One participant cited a combination of both personal and professional reasons for working as a medical advisor since he/she had an interest in physical medicine and viewed the opportunity as an interesting and exciting challenge. A fourth physician stated he/she was recruited to work as a medical advisor and “it fit well into my plans,” both personally and professionally. 64 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Medical advisor training The specific nature o f the medical advisor training varied according to length o f practice at the WCB. A senior medical advisor reported his training consisted o f file reviews without formal lectures or a focus on disability management: [Training] was a week in Richmond [WCB head office] reviewing files basically with one or two different medical advisors... There weren’t any lectures and disability management was not part of the agenda at that time. It was how to understand how the Board [WCB] was organized, how the files were organized, the paper files, and how I was to answer the questions that were posed to me by the case managers. The medical advisor found the training adequate for the work initially, however states “the job has modified itself over the years and .. .you grow into it.” The work evolved to a team concept with more communication between team members, particularly with the advent o f computer files, to the benefit o f workers: When you had a paper file it mandated that that file could only be at one place at one time, so you pretty much worked in isolation and communicated through the printed word... and that process was fairly slow. But now because of everybody working on the same file at the same time, there’s a lot more communication, not just only on the file, but personal communication between the various members o f the team... It’s done much more efficiently and much 65 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. more quickly and I think that overall it benefits the workers because they get through the system quicker. Participants advised that in recent years medical advisor training has progressed to more formalized sessions with specific topics consisting of: .. .Basic musculoskeletal training.. .training in the use of actual systems that we use, the e-file and computers. Also training on the Compensation Act, law and policy, and then a fair bit o f simulation in terms o f file review, dealing with causation issues, and also reviewing clinical care plans, and looking at the life o f a claim. However, additional mentoring was suggested to augment training as “that’s the real training.. .getting in there working on a desk, attending team meetings, learning the process.. .It’s really a full year before you’re up to speed.” Another physician suggested more education in occupational medicine would be of benefit since “it was presumed we had a lot of the knowledge beforehand.” The physician also advocated for more industry specific training in relation to team alignment, as well as working with the Prevention department: When I’m allocated to a certain area... I should have got a lot of training specific for that area. So I’m giving opinions on things that I really haven’t a lot of exposure to .. .And there’s so much we could learn from Prevention in our work and our job and that hasn’t happened.. .1 like to picture what’s 66 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. happened, so if somebody is pulling a chain on something, I want to know the weight o f the chain, I want to know the force behind it, I want to know the position of the limb in question. ..If I can go somewhere like the Prevention [web]site and see the video of this worker doing the job in question... it’s much more informative. Central Theme Throughout the lengthy process o f data analysis and reviewing the participants’ stories again and again for further meaning, I gained an awareness of the central or core theme within the data. All four medical advisors interviewed for this study are committed to providing quality medical care for injured workers. This was reflected in all the major themes that emerged from the data. The structures o f the organization to which participants provide services assist the medical advisors in their efforts, as does collaboration with WCB team members and attending physicians and specialists. The participants’ stories illustrated a commitment to quality medical care that assists an injured worker to optimize his/her recovery. Major Themes and Sub-themes Providing Medical Opinions Requiring factual information All participants identified and stressed that acquiring the accepted facts on the claim file, in terms of the mechanism of injury as well as the objective medical findings, was essential to providing medical opinions regarding causation and to answering other medical questions posed by Board officers. According to one medical advisor: I need the case manager or entitlement officer to tell me what they consider 67 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. to be the truth or fact, accepted as information.. .The patient bent over and picked a up chair. The chair weighed 20 lbs. What I don’t like is when they give me multiple different scenarios as to what happened and don’t tell me which one of those scenarios they consider to be the truth... So I need information about what they [claim owners] consider to be fact... I don’t come up with truths or decision making. Another participant had similar views regarding the importance o f receiving documented facts from claim owners with respect to the mechanism o f injury, including objective medical information from attending physicians whose perception o f the details o f the incident may differ from the facts accepted under the claim: I mean there’s all kinds o f opinions, but an opinion, say on causation, which is probably the most controversial kind o f thing people think you have to deal with as a medical advisor, you’re looking at an accepted mechanism of injury. What did the investigation by the claim owner determine were the facts around it? So then you look at what’s being presented as the medical condition. Do these things add up? And you’re providing your best opinion based on current knowledge of medicine and the accepted facts on the claim .. .1 need the accepted facts because the accepted facts are not necessarily what the doctors have put in their medical reports. Very often the physician’s understanding o f what took place is very different from what had been the accepted facts. You need 68 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. to know exactly what took place, what’s been accepted as accurate and factual, and I need the objective medical information from the physicians who’ve attended that. Participants expressed frustration with the time consuming process of reviewing a file when asked to provide opinions for questions that were received without contextual or background information. This medical advisor believes claim owners should be: Providing more information up front when they’re asking you for an opinion. People have improved, but some people give you very little and by the time you’ve spent... an hour or so reading this huge file, finding pieces o f information that, in order to put together the basic facts, and that probably should have been done by the claim owner before they sent it to you. It’s not really good use o f my time to have to read through every little piece o f paper in the file to dig up the accepted facts, what the claim’s actually accepted for. Another participant found that claim owners could often answer their own questions after a thorough review o f the information on file. The medical advisor reported occasions when he/she received a question with no background information whatsoever, only to find that the question had already been adjudicated: I think a lot o f the questions we’re asked by case management... are 69 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. inappropriate... and they could make a decision on a lot themselves. I’ll sometimes go through the file after spending an hour and say, ‘but didn’t you answer this question two years ago?’ Medical advisors concurred they require “clarity in the question” submitted for a medical opinion that is confined “to my area of expertise, which is medical.” According to one participant, “often you get very vague questions that are not specific medical questions and you can’t provide an answer if it’s not a specific question.” This medical advisor suggests claim owners ensure the appropriate information is available for review prior to submitting a request for an opinion: It’s quite important that when they ask me a medical question, that they have got all o f the information together that’s necessary. For example, if they don’t have all of the medical records, if they’re missing an operative report, if they’re missing an x-ray report, if they’re missing physicians’ reports, that’s crucial. So there’s really no point in sending me the question until that information is available. One medical advisor described the challenges associated with providing medical opinions on claim files and likened the scenarios to hypothetical situations versus private practice and “a real situation” where a physician speaks with and examines a worker first hand. The participant stressed how his/her opinion must be received within the context of the information provided by the claim owner in order to avoid misinterpretation: 70 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. It’s a hypothetical situation to me because I haven’t been to the work site, I haven’t seen the accident, I haven’t had a first hand history and so often there’s questions that I would specifically like to be clear in my mind. So I’m getting third hand information and it’s always based on the information presented to me that I’m giving the history, so it may be in the big picture an inaccurate opinion because I don’t have the whole story, and we all know how a story can be presented in different forms. So I hope my opinion is taken in that light. Sometimes it’s not, sometimes it’s taken as a dogmatic statement relating to this specific worker, whereas because I don’t know the whole details, I’m just relating the history I’m given and so sometimes I feel that there’s room for misinterpretation o f my, a misuse o f my opinion in the big picture. Whereas when I’m seeing a worker in the office [private practice], I’m able to make a much more informed opinion because I have a first hand opinion, I can decide whether I believe my patient as to their history, whether there’s reasons for me not to believe him, and whether his history fits in with what I know about the job and occupation.. .1 can actually examine the patient, decide what the diagnosis is and I don’t actually have to be work specific. So I can say that this is what his problems are and know that I don’t have enough information for causation. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Clarifying the diagnosis Medical advisors agreed that when asked to clarify the diagnosis, several options were available to assist in this endeavour including discussing the file with the attending physician, performing a physical examination o f the worker or an At Board (AB) examination, or referring the worker to a third party such as a sports medicine physician, orthopedic surgeon, or other specialist. Although AB examinations may be helpful to clarify medical findings, participants also spoke of other concerns: For diagnostic clarification they’re [AB exams] often useful. If the worker, patient, is already involved in several medical [investigations], often a phone call with the orthopedic surgeon may be sufficient to get the information that I need. And you know, an At Board exam may not be helpful in that situation because we already have two or three opinions and to add a third may just be confusing. Another medical advisor seldom found AB exams helpful citing other resources for diagnostic clarification: I mean, they were traditionally used to sort out what the diagnosis was and they’re not the most efficient way o f sorting out the diagnosis. Often a call to the family physician, discussion with them, decision that they don’t know, that they think an orthopedic assessment is useful. There’s many other routes that actually provide the information in a more efficient and probably a more 72 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. acceptable manner to the worker. No previous relationship with worker Several participants indicated that providing objective opinions for files o f workers whom they do not know, where there has been no previous relationship, may be an easier task opposed to general or private practice where physicians are familiar with clients. Attending physicians have knowledge o f the holistic patient that comes from having built a relationship with the individual that could influence the return to work process: When you’ve known somebody for 30 years you also have a personal history between each other. Sometimes that can be o f great benefit, but sometimes it can be a great impediment. When you’ve never met somebody, all you get to look at are the facts, and that’s where it’s critically important that the treating physicians and other people working with the injured worker have documented those facts accurately, that’s where the record is o f vital importance. But in the best case scenario, if the facts are documented then you can look at the facts and compare how this worker’s doing compared to what the average person would do from your experience in a similar circumstance. If you’re the treating physician you might say, well he’s a little slow getting better from this operation because his Aunt Nelly has been sick and he’s really had to help her out and I can understand that I’m really not that concerned about how he’s doing. Whereas if you’re the medical advisor, you don’t know or care about Aunt Nelly. You’re really concerned with is this person going Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. to his rehab appointments.. .is he getting better the way he’s supposed to, should he be at a trial of employment or gradual return to work. This medical advisor clarified that medical questions have medical answers regardless of the circumstance under which the client was seen: You’re providing opinions all different kinds of things... some things are straightforward... does this person need an MRI? Or would it be useful or helpful? And those are very medical questions that have medical answers and it wouldn’t be a different answer whether you were seeing them as a patient or seeing them as somebody else who had a need. Causation questions, again you’re weighing evidence and you’re looking at the medical literature and you’re trying to be very objective and it’s probably easier to be objective when it’s not your patient than if it is your patient... because you’re just looking at the facts. Another participant concurred that providing opinions on files o f individuals he/she does not know is less difficult since medical advisors do not communicate their opinions or “perceived negative” information to workers: I think it’s much easier to give objective opinions when I don’t know the people.. .1 think because a lot of the objective opinions we give are negative, and I think as physicians we’re not good at giving negative information to 74 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. patients, or at least perceived negative information, like you should probably go back to work, or you should probably become more active. Those things sometimes people don’t want to hear.. .Because [in private practice] we know them and we know where they’re coming from with their work injury. We take into consideration a number of factors in the office that we would not take into consideration in giving an objective opinion from the Board. It’s more o f specific medical response when people ask us [medical advisors] questions, but if as a general practitioner, we’re asked whether this patient can return to work, we think o f the factor o f the kids... the w ife.. .and I know that he doesn’t like his work, I know he doesn’t like his boss... Where I [as a medical advisor] can totally step away from all those issues... The medical advisor stated that he/she, unlike the family physician, does not explain the rationale of return to work as part o f the recovery process nor answer further questions if the worker is not agreeable to a return to work plan. When asked whether a physician’s time in the office is a factor for limiting discussions relating to the return to work process, the medical advisor replied, “I think it’s an issue of we like our patients, in general we like our patients and we don’t want to upset them.” These quotes illustrate the commitment family physicians feel toward their patients, similar to McWhinney’s (2000) concept of unconditional relationships between family physicians and their patients, and “the commitment, therefore, is to a person whatever may befall them.” In their 75 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. study of the experiences of family physicians in managing injured workers, Russell et al. (2005) found the commitment o f general practitioners conflicts with insurer requirements: Commitment to the patient was a core value across the Varied work settings o f the physicians we interviewed. Our participants’ experiences suggested that this aspect o f the culture o f family practice conflicts with insurer requirements for family physicians to adhere to pathways o f care, particularly those requiring liaison with other contributors to the workers’ compensation system. Even when doctor-patient relationships were challenged by the effects o f an injury, family physicians saw a clear advantage in maintaining relationships as a base for further effective health care. Similar to other participants, this medical advisor reports on the objectivity of his/her opinions, but also likens opening a claim file to that of a mystery novel which provides both interest and challenge to his/her work. However, the participant reiterated that the injured worker is central to the “mystery” as: Every time I open up a file there is, it’s a hidden story that is written in code. The interesting part o f the job is to be able to decipher the code and to pick out amongst the whole raft of information, the salient points, the things that are really important, that stick out that tell you about this person and how they’re doing... I find that particularly fascinating because it’s like a mystery. Each case I look at to, to know is this person’s 76 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. illness related to their reported incident.. .1 find it interesting in terms of deciphering the mystery and sometimes the opinions given I think can be more objective than the treating physician’s opinions because I’m not directly involved. Although medical advisors are not personally acquainted with injured workers, they are nonetheless committed to providing objective medical opinions for files and assisting with facilitating appropriate interventions for the individuals. Categories o f injuries Participants found that providing opinions for and assisting in the management o f work injuries diagnosed as a sprain or strain was relatively straightforward with a predictable outcome. According to one medical advisor: I don’t find those [sprains and strains] difficult. I think because the medical is fairly concrete in those areas. I know what to expect and I know what the best interventions are, I know that I don’t have to worry about there being something else going on. However, medical advisors indicated the management of back strains is more challenging. One medical advisor described some o f the complexities that can be associated with a back claim and which are often unrelated to the compensable claim: If you’re talking about a back sprain, that’s a diagnosis that’s really lumped 77 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. into back pain which is you know, 45 or 50% of the Board’s sort o f burden, and it’s often difficult to distinguish between true pathology, such as either a disc or a neurological problem or myofascial pain, or a true strain which does occur, or mechanical back pain which is probably the commonest cause of back pain, or a whole range o f other issues such as chronic depression, chronic substance abuse, alcoholism, main one there, poor work enjoyment or employer employee conflict, which has very little to do with how the back actually functions. But people get back pain for all kinds o f different reasons, some of them are medical and some of them are social. Another medical advisor shared his/her experiences in assisting in the management o f back strains by citing the difficulties o f educating all stakeholders on the effects of recurrent strains the aging back: Yes, I think that the more difficult [cases] are the back, recurrent back strains where they’re working with the same employer for many years, have many, many incidents, but each incident is really it’s own incident. It’s really quite minor, but over time that aging back is taking longer and longer to get better, but it’s still really just a back strain. And you know, somewhere down the road we get into that aging back becoming a bigger and bigger problem and it’s very difficult to get anybody, Board officers, physicians, everybody, and the worker, to understand that it wasn’t all the back strains that caused Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. that aging back, it was just aging. So I think backs have to be the most complicated and difficult ones to manage. Cases involving pain, nonspecific, chronic, and complex regional pain syndrome, were also identified as challenging files on which to provide opinions. When asked whether the subjective nature o f pain added to the challenge of providing medical opinions, one participant replied: I think that’s part of it. I think that because when pain becomes an issue, normal medical strays away from normal natural history. For example, someone sprains their hand, their wrist, usually we would say that they probably need a week or two of rest, and then start mobilizing, and mobilizing as much as you can, encouraging them to be as active as possible. But then when pain becomes an issue and they stop using the limb for any un-natural way from the perspective o f the pain, then I have trouble making sense of the timelines and the degree o f disability predicting long terms results etc., because it doesn’t follow. Participants’ views diverged with respect to challenges associated with working on multiple trauma cases. Two medical advisors described the claims as straightforward and less difficult to manage than back strains and non-specific pain since multiple trauma injuries are well defined with clear diagnoses from which recovery periods are determined. However, one Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. physician noted that, at times, the less life threatening o f the multiple injuries can often come to light at a later date: They [multiple trauma cases] are fine to deal with. The only problem with that is sometimes when the triage occurs and you have the most serious injuries listed, it’s the less serious or less life threatening injuries, not necessarily less serious, that don’t surface until later. So it may be you have somebody with bilateral fractured femurs, pneumothorax, and their medical attention is based on those, and then four months down the road you notice that somebody has a cognitive deficit or whatever. They’re the difficulties in those injuries, but generally, by and large, the multiple traumas are more straight forward than the non-specific pain. Another medical advisor reported his/her experiences with multiple trauma cases by stating the complexities o f the injuries compound each other: You get a multiplying effect when you have a head injury on top of a major fracture on top of soft tissue injuries, and it’s compounded by the fact that these are always very prolonged. You get a lot o f chronic pain and chronic pain behaviour, you get loss of muscle mass and you get deconditioning, you get social withdrawl, you get loss of self esteem and depression, you get family breakdown, and you get substance abuse. So by the very nature, they’re far more difficult claims to manage. 80 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Working With Attending Physicians and Specialists Building relationships Participants’ experiences with attending physicians and specialists was varied, but all found that collaborating with physicians with whom they had previous working relationships or with whom they had established a rapport was advantageous to the return to work process. One participant points out his/her different approach when contacting a physician with whom he/she is familiar as compared to one he/she has not met nor spoken to previously, by commenting: More than half the calls that I make are to local physicians, who, the vast majority whom I know and have practiced with, so there’s an advantage in that they know me and I know them, and usually I can get what I want fairly quickly, and usually they accept, they know what I do, and they also know how I practice medicine and they usually are fairly receptive. If I’m calling someone I don’t know... sometimes I have to be a little more subtle in terms of trying to achieve the desired results and a little less direct because I don’t know how exactly they’re going to receive my call, whether they feel it’s interfering or manipulative or in some way trying to usurp their authority. Another participant also explained the purpose o f his/her calls to community physicians and stated that he/she was well received because of past working relationships: I think in general, at least in this town, because we all know each other so well, we’re well received. I think they’re [attending physicians] are 81 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. happy to get another opinion and by the time we’re calling them in this town, usually they realize that there’s a problem. I mean we do call them with straight forward cases, but that’s pretty rare. We call them to set up return to works and whether they need to be in a rehab program etc., and all that stuff is well received, so I don’t find that the least bit anxiety provoking. One medical advisor reported his/her experiences with family doctors revealed categories o f family physicians ranging from those having skills in disability management to those with no knowledge and no willingness to accept intervention from the WCB to assist the worker in the recovery process: There’s probably three different types o f family physicians out there; one are the physicians that are very good in disability management and they’re happy to discuss or share a claim with you. There’s the other physician that isn’t awfully knowledgeable and is delighted at any intervention that you may offer and they’re happy to hand over management or take heed o f any help or suggestions that you may have... And there’s the third physician who does not have any knowledge about disability management, feels that a back claim should stay home on bed rest for three or four months, and does not want outside intervention. And he doesn’t understand the concept of temporary or partial disability and it’s an all or nothing and feels that somebody is unable to work and doesn’t 82 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. have any idea about a modified return to work. The participant’s experiences with family doctors who lack training in disability management is supported by the literature and the need for continuing physician education in occupational medicine and the return to work process (Guirguis, 1999; Pransky et al., 2002; Schweigert et al., 2004). In such a challenging circumstance with little or no cooperation from the family physician, the medical advisor finds “it is really difficult.” He/she suggests an opinion from a third party, an orthopedic surgeon for example, to assist with solutions and resolving the impasse: .. .knowing that you have actually tried to involve the treating physician in the plan. So you may have to go ahead with an independent plan stating that based on the information that you have, that total permanent disability isn’t there and that there is a role for a return to work in a modified capacity. Another medical advisor expressed the challenges involved in attempting to reach attending physicians for collaboration o f treatment plans, by adding: There’s people you never reach, they’re never available and they never return your calls. You send a fax asking them to call and they never respond to your fax. There’s those who take the call right when you call, and there are those who return calls fairly promptly. So you have all ranges o f willingness to participate in collaborative efforts. 83 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Participants’ views also varied with respect to their approach when contacting a specialist physician compared to an attending physician. One medical advisor described his/her approach with specialists as more conciliatory and added that he/she felt most of the orthopedic surgeons he/she has contact with are well aware of the importance o f early return to work because of “their confidence in their diagnosis and treatment.” One medical advisor said his/her approach in contacting a specialist was no different than with attending physicians citing “most o f the specialists I call are ones that I deal with on a daily or weekly basis... so most o f them I know personally... I don’t have any particular difference in the way I treat them.” Another participant felt it was easier to access a general practitioner because of their availability in the private office setting compared to specialists who are often in the operating room. He/she also reported that communication with specialists is enhanced in smaller communities in which there is a WCB office: .. .It’s a different kind o f communication [in a large urban centre] than dealing with our own specialists in our community... I can have much easier access to them to talk to ... I think that’s because there’s offices, WCB offices, in these communities, they’re used to that level of interaction with the specialist... However, dealing with out o f province physicians with whom no rapport has been established and who are not familiar with the WCB of BC practices o f assisting with the management of injured workers has proved challenging. According to one medical advisor: 84 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The biggest problems are actually when we’re managing out o f province situations where the physicians are in another province, used to a different WCB system that doesn’t get involved in management of the claims and expediting medical services, and assisting physicians to access things. They are used to the medical advisor... at the end of the whole thing and writing an opinion as to what’s related and what isn’t, and they’re not used to talking to people from the Board... They don’t understand why we would want to speak with them and they often will, simply not speak to us, will not respond to letters or faxes. There is also the inability to access expedited consultation and investigation in those provinces... It’s tough managing workers when they move away from their worksite to another province. When asked whether he/she believes the out of province physicians may feel threatened by another physician providing advice with respect to care, the medical advisor agreed and replied he/she endeavours to mediate the situation with ongoing attempts at communication and education: ... Absolutely, absolutely because they’re not used to the model, the advice management model. It’s completely foreign to them. They don’t understand it, they have no idea... You try to phone, you try to fax, you try to send letters, but I’d say you’re less than 50% successful out o f province. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The medical advisor’s experience concurs with the findings of Russell et al. (2005) whose study on the experiences of family physicians’ managing injured workers found that “while appreciative of the input of other professionals within the workers’ compensation system, family practitioners were suspicious of external influences on clinical decision making” (p. 78). Another medical advisor found that claims allocation through industry segmentation has posed challenges to building relationships with all physicians, general practitioners and specialists alike. The participant focuses on establishing rapport with physicians in order to achieve positive outcomes for injured workers: ... The difference is talking to a stranger versus talking to somebody that you’ve built up a rapport with over the years. So an orthopedic surgeon that feels you’re a competent physician and is willing to discuss things with you has no problem making time to speak with you. You’ll have the few that aren’t really interested in a plan, but that’s the same with family physicians. So it brings me to the issue o f industry segmentation, and how, what a difference that has made because speaking with a physician that you haven’t built up a rapport with, that you may never speak to again, you’re investing time, they’re investing time with you... Sometime you’ll invest time [and] you may not come to a good outcome with the specific patient or worker that you’re talking with, but you’re then trying to invest time for the future, the next worker or patient that you may have success with. But whereas if you’re never going to encounter this physician again, it makes it a little bit more challenging and then the same for the physician. I know 86 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I’ve physicians in certain areas that I’ve worked with [over the course of several years] and they will feel free to call my phone if they have a question, so it’s the physicians [who] are now calling me as opposed to me calling them. Even if it’s not my claim or it’s a generic question or something they know that they can bounce things off me, and that’s nice. This medical advisor finds satisfaction speaking to the same community o f physicians where rapport and a relationship are built. Success in the relationship building is reflected when community physicians initiate calls to him/her for assistance in managing injured workers’ claims. All participants agree the 19930 fee code, for which physicians can bill their telephone consultations with medical advisors (and others in the case management team), is a form of respect indicating value for their time and discussions. A medical advisor found that many physicians will often discuss claims regardless o f the fee code in order to ensure best practices for their patients: Physicians are very appreciative of the fact that you understand the value of their time and being disruptive and... they’ll often talk to you anyway even though they don’t know it exists because they really do want to do the best for their patients. But that [the fee code] does help to make it easier to get through. 87 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. This quote again illustrates the commitment general practitioners feel towards their patients which was highlighted as a core value in the study by Russell et al. (2005). This medical advisor also acknowledged the 19930 fee code as a form of respect for the attending physician’s time, however, indicated the practitioner’s willingness to discuss the case was because o f a desire for better practice management rather than for a fee: [The fee code] it is sort of saying that I understand that I’ve dragged you away from your office, but the ones that come willingly to the phone, they don’t do it for the fee code, they do it because it’s better practice management. They understand that it’s better medicine and so they’re doing it because it’s good practice. Similarly, this participant spoke of a satisfying experience when, during a telephone conversation with a family physician, he/she was able to provide education and advice that assisted the practitioner to better communicate with his patient: ... And it was talking to the physician and he was saying, “well, what do you think I should tell this patient?” ... He was really looking for education, support and advice, and I really felt that we had a good conversation and... hopefully helped him communicate with his patient better.. .They are really good experiences when you think you’ve made a difference... 88 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. All medical advisors agreed that calls to attending physicians were generally positive interactions, or as one put it, “usually positive, sometimes neutral.” Evidence based treatment plans Although participants had differing views on whether attending physicians understand particular recovery guidelines, medical advisors used comprise and problem solving approaches when collaborating with general practitioners on treatment and return to work plans. One medical advisor explained that evidence based practice is expected o f physicians in many other realms as well as the WCB: I think that the physicians are coming around. I think that they’re having this presented to them in many other areas other than the WCB world. Certainly in terms of laboratory testing and what the government’s willing to pay for, and drugs, what Pharmacare will pay for. Everything comes down to evidence based medicine and best practices and so they are familiar with rationale forjudging things based on that. They know it’s the standard and they also know that they are generally not up to speed on the knowledge, so for the most part, they’re accepting of that and actually willing to accept the literature, or CDs, or whatever we have to have help bring them up to speed on it. The medical advisor found that many physicians are not familiar with practice guidelines, however do recognize that the WCB patient typically has a longer recovery time which often leads to more medical investigations: 89 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I don’t think they [attending physicians] know the guidelines at all. They don’t know that a back strain normally gets better in six weeks. Any of them who see a lot of people with a particular condition usually will have identified that the WCB patient takes far longer to get better from the same injury than the guy who did it playing volleyball... They usually recognize that if they’ve been in practice for any length of time at all and see the same injuries on a repetitive basis, but in any practice, WCB is actually quite a small part o f your total volume of patients, so it’s not easy to get a good perspective on this. They often just think they’re missing something, that they’ve got the wrong diagnosis, and so you’ll see more investigation and requests for referral because they feel that they’ve missed something. The notion that the WCB client has a longer recovery time is supported by Derebery and Tullis (1983) and the Australasian Faculty o f Occupational Medicine (2001) who posit that those who are injured and claim compensation for the injury will usually have delayed recovery and poorer outcomes than those not involved in the compensation system. This medical advisor also reported that older physicians have a more difficult time accepting new evidence citing they are practicing the art of medicine rather than approaching it from a scientific basis. He/she added: The other clarification o f that is that the older physicians have a harder 90 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. time accepting new evidence... simply because it doesn’t fit their knowledge base that they’ve always practiced on. They’ve basically practiced the art o f medicine and they have never been pushed to do it from a scientific basis which is what we’re doing when we look at evidence based medicine and those kind of timelines. And they also feel that their opinion, whatever it is, is their opinion, and it’s valid and that’s how it will be. It’s a very dogmatic thing. It’s not all of them, but it’s a large number o f them, the more senior physicians... Both the CMA (2000) and PEPWH (2000) advocate use of an evidence based treatment or care plan that identifies the best sequence and timing o f interventions. However, Derebery et al. (2002) also report that physicians practice largely by dogma and tradition, with some estimates that only 10 to 20% o f diagnostic and therapeutic actions are based on scientific evidence. In their study of family physicians’ perspective on soft tissue injuries, Guzman et al. (2002) found that most physicians seemed aware o f their role in the return to work process, but their advice on activity after injury differed from that in practice guidelines. It appears somewhat ironic that while physicians seemed to be aware of their role in return to work, they did not consistently recommend interventions that will ultimately assist their patients, injured workers, in the recovery process. Another participant felt that most attending physicians are aware o f recovery times and therefore he/she does not reiterate the evidence based guidelines in his/her discussions. However, his/her call to the general practitioner “is enough for them to clue in to the fact that this isn’t fitting very well with the natural history o f the disease process.” 91 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A medical advisor explained that recovery guidelines can be provided for attending physicians; however, specific solutions to assist with an appropriate recovery plan for the worker and promote trust in the claims process have proven beneficial: First of all, there are the recovery guidelines that you can provide, but again that’s only so relevant. When you’re a family physician in the community and you’ve got somebody presenting to you and saying they’ve got the worst pain ever, and you’re saying, well they should have recovered and the family physician is saying yes, I know they should have recovered, but... they’re still here in front o f me complaining. So using the evidence base that return to work is good practice, using hurt versus harm is very helpful, and coming to a compromise.. .and this person looking at the modified work that can be done is helpful to all parties because it helps them be reassured that a durable, safe return to work is happening. I know that a lot of physicians have been burned by employers that they’ve been assured that the worker is going back to modified work and then end up having to do way more than they were told... So that’s the reason why a lot of the physicians in the community aren’t prepared to allow a modified return to work unless they have somebody that they have confidence in will be supporting that return to work.. .it’s having confidence in the system. Similarly, a participant advised that his/her communication and education through a telephone call to the attending physician not only assists in preparing an evidence based recovery plan, it is 92 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. also useful in obtaining information, perhaps previously unknown, that may impact the return to work process: If you sprain an ankle, it is not all better in eight weeks, it might be mostly healed, but it’s still painful. So you.. .work with the physician to say, well we know that the ligament is going to be strong, and we know that using that particular body part is not going to be injured by going to work, and we also know that working isn’t going to interfere with healing, and is there some other reason that this person is not going back to work? Quite often you’ll find that there are some other issues that the physician really didn’t want to put down in black and white.. .But physicians probably benefit from being reassured by the evidence base that a return to work would not be harmful to this worker and in fact may be beneficial... Role o f the attending physician Most participants expressed the same view that, in their experiences, the majority of attending physicians with whom they have had contact do not clearly understand their role in the compensable return to work process. According to one medical advisor, attending physicians may not recognize their role as influential to a successful recovery: I think they [attending physicians] understand it [their role in compensable return to work] in a global sense, that somehow they’re important. I don’t think they understand it from the sense, the point o f view of the Board... 93 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I don’t think they realize that they’re as important as they are. I don’t think they realize that they are an important part o f the person getting better. This is somewhat contradictory to the findings of Guzman et al. (2002) who performed a study on family physicians’ perspectives on soft tissue injuries. They reported that most physicians “believed that their own ability to explain the nature of the injury and prognosis was crucial for addressing workers’ fears and helping recovery.” The participant goes on to state that he/she believes physicians practice more o f a medical model o f management rather than a functional model that focuses on the goal o f return to work. He/she attributes this in part to their medical training and provides a general practitioner’s office scenario as an example: I think that when you’re dealing with 30 different people a day, or maybe 40, depending on how busy you are, and you’ve got Joe Smith with a slow to resolve ankle sprain at 10:10am and you’re with him until 10:20, by 10:21 you’ve forgotten about Joe Smith. And you’re not going to think about him for the rest of the day. So you will think about those issues with Joe Smith’s sprain for the time he’s sitting in front o f you, and it may not be front and centre that the return to work is an important... aspect o f getting better. I think that physicians are a little more focused on, is the swelling going away, is the range of motion improving, is the pain getting less, how’s your gait, those kind of issues than, are you back to work yet... I think it’s partly because o f their training. 94 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The medical advisor’s views also reflect those of Christian (2000), who, in her article, Reducing disability days: Healing more than the injury, discusses the limited time in the office visit, but also writes of the remarkable personal power physicians have to influence outcomes by building trust, recommending specific treatment, and forecasting the eventual outcome. The following quote illustrates how another participant found that attending physicians do not perceive their role as having anything to do with assisting injured workers to return to work, despite the BCMA Agreement (2002) which documents that physicians are to provide care to injured workers and facilitate a safe, early return to work. The medical advisor goes on to say that the concept of return to work is not even in the attending physician’s vocabulary until the WCB brings it to their attention: I think that for the most part they [attending physicians] don’t see return, anything to do with return to work as their role. They see their role as, as providing appropriate treatment for whatever the condition is that the worker has. I don’t think it crosses their mind that their role is to return the person to work. Their role is to assist the person to recovery from whatever their condition is. Return to work is not in their vocabulary until we put it there. So unless we communicate with them early on, it’s not something that’s going to be on the radar screen at all... They don’t read the BCMA agreements. 95 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The participant provides a solution to the problem by advocating for more WCB education of physicians as to expectations in the compensable return to work process, in accordance with the BCMA Agreement, immediately upon receipt o f the physician’s billing number which permits practitioners to bill the WCB for services provided. The literature review also supports the statements of the medical advisors regarding the need for continuing medical education in order for positive physician participation in the compensable return to work process (Guirguis, 1999). One participant disclosed that he/she felt attending physicians sometimes found their role in compensable return to work to be confusing, particularly when they were unaware o f WCB sponsored interventions or when Board opinions differed from their own, by adding: I think sometimes it’s confusing to them [attending physicians], that they feel we’re taking stuff away from them or we’re not. They can’t figure out what’s going to happen with this particular case, for example, a referral to an occupational rehab program, or a referral to a specialist, and they go, okay, well I didn’t ask for that, and all of a sudden it’s happening. So I don’t know that they get angry by that, but the next time around when something doesn’t happen, they’re confused as to when we’re going to intervene, or when we’re going to refer. [We] try to keep them in the loop or talk to them as much as we can, but I think they find that confusing, as to what their role is in disability management. The participant’s account o f confusion amongst attending physicians corresponds to the information garnered by Schweigert et al. (2004), whose study, aimed at understanding the 96 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. treating physician’s perspective with respect to barriers their patients face when returning to work from injury and illness, found that general practitioners felt their role in the return to work process was not clear and they were “overwhelmed with too much or inappropriate information at times” (p. 427). The medical advisor further illustrates confusing and problematic situations that may arise for attending physicians; however in contrast, he/she believes that specialists are not at all confused as to their role in the management of injured workers: They’re [attending physicians] are saying they [the worker] can’t work and we’re [WCB] saying yes, they can, but you manage the case... you look after the patient. I think that’s difficult for them. That’s a difficult role to have... The specialists, orthopedic surgeons, etc., aren’t confused about their role at all, they know what their role is ... A participant found that a medical advisor’s ongoing communication and education from repeated individual contacts with area specific attending physicians builds rapport and trusting relationships which ultimately enhances their understanding and cooperation in the compensable return to work process: I don’t think that it’s the majority [of physicians that understand their role in compensable return to work]... When you work in one area and you work with a physician again and again and again, I think there’s a lot o f education that we can give the physicians and you see them buying into return to work, and it’s often area specific. There’s a lot out there that haven’t had that 97 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. consistency, that haven’t bought into the program, that aren’t seeing the results and so they haven’t bought into and I don’t know that it’s the majority... I think it’s the rapport, the personal rapport is probably the best... We’ve all had so many lectures, we’ve all been thrown so many figures and I think in the end o f the day, it’s the guarantee that we’re going to be able to replicate the situation or scenario... they trust in the system. That, ok, I’ll buy into [it], the first time when I see this injured worker I’m going to say, you know we expect you to follow these guidelines, we expect somebody’s going to help you get back to some form of work... .and so it’s consistency, it’s trust in the system, and it’s having, I think, individual contacts that has helped most. Role o f the medical advisor Participants were also united in their opinions that, in general, the majority o f attending physicians do not understand the role of the medical advisor, mostly likely because o f the evolution of the role and/or a lack o f communication. According to one participant, his/her role at the WCB has changed within the claims’ management process: I don’t think that they [attending physicians] probably know my role because first of all my role has changed somewhat over the years as the model for treating injured workers has changed and my own role within the Board has changed from doing mostly the old fashion file review to where we’re now subdivided into teams... entitlement and case management. So the people [attending physicians] that I work with in my practice of medicine aren’t aware of those subtleties. 98 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. When asked as to specific strategies that would be helpful for attending physicians to understand the role of the medical advisor, the participant replied that understanding the role was not vital. Rather, he/she focuses on interactions with physicians to problem solve and assist with appropriate interventions for injured workers: I don’t think it’s vital for them to understand what my role is at the Board... I think in terms of when I deal with physicians personally about their problem cases or workers and usually we can come to some kind of solution over the phone most of the time or occasionally face to face. Sometimes I’ll see them in the hall and I’ll say, hey, what about Joe Worker, he’s not doing so well. One participant reported that the physicians he/she has worked with over the years have a good understanding of the role of the medical advisor because o f repeated contact. However, the medical advisor also explained that the role has evolved to much more of an advisory capacity rather than strictly physical examinations and treatment recommendations which some attending physicians had been familiar with in the past: There’s a lot o f physicians out there that don’t have a clue of our role... and I suppose our role has changed. We’re much more in an advisory capacity. We’re much more involved in claim acceptance, in causation, I think than the old medical advisors used to be. The old medical advisors helped in At Board exams, helped in either the worker has to go back to work or we’ll get them further treatment. So that was sort o f their role, where we’re 99 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. much more involved now I think in as to causation, biological plausibility, and early claims management. Another participant agreed that the role of the medical advisor may not be clear because of their involvement in various aspects o f an injured worker’s claim file. However, he/she also spoke o f how physicians are surprised that, unlike a general practitioner in private practice, the medical advisor does not have ultimate authority over a claim and is not the decision maker: I think [the medical advisor role is not clear] because we’re involved with a lot of different aspects of a claim. I think a lot o f physicians think we’re the ones that have power about decisions... They’re surprised that we’re not the most powerful person in the team. I think that’s the biggest surprise to them... they’re used to what I say goes. They don’t understand the quasi judicial role of a case manager. That’s hard to explain. A participant reported he/she provides individual education to new physicians with whom he/she has contact, however suggested the WCB provide information on the role o f the medical advisor to physicians at large in the province in a more broad based fashion in order to target a larger audience: In the area that I’m dealing with... they [attending physicians] have learned [the role o f the medical advisor] because we have explained it to them, but they wouldn’t normally know what that role meant without somebody 100 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. explaining it to them... You get a new physician that’s just moved here from a foreign country, they have no idea what our role is, so the first thing you do is explain it to them, how the system here works because it’s completely foreign to them. Participants had none or varying opinions regarding their impressions o f how attending physicians viewed them in the role o f medical advisor. One participant described that he/she thought general practitioners viewed medical advisors as being on a different practicing plane with responsibilities having less serious implications: I think you’re not viewed as being on the same level as them, that you’re job is easier than theirs, and they’re probably right... because although we have responsibilities, we don’t have responsibilities to the same degree as they do. The decisions they make from day to day are life altering decisions... Somebody can come into their office with a cough and be told they have a cold, and go home, have a pulmonary embolism and die. They have to decide which of those group of people needs further investigations etc., so each one o f their decisions can result in a very negative result. Where around here, even a bad decision we make is unlikely to result in a very negative outcome. We all make decisions as physicians, but the decisions they [attending physicians] make are much more stressful. 101 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. This participant’s perception o f how attending physicians may perceive him/her in the role of medical advisor was that of an incomplete physician as a result o f less clinical work as compared to private practice. However, the medical advisor identified he/she has received positive feedback indicating his/her opinions were valued by other physicians. When asked what the participant thought came with the label ‘medical advisor,’ the participant replied: ... that I’m not a real doctor... that I’m only half a doctor because I don’t do as much clinical work as I d o... That’s my perception of how they [attending physicians] perceive me, but I don’t know whether they do or not. I know speaking with some physicians, they value my opinion a lot as a medical advisor. I suppose it varies, some will see me as a great help and part o f the link in the chain, and others may see me as a bit of a pest... trying to change their style o f practice, and a pen pusher... The aforementioned comments correspond with that o f Russell et al. (2005) who also found that attending physicians did see the potential advantages in communicating with the nursing and medical specialists involved in the workers’ compensation system, however, had concerns with conflict of interest with work-based physicians requesting information citing they were very allied with the company and returning the individual to work without restrictions. All medical advisors believed they brought the most value to a claim file at the start or beginning of the process when clarifying the diagnosis, answering questions regarding causation and biological plausibility, and providing direction for appropriate treatment. According to this participant, the medical advisor brings value to a claim early: 102 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Very close to the beginning, in terms of delineating... the real diagnosis. Does it actually make sense in terms o f what took place and is the initial treatment appropriate. Are we going on the right track, setting the direction right at the beginning. And if things are not, then it’s getting involved with some communication early on I think is very helpful. Communication with physicians early in the claim was thought to be vital to ensure general practitioners were apprised of the correct information regarding the availability o f modified or alternate duties at the worksite. This also assists with avoiding confusion between the worker and his/her physician: .. .helping the attending physician understand that just because they [the worker] can’t do their usual job doesn’t mean they can’t do anything. In terms o f return to work, that’s probably your earliest point of being helpful because physicians very often don’t have the right information. They say they [the worker] can’t work, but don’t realize they could be working in the office or having a booth job ... Physicians generally have no idea that employers do have a mandate to attempt to find modified duties for workers... Communication can be very helpful.. .the earlier the better because otherwise the worker’s getting the wrong message from the physician and the physician’s getting the wrong message from the worker about what his options are. 103 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A second area in which medical advisors were identified as being most effective is near the end o f a claim when a worker has reached maximal medical improvement or plateau. One participant explained that recognizing when a worker has reached this point is valuable for all stakeholders, particularly attending physicians who may not understand that further treatment is no longer required: Then the other place [medical advisors are of most value] is when workers are really not improving. When you’re getting near, essentially maximal functional improvement... and there may be sort of an ongoing searching for answers. But, in reality we’re really done and we need to move on and I think we can assist in identifying that point in time, and help physicians to get on board because often they really don’t know what to do anymore. But they don’t, the person isn’t back to their usual work, and so they’re reluctant to say they’re as good as they’re going to get, and providing assistance to kind of move things at that point is helpful. Russell et al. (2005) alluded to a similar situation in which a worker was not improving despite numerous treatment interventions. In the study of family physicians’ experiences managing injured workers, a general practitioner spoke o f her increasing isolation in dealing with the patient: It’s become increasingly... clear that you are not going to solve the problem for them... So you can imagine having somebody coming in on your list and 104 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. you go “Oh boy, here she comes again.” I have done all the medications and all the splints and the specialists and everything. And she will say “Guess what? My wrist is hurting.” And you go “oh” [sighs]. (Managing injured workers section, 1 5) Similarly, another medical advisor found his/her involvement at the point o f maximal medical recovery communicates “closure... with a degree of confidence” in terms o f recommendations for a medically appropriate and safe return to work that all stakeholders need to hear: I think at the end when we say, you’ve reached maximal medical recovery and here are your restrictions, here are your limitations, or there are no restrictions or limitations. Just in that, the other players on the team hear that the patient is not going to suffer it they go back and do this particular thing... Two participants expressed interest in performing more outreach with community physicians by way o f education initiatives and worksite visits. However, they indicated that this was not always feasible on a consistent basis due to constraints with time and industry segmentation since attending physicians are situated throughout the province and not always in one central location. One further area o f interest was within the realm o f research. A medical advisor suggested participating in studies with educational institutions and collaborating with major industries in order to further knowledge and obtain high level evidence on various topics. This could ultimately lead to new literature from which medical advisors could draw upon when providing recommendations to assist injured workers. 105 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Working Within the Workers ’ Compensation Environment Structure and policies Participants did not find the structure o f the workers’ compensation system to be arduous or problematic to work within. Despite one participant’s initial challenges with the structured system, the medical advisor adapted easily: I initially found it quite difficult to work within that structured system, but as time went on, for some reason it became a lot easier for me to accept that what I said, if it didn’t fall within that structured system, may not change what was going to happen for a particular client... but it doesn’t bother me anymore. Because this medical advisor reported his/her style o f practice was similar to the WCB’s approach with regard to time frames and recovery guidelines, he/she did not find it difficult to become accustomed to the insurance environment. The participant also spoke of how the quality of a medical advisor’s opinions is affected by the information he/she receives from team members with whom he/she is aligned: I don’t find the rules... time frames and recoveries, seeing how that was the style of my practice anyway, I don’t see that as problematic.. .One o f the steps as an opinion of biological plausibility, you are... only as good as the information you get, so a lot o f your opinions I suppose, a lot of your work may be hampered by if you’re not in a strong team because we work in a 106 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. team environment. The medical advisor described appreciating the strong members in his/her team, those who understood concepts and disability management, and “they make the work more interesting.” Another participant reported the WCB policies as proactive since “it assists the worker to have the best possible outcome.” However, the majority o f the participants found policy in relation to appellate returns difficult to work with when the decisions did not make medical sense or were not biologically plausible: I find them difficult because o f how often some o f the decisions are not based on medical issues. So I have to give a medical opinion about something when a decision has been made that is not based on medical fact. It’s challenging dealing with appeals... sometimes there is a condition accepted that isn’t a diagnosis and so that’s really hard or it doesn’t makes biological sense... So when you’ve got two completely different diagnoses that aren’t biologically finked and yet the appeal has accepted them as part and parcel o f the claim, it’s very hard to move on from there. This quote illustrates that in spite o f initial frustrations with appellate returns, the medical advisor moves forward with the claim since he/she is able to assist in providing injured workers with a high quality of medical care, and find satisfaction in doing so. The participant added: The areas that seem obstructive within the confines of that kind o f system 107 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. are more related to appeals... where things maybe don’t make medical sense, but... that is law and policy. I think that when you first start into the system, that’s more frustrating than once you’ve been here, you just have to kind o f roll with it because, for the most part, you’re able to assist in providing very, very good medical care to injured workers, which is wonderful. The participants emphasized that, while working within the WCB insurance system, their task is to provide opinions based upon medical fact with “medical answers” to “medical questions.” According to one medical advisor, “I have to focus on primarily what’s good medicine and what’s safe medicine.” Expedited services Medical advisors found that working within a system that has the capability to expedite medical services was extremely rewarding and an “ideal situation from a medical point of view.” This participant is o f the opinion that all patients, whether they have a compensable injury or not, should have expeditious treatments: From the point o f view o f a practicing physician, I think it’s how I wish the whole system would work, I wish that everybody could be expedited. For example, when you have to wait nine months to have a knee replacement or a year, and wait two years before you see the surgeon, that’s putting a terrible burden on people. Where in the system that we work, I think that’s the way 108 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the whole system should work. Another participant reiterated how an injured worker “has all the benefits of easy access to the most appropriate care,” and finds this very rewarding compared to the frustrations o f long wait lists in general practice: They [injured workers] have phenomenal access to everything, far better than your patients in the mainstream could ever have. That’s very rewarding, you want something, you get it done. In general practice, you wait years or months to get anywhere for your patients and that’s very frustrating. Although a participant did not bemoan services provided by the compensation system, he/she expressed concern that expedited services may be used improperly rather than when medically appropriate simply because o f availability: I don’t bemoan that things are readily available... I do however have my fears that because services are too readily available, they may be abused. And so from that sense if a worker needs an MRI within a week, then that’s wonderful that it’s there. S o l don’t say that it’s unfair that they can get it in a week and a non-worker can’t, what I do bemoan is that if a worker is getting an MRI within a week and they don’t actually need it, there’s not a medical reason for an MRI within a week, and that the worker is getting surgery within a month o f an injury and probably best medicine 109 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. is to leave him six months before he gets that surgery. Case management/team environment Participants valued the case management model and working within an interdisciplinary environment since team members presented various perspectives that ultimately assisted with improved outcomes for injured workers. As one medical advisor commented, “I like the multiple different approaches and ways of looking at things coming into play to affect a worker, and usually in a positive way.” One participant reported the case management model as the “very best approach” and did not find the collaborative team approach intimidating: No [it is not intimidating], I think it’s the very best approach that you could ever take to these situations because somebody’s representing each interest... There’s a balance of all these things and there’s a big picture perspective. Other Boards ... in this country operate very, very differently where they only really get involved at the end o f the claim or at least the medical perspective is only at the very, very end of the claim ... I think that the model we have here is excellent compared to what I’ve seen other places, it’s definitely superior. Participants also reported that working within a team environment was not without its difficulties. One challenge involved the potential for misrepresentation o f medical opinions due to the nature of questions posed by team members: 110 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. By asking their questions, [team members] can put you in a comer and you know that the questions are sometimes taken out of context o f the illness and the disease, and that by answering their specific questions again, they may misuse your answer... Because of the wording of the question, they may misrepresent you, and that I suppose can be a little intimidating. This was attributed to individuals “having certain styles,” however, the participant will advise a team member when he/she is uncomfortable answering the question. An additional challenge, and this medical advisor’s least favourite aspect of the work, was when the team was seen to be breaking down somewhat and did not conduct itself in a professional manner. Individuals were not respectful of each other or o f the medical advisor’s time: I think probably that the least favourite is, and it’s more isolated kinds of things, where your team is breaking down a it... where you’ve got people within your team perhaps not respecting other people in the team, and you’re basically providing service to a lot o f people [individuals within the team] with a very limited amount o f tim e... It doesn’t come down to very many hours per person per week, and yet there’s always a huge load of things to do, and there are times where some people on your team don’t respect that... it’s unprofessional, so that’s frustrating to me because we, they, should be able to do better. I ll Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The participant suggested team members communicate their priorities as a means o f overcoming the difficulties: Communication more than anything. If they’ve got a priority, you’re going to give them your share o f time, but if they don’t communicate to you what their priority is, then you’re going to go with what you think is the priority. Participants spoke o f the value of the 85 day file review process as a method o f ensuring appropriate treatment and return to work plans are in place for injured workers and to reaffirm that the entire case management team understands the direction o f the claim. Medical advisors also found the process useful for identification of injured workers’ claims whose course was not clear or was inappropriate with respect to recovery guidelines, as the following quotes from three participants illustrate: That’s very beneficial [the 85 day review process] because it tidies up everything and it makes sure that there is a plan. It gets everybody on the team to be on the same page, and so when there isn’t a good strong team to begin with, I think the 85 day review is needed. ♦ There are instances when some case managers carry case loads that have multiple recurrent surgeries that put people over the 85 day list. But in general, most medical problems are better within 85 days, so when they go 112 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. beyond that point, there’s usually something wrong, whether it be they shouldn’t be on claim or they’ve had multiple other problems develop, so it’s something that I think as a medical advisor, I think we play a very positive role in the process. ♦ I think that [the 85 day review process] is really helpful because... [often] we should have seen it [the file] way sooner and at least it’s a way to pick it up... Every time we’ve done it, I’ve seen many claims that if I had seen them two months before, six weeks before, we could have made more of a difference to how they were going... And so if we can make a difference to the outcome, to getting appropriate intervention earlier, we can make things better for that worker. Participants are acutely aware o f the positive role they play in assisting workers in the recovery process by facilitating appropriate and timely medical interventions. Medical advisors also recognize the value of their involvement early in the injured worker’s claim in order to promote a positive outcome. The quotations have illustrated the ongoing commitment medical advisors have to providing quality medical care to injured workers. This commitment is reiterated through the following statements as individual participants describe what it means to be a medical advisor: ... I provide medical advice and opinions on claim s... I am a medical back up or support to a team that helps provide best care to an injured worker 113 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. while ensuring that the evidence based disability management is maintained. ♦ .. .1 work as part of a team that assists injured workers to access timely, appropriate medical care and maintain a relationship with their employer so that they’ve got jobs to go back to what’s appropriate to whatever their condition is .. .The primary role I play is in assisting workers to get good care and have optimal recoveries and return to work. According to one participant, practice as a medical advisor is “an interesting area o f medicine,” while another concluded that “we help the medical people understand the insurance system and we help the insurance system understand the medical aspects of the injuries.” 114 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter 5 SUMMARY, CONCLUSION, AND RECOMMENDATIONS Summary The purpose o f this research was to conduct an exploratory, qualitative study on the experiences of medical advisors in the compensable return to work process and the experiences of medical advisors in the compensation system. This was undertaken by applying a descriptive phenomenologic methodology. Four medical advisors were interviewed with the goal of exploring and gaining an essential understanding of their lived experiences. This research sheds light upon an area o f inquiry not previously studied. There is substantial literature regarding the role o f the attending physician and the return to work o f injured workers. According to the CMA (2000), the physician is to understand his/her patient’s role in the workplace and support the return to work process. It has been recognized that prolonged absence from one’s normal roles, including the workplace, is detrimental to an individual’s mental, physical, and social well being (ACOEM, 2002; CMA, 2000). Medical advisors, physicians who contract their services to the WCB, emphasize the goal of return to work within the Workers’ Compensation Act (WCB, 1999). Their focus is on appropriate treatment for the compensable injury and the safe, early return to work o f injured workers in order to enhance the recovery process. Medical advisors collaborate with attending physicians and specialists to prepare clinical care or treatment plans to assist injured employees with a safe return to work. In a study o f family physicians’ experiences in managing injured workers, Russell et al. (2005) found that commitment to the patient was a core value across the varied work settings of the practitioners interviewed. However, the literature review also revealed a gap with respect to 115 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the experiences o f medical advisors in the workers’ compensation system. Hence the research question, what are the experiences of medical advisors as they assist in the management of injured workers in the workers’ compensation system? I hoped that the information obtained in this study would enhance my practice and professional relationships with medical advisors, and indirectly with attending physicians, with whom they collaborate. This study employed a qualitative design using a phenomenological approach to describe the lived experiences of medical advisors. The study allows an understanding of the experiences o f medical advisors from the “participants’ perspectives” (Bogdan & Biklen, 1998). I approached this study with an open mind and endeavoured to minimize and acknowledge my prejudgements and biases from my previous association with the medical advisors to permit their experiences to be heard. Criterion sampling, useful when doing small exploratory studies (Miles & Huberman, 1994), was appropriate for this study as all the individuals studied represent people who have experienced the phenomenon. The population sample consisted of all four physicians, two males and two females, who contract their services to the WCB of BC in a northern rural service delivery location. The participants are experienced physicians who graduated from medical school from between 20 to 35 years ago. Experience as a medical advisor ranged from 4 to 12 years. The participants were recruited by me, an insider on the research site and to the participants. The data collection technique employed the phenomenological orientation of in-depth interviews (Creswell, 1998) that utilized open-ended comments and questions. However, question sequencing was flexible to allow the interviews to be participant directed. The issues of interest to me as the researcher included: what are medical advisors’ best and worst experiences, 116 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. what it is like answering questions on claim files, how do medical advisors feel when they discuss files with attending physicians and specialists, and what are the experiences o f medical advisors working within the structured workers’ compensation environment. These issues were refrained to serve as samples of the semi-structured interview questions. There were no known risks or benefits associated with the medical advisors’ participation in this study. The principle of beneficence, a duty to benefit others and maximize net benefits in research ethics (Canadian Psychiatric Association, 2000; Interagency Advisory Panel on Research Ethics, n.d.; Nuhfer, 2001), was applied in this study as the research is intended for the advancement o f knowledge and for the benefit of medical advisors and physicians as a whole. The principle of non-maleficence, the duty to do no harm to the research participants, was also applied through the maintenance of confidentiality, anonymity, honesty, and professional conduct. The data analysis process involved data reduction, the analysis o f specific statements and the generation o f themes in a search for all possible meanings (Creswell, 1998; Lester, 1999; McMillan & Schumacher, 2001). In the initial phase of data analysis, I listened to the audio­ tapes several times to better acquaint m yself with the data and become familiar with each participant’s story. The second phase o f analysis consisted o f engaging the services of a qualified transcriber who transcribed the audio-tapes verbatim. I checked the transcripts for accuracy and removed all identifiers. Spoken mannerisms or props were excluded in this manuscript unless relevant to the quote. I immersed m yself within the data, cycling through the transcripts, and comparing and contrasting information between the interviews. Essentially, prolonged engagement with the transcripts enabled me to develop a deep, rich understanding of the data and recognize and identify emerging themes. 117 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Qualitative researchers use as many strategies as possible to ensure validity in design (McMillan & Schumacher, 2001). The verification strategies employed in this study included data triangulation, as process of corroborating evidence with the four key informants with regard to their experiences as medical advisors, with comparisons made to the literature; data was recorded with tape recorders; peer review as a graduate student provided an external check o f the research process and verified themes in the data; member checks as individual summaries were submitted to each medical advisor to ensure accuracy o f findings; and, descriptive, thematic report writing to allow the reader to make decisions about transferability and better understand the major ideas that emerged. Three major themes emerged from the data: providing medical opinions, working with attending physicians and specialists, and working within the workers’ compensation environment, as well as several sub-themes subsumed within each of the major or key ideas. It became apparent that the central theme, a commitment to quality medical care, was the foundation through which all themes were interwoven. Medical advisors’ commitment to assist with providing quality medical care to optimize the recoveries o f injured workers was evident throughout the data analysis. This commitment was similar to that found in the literature in a study by Russell et al. (2005) who identified commitment to the patient as the core value o f family physicians managing injured workers. The first major theme, providing medical opinions, includes the sub-themes o f requiring factual information, clarifying the diagnosis, no previous relationship with worker, and categories o f injuries. In order to provide opinions, medical advisors require the accepted facts in terms o f the mechanism o f injury, as well as the objective medical findings, with clarity in the questions that are within the medical realm. Opinions must be received within the context o f the 118 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. information provided by the claim owner. Medical advisors have several options available when clarifying the diagnosis including discussing the file with the attending physician, performing an At Board examination, or referring the worker to a specialist. Participants found that it may be easier to provide objective opinions for files when there has been no previous relationship with the worker, as opposed to an attending physician who is familiar with the client and his/her family. According to one medical advisor, providing opinions on files o f individuals he/she does not know is less difficult since physicians are not good at giving perceived negative information such as advising a return to work. This is supported by the literature (Russell et al., 2005) and McWhinney’s (2000) concept of unconditional relationships between family physicians and their patients. Although medical advisors are not personally acquainted with injured workers, they are committed to providing objective medical opinions for files and assisting with facilitating appropriate medical interventions. Medical advisors found that assisting in the management of sprains and strains was relatively straightforward, with the exception of back strains which are more complex and challenging. Cases involving pain, nonspecific, chronic, and complex regional pain syndrome, were also identified as challenging files on which to provide opinions. Participants’ views diverged with respect to multiple trauma cases with two medical advisors reporting the claims as straightforward with well defined clear diagnoses, while two indicated the files can be challenging because the complexities of the injuries compound each other. The second major theme, working with attending physicians and specialists, includes the sub-themes of building relationships, evidence based treatment plans, role o f the attending physician, and role o f the medical advisor. Medical advisors found that collaborating with 119 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. physicians with whom they had previous working relationships or with whom they had built a rapport was advantageous to the return to work process. One participant reported his/her experiences revealed three categories of family physicians ranging from those having skills in disability management to those with no knowledge and no willingness to accept intervention from the WCB to assist the worker in the recovery process. Medical advisors’ views varied with respect to their approach when contacting a specialist physician as compared to an attending physician. One participant described his/her approach with specialists as more conciliatory and added that orthopedic surgeons are well aware o f the importance of early return to work because of their confidence in their diagnosis and treatment. A participant found that claims allocation through industry segmentation has posed challenges to building relationships with all physicians, specialists and attending physicians alike. Another participant also reported challenges when working with out o f province physicians citing they are not used to the advice management model and may feel threatened by another practitioner’s recommendations. This is supported by Russell et al. (2005) whose study found that family physicians were suspicious of external influences on clinical decision making. Although medical advisors had differing views as to whether attending physicians understand particular recovery guidelines, all used problem solving approaches when collaborating with practitioners on treatment and return to work plans. The views of those participants who felt that many attending physicians are not familiar with practice guidelines are also supported by the literature (Derebery et al., 2002). Most participants were o f the opinion that the majority of the attending physicians with whom they have had contact do not clearly understand their role in the compensable return to 120 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. work process. According to one medical advisor, attending physicians do not see themselves as influential to a successful recovery. This view concurs with that of Christian (2000) but is contradictory to Guzman et al. (2002) whose study of family physicians’ perspectives on soft tissue injuries reported that general practitioners believed that their ability to explain the nature o f the injury and prognosis was crucial to addressing workers’ fears and helping recovery. One participant found that attending physicians do not see their role as having anything to do with assisting injured workers to return to work until the WCB assists with the process. Another medical advisor’s view that attending physicians find their role in compensable return to work confusing is supported by Schweigert et al. (2004) who found that general practitioners felt their role in the return to work process was not clear and they were overwhelmed with too much or inappropriate information at times. Participants were united in their opinions that the majority of attending physicians do not understand the role of the medical advisor, most likely because the role has evolved and/or a lack of communication about their role. Medical advisors indicated they bring most value to a file at the beginning of the claim to assist with early management and facilitate appropriate treatment, and at maximal medical recovery to identify when the worker has plateaued and no further medical intervention is required. In the third and last major theme that emerged from this study, working within the workers’ compensation environment, the sub-themes o f structure and policies, expedited services, and case management/team environment were also included. Medical advisors did not find the structures o f the workers’ compensation system to be arduous or problematic to work within. In fact, one medical advisor found the policies proactive in assisting injured workers 121 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. with the best possible outcomes. However, participants indicated that working on appellate returns can be challenging when decisions did not make medical sense. Medical advisors found that working within a system capable o f expediting medical services was ideal from a medical perspective, as well as rewarding when compared to the frustrations of long wait lists in general practice. One participant, however, expressed concern that the expedited services may be used improperly rather than when medically appropriate simply because o f availability. Medical advisors value working within an interdisciplinary environment and the different perspectives of their team members to assist with improved outcomes for injured workers. However, a participant also commented that working within such an environment is not without its difficulties citing occasions when the team was breaking down somewhat and not conducting itself in a professional manner. In essence, the medical advisor assists to provide best care to injured workers in order to optimize their recoveries and return to work. I felt very privileged that the medical advisors granted their time and attention to this study and shared their experiences through stories. However, I am not surprised at the willingness of these professionals to participate in academic research in the pursuit of the advancement o f knowledge. The quest for knowledge is an enduring enterprise intrinsic to many who are part of the medical profession. Conclusion The data gathered from this study assists with providing an understanding o f the experiences of medical advisors in the workers’ compensation system. This research adds to a knowledge base on how to better work and communicate with medical advisors, as well as attending physicians, in the compensable return to work process. 122 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Recommendations This research is preliminary and therefore provides one description of the experiences o f medical advisors in the compensation system. The study acknowledges the stories o f a population of four medical advisors in one service delivery location and provides descriptions of participants’ experiences providing medical opinions, working with community physicians, and working within the environment of the workers’ compensation system. There is a discemable gap in the literature with respect to illuminating the experiences of medical advisors in the workers’ compensation system. This study has begun to address this obvious gap from the perspective o f a nurse advisor working within the same compensation system to assist workers in the recovery process. It is my hope that this study motivates further research and additional investigations with similar designs to extend findings. My suggestions include studying medical advisors in other service delivery locations across the province to compare and contrast findings. Since this study was o f participants in a northern rural location, further research could also focus on experiences o f medical advisors in urban or metropolitan locations. It is my belief that further research has the potential to impact the workers’ compensation system in a positive manner. Limitations o f the Study I have identified several limitations to this research study. Because this investigation involved a small number of participants, four medical advisors, the results cannot be generalized to all medical advisors. Since I am a nurse advisor, not a medical advisor, I have not shared the same experiences as the participants and therefore bring a different perspective to the research. In view of the fact that medical advisors are colleagues o f mine in the workers’ compensation system, my prior relationships may have affected the research while I prepared to acquire new 123 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. knowledge, despite my best efforts to minimize any biases and prejudgements. It would not be possible to replicate this study since any further interviews or conversations with the participants would most likely focus on other positions, points o f view, and new stories. In fact, replication is not applicable to this research since the study is discovery oriented, seeking to gain an in-depth understanding of a particular lived experience. Lastly, my background in health care and in the workers’ compensation system may have influenced the way I asked questions in the interview. However, I believe that this enriched the data in this study. Implications for Practice and Future Research This research study has clear implications for my professional practice as a nurse advisor. The insights and understandings that have emerged as a result of this research also have potential value for use by my colleagues in the workers’ compensation system. Specifically, the study revealed that medical advisor training may benefit from a longer mentorship to assist in preparing physicians for the medical advisor role; that medical advisors require factual information and objective medical findings in order to provide medical opinions, including background or contextual information with questions from the medical realm (and that this has not always been done on a consistent basis); that medical advisors have different methods of approaching and collaborating with physicians in the compensable return to work process; that medical advisors value the perspectives of their team members in the case management/team environment; and, in essence, that medical advisors are committed to providing quality medical care to injured workers. Personal Reflections on the Research I undertook this research to explore medical advisors’ experiences in the compensable return to work process. I hoped the information garnered from this study would enhance my 124 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. professional relationships with both medical advisors and attending physicians with whom I collaborate to assist workers in a safe and early return to work. I found the data to be rich in detail and filled with candid, thoughtful reflections. The data ultimately revealed that each o f the medical advisors, despite their differences and because of their similarities, is committed to quality medical care for injured workers. This was reflected in their accounts o f requiring factual, objective information in order to provide medical opinions and in their ongoing efforts at building relationships with attending physicians and specialists to ensure injured workers have access to appropriate and timely interventions. Medical advisors appreciated the perspectives o f their colleagues in the case management team environment as it assisted with improved outcomes for injured workers. Participants were clearly aware o f their positive impact on the compensable return to work process. I found the medical advisors’ stories regarding family physicians’ practices and their dedication to patients very insightful, in particular the challenges some general practitioners have with making recommendations the patient/worker may not be agreeable to. I found this information very enlightening and believe it will assist me to further understand the perspectives of attending physicians in terms o f their relationships with patients/workers when return to work planning is discussed. I must be respectful of that relationship, but at the same time, communicate assurances that return to work planning is intended to enhance, not jeopardize, the recovery o f the general practitioner’s patient/injured worker. I was not surprised at the medical advisors’ continuing efforts at relationship building with other physicians and their methods at respectfully problem solving to assist injured workers in the recovery process. The medical advisors’ ongoing and persistent belief in communicating with physicians was also not surprising to me since I have been witness to this in my work, and it 125 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. further supports their commitment to quality care for injured workers. However, I found it interesting to hear the participants’ perspectives regarding the challenges of communicating with other physicians who are not apart o f the similar geographic community. Performing this research was an extremely satisfying and humbling experience. I am very grateful to the medical advisors in this study for sharing their stories which broadened my understanding o f their experiences in the compensation system. Their stories and insights revealed a professional commitment that serves as an example to those with whom they work. The literature (Russell et al., 2005) has revealed that family physicians managing injured workers are committed to their patients; this research finds that medical advisors are committed to providing quality medical care for injured workers. Since this study illuminated the experiences of medical advisors, I believe that all of my colleagues at the WCB will benefit from this research. The insights I have gained from this study will facilitate improvement in my professional practice with both medical advisors and attending physicians, and as a result, positively impact injured workers in the compensable return to work process. 126 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix A The Role of the Physician in Compensable Return to Work: Experiences of Medical Advisors in Managing Injured Workers Consent to Access Site Form I, Lydia Amold-Smith, request use o f an office or conference room at the Workers’ Compensation Board office, 1066 Vancouver Street, Prince George, B.C., in order to conduct four interviews for research that forms a component o f my Masters o f Disability Management degree at the University o f Northern British Columbia. The purpose of the research is to understand Medical Advisors’ experiences in managing clients in the workers’ compensation system. Four confidential interviews, one with each Prince George Medical Advisor, are scheduled to take place from January 2006 to February 2006. The interviews will consist o f audio-taped conversations lasting approximately 60 to 90 minutes. If a face to face interview is not feasible, the interview will be conducted via telephone or video conference. The interviews will be scheduled so as not to interrupt the regular business practices o f the Workers’ Compensation Board. As the sole researcher in this study, I will provide the audiotaping equipment required. There are no known risks for the Workers’ Compensation Board if office space is provided for this study. I cannot guarantee that the Workers’ Compensation Board will benefit from providing interview space for this study. However, this study may add to knowledge o f how to better work and communicate with Medical Advisors and attending physicians in the return to work process. Complaints may be directed to the office o f the Vice-President o f Research at 250-960-5820. The choice to provide consent for interview space for this study is completely voluntary. The Workers’ Compensation Board o f B.C. is free to withdraw consent for interview space for this study at anytime without prejudice. If you have further questions, please contact me at: Lydia Amold-Smith c/o Dr. Henry Harder, University o f Northern British Columbia 3333 University Way Prince George, B.C. V2N 4Z9 Telephone: 250-612-4931 The signature o f the Workers’ Compensation Board Manager indicates he/she has read this Consent to Access Site Form and agrees to provide interview space for this study at the Prince George Workers’ Compensation Board office. 127 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Date Signature o f Workers’ Compensation Board Manager Printed Name o f Workers’ Compensation Board Manager _________________________________________________ Signature of Investigator Date_ Printed Name of Investigator ____________________________________________________ Date Signature o f Witness Printed Name o f Witness Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix B Medical Advisor Interview Guide 1. Tell me about yourself. Where did you receive your medical training and in what year did you graduate? • What was your training in occupational health and/or disability management prior to contracting services to work for the Board? Since coming to the Board? • How long were you in private practice before you commenced employment with the WCB? • Have you worked for other insurance companies? If yes, tell me about your role at that time. • What made you decide to work for the WCB o f BC? • Tell me about your medical advisor training. How long was it? What specific topics were covered? What was the format, for example, lectures and case studies? • Do you feel the training prepared you for this job? If yes, how? If no, what would you change about the training? 2. Explain what it is like, how it feels, to provide opinions on files for injured workers you have not seen or examined, that are not your patients. • What do you find is the most and the least helpful when you are asked to provide opinions on files? • What type o f injuries/cases do you find most challenging to work on and why? 129 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 3. Describe how it feels when you telephone family physicians to discuss treatment plans. How are you received? What type o f feedback do you receive? Can you provide an example? • How does it feel to call a general practitioner versus a specialist? Is one call more challenging than the other? Is there a difference in your approach? Why or why not? • How are your recommendations regarding evidence based treatment plans received? • Are family practitioners appreciative of the input of another professional or have you experienced resistance? How does that feel? Can you provide examples? • Do you think the majority of attending physicians you have dealt with understand their role in compensable return to work? Why or why not. • Based on your experience, do attending physicians understand your role as medical advisor? If yes, what has contributed to this understanding? If no, why not? What strategies would be helpful? • What do you think comes with the label, medical advisor, amongst your peers? In other words, how do you think attending physicians view you in this role? 4. How does it feel to work within the WCB insurance environment? Within a structured environment and within the constraints of the Workers’ Compensation Act, with the level or degree o f service offered, and within the case management model. 130 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. • In your experience, where in the claims process do you feel the medical advisor brings the most value? 5. What are your best and worst experiences as a medical advisor? 131 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix C The Role of the Physician in Compensable Return to Work: Experiences of Medical Advisors in Managing Injured Workers Transcriber Confidentiality Agreement You have been asked to perform duties at transcribing audiotapes for myself, Lydia Amold-Smith. The audiotapes consist of four 60 to 90 minute interviews I have conducted for research that forms a component of my Masters of Disability Management degree at the University of Northern British Columbia. You will be provided with the audiotapes, a dictaphone, and USB storage device as the required equipment for transcription. Audiotapes are to be transcribed and saved to the USB storage device. Upon completion of the transcription, the USB storage device, audiotapes, and dictaphone are to be returned to me. The fee of $ 18.00 per hour of transcription time will be paid to you. Upon completion of transcription of the individual audiotapes, you will notify me at 250-612-4931 or at amold-l@unbc.ca in order that I may collect the USB storage device and pay you the appropriate fee. The information contained on the audiotapes is strictly confidential. If you agree to perform the transcription duties, you will agree to the following: • You will hold confidential all information contained in the audiotapes • You will not discuss the information contained on the tapes with any person other than myself, Lydia Amold-Smith, and, • You will not save nor make copies of the transcribed material. Do you understand that you have been asked to maintain confidentiality of transcribed material? Yes No Agreed and accepted by: ___________________________________ Signature of Transcriber Date Printed Name of Transcriber ___________________________________ Signature of Researcher Date Printed Name of Researcher 132 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix D The Role of the Physician in Compensable Return to Work: Experiences of Medical Advisors in Managing Injured Workers Agreement of Participation Forms Information Sheet Researcher: Lydia Amold-Smith c/o Dr. Henry Harder, University o f Northern British Columbia 3333 University Way Prince George, B.C. V2N 4Z9 Telephone: 250-612-4931 Supervisor: Dr. Henry Harder, Chair o f Disability Management Program, University o f Northern British Columbia (UNBC) Title of project: The Role o f the Physician in Compensable Return to Work: Experiences of Medical Advisors in Managing Injured Workers You are invited to participate in a research study I will be conducting over the next several months. The purpose of the study is to gain an understanding o f the experiences o f Prince George, B.C., Medical Advisors in managing clients in the workers’ compensation system. You were selected as a participant because you are a Medical Advisor working in the Prince George area office of the Workers’ Compensation Board. This research forms a component of my Masters o f Disability Management degree at the UNBC. If you choose to participate in this study, interviews will be arranged at your convenience at the Workers’ Compensation Board office in Prince George, B.C. A telephone or video conference call will be arranged if a face to face interview is not possible. Your participation will involve one conversational interview lasting approximately 60 to 90 minutes, as well as a follow-up telephone call or meeting. You will not be required to answer specific questions you do not wish to address. The interview process can be discontinued at any time at your request. Participation in this study is completely voluntary. There are no known risks associated with participation in this study. I cannot and do not guarantee that you will receive any benefits from this study. However, the study may add to knowledge of how to better work and communicate with Medical Advisors and attending physicians in the return to work process. There is no financial compensation for your participation in this research. The interviews will be tape recorded for later transcription to written form. The information will be coded to insure identifying information is not revealed. All information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission. In any publication, information will be provided in such a way that you cannot be identified. 133 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. As this study has only four participants, I cannot guarantee total anonymity. However, every effort will be made to ensure complete confidentiality. The individuals who will have access to the research material include myself, the sole researcher in this study, the UNBC research committee, and the transcriber who will sign a confidentiality agreement. The information gathered from interviews in this study will remain in locked storage for one year after completion o f this thesis, after which time the material will be destroyed. Each study participant will receive a summary o f the research findings. Complaints may be directed to the office o f the Vice-President o f Research at 250-960-5820. All complaints will be treated in confidence and investigated, and you will be informed o f the outcome. Should you decide to participate in this study, you are free to withdraw your consent and to discontinue participation at any time without prejudice. If you choose to withdraw, corresponding information will also be withdrawn from the study. If you have further questions, please contact me, Lydia Amold-Smith, at 250-612-4931. If you choose to participate in this study, you will receive a copy of your signed consent form. 134 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The Role of the Physician in Compensable Return to Work: Experiences of Medical Advisors in Managing Injured Workers Agreement of Participation Form Research Participant Informed Consent Form Do you understand that you have been asked to participate in a research study? Have you read and received a copy of the attached information sheet? Do you understand that the research interviews will be recorded? Do you understand the benefits and risks involved in participating in this study? Have you had an opportunity to ask questions and discuss this study? Do you understand that you are free to refuse to participate or to withdraw from the study at anytime without prejudice? Has the issue of confidentiality been explained to you? Do you understand who will have access to the information you provide? __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No This study was explained to me by:_______________________ Print Name I agree to take part in this study: _______________________________ Signature o f Research Participant Date_____ Printed Name o f Research Participant _______________________________ Signature o f Witness Date Printed Name of Witness I believe that the person signing this form understands what is involved in the study and voluntarily agrees to participate. _______________________________ Signature o f Investigator Date_________________ Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The Information Sheet is attached to the Consent Form and a copy is provided for the Research Participant. 136 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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