Dramatic ReturnsReaders’ Theatre Workshop

Dr Anil Adisesh

JD Irving, Limited - Research Chair

in Occupational Medicine

Dr Burton McCann

District Medical Officer for Veterans

Affairs Canada & Family Physician

Faculty/Presenter Disclosure

• Faculty: Dr Anil Adisesh

• Relationships with commercial interests:

• None

CFPC CoI Templates: Slide 1

1) Develop potential resolutions in difficult return-to-work

situations.

2) Consider different stakeholder roles in difficult return-to-

work situations.

3) Recognize scope of return-to-work issues

Objectives:

$16.6 billionestimated direct cost of absenteeism to the Canadian economy

Conference Board of Canada: Missing in Action—September 2013

• own illness or disability• caring for own children• caring for elder relative • maternity leave • parental leave• other personal or family responsibilities• vacation• labour dispute (strike or lockout)• temporary layoff due to business conditions• holiday (legal or religious)• weather

Reasons for work absences

Absenteeism rates by Province, 2011

Source data – Statscan http://www.statcan.gc.ca/pub/75-001-x/2012002/tables-tableaux/11650/tbl-6-eng.htm

0 2 4 6 8 10 12

Saskatchewan

Quebec

Nova Scotia

New Brunswick

Newfoundland and Labrador

Manitoba

Prince Edward Island

British Columbia

Ontario

Alberta

Days lost per worker in year

0 1 2 3 4 5 6 7 8 9 10

Saskatchewan

Quebec

Nova Scotia

New Brunswick

Newfoundland and Labrador

Manitoba

Prince Edward Island

British Columbia

Ontario

Alberta

Days lost per worker in year

Illness or Disability Absenteeism rates by Province, 2011

Source data – Statscan http://www.statcan.gc.ca/pub/75-001-x/2012002/tables-tableaux/11650/tbl-6-eng.htm

The Treating Physician’s Role In Helping Patients Return To Work After An Illness Or Injury

The CMA recognizes the importance of a patient returning to all possible functional activities relevant to his or her life as soon as possible after an injury or illness.

Prolonged absences from one’s normal roles, including absence from the workplace, is detrimental to a person’s mental, physical and social well-being. Physicians should therefore encourage a patient’s return to function and work as soon as possible after an illness or injury, provided that return to work does not endanger the patient, his or her coworkers or society.

(UPDATE 2013)

The line manager performs a central role

•departmental culture and attitudes

•monitoring absence patterns in their department

•holding return-to-work interviews

•attendance reviews

The Line Manager’s Role

Waddell G, Burton K 2006

The Benefits of Work – Getting a Balance

• Employment is generally the most important means of obtaining adequate economic resources, which are essential for material well-being and full participation in today’s society;

• Work meets important psychosocial needs in societies where employment is the norm;

• Work is central to individual identity, social roles and social status;

• Employment and socio-economic status are the main drivers of social gradients in physical and mental health and mortality;

Importance of Work

• higher mortality;• poorer general health, long-standing illness,

limiting longstanding illness;• poorer mental health, psychological distress,

minor psychological/psychiatric morbidity;• higher medical consultation, medication

consumption and hospital admission rates.

Worklessness

“As difficult as it may be, we must, with understanding and compassion, objectively assess impairment and not confuse our role as the patient’s advocate with our responsibility for objectivity.”

(Aronoff GM. Pain. In: Demeter SL, Andersson GBJ, Smith GM, editors. Disability evaluation. St. Louis (MO): American Medical Association/Mosby; 1996.)

A common example is the physician who advocates on behalf of a patient who is pursuing long-term disability benefits in the context of remote soft tissue injuries that have long-since healed. Although the physician has the best intentions, such advocacy may not be what is physically or psychologically best for the patient.

(Clifford JC doi: 10.1503/cmaj.114-0009)

Patient Advocacy

Sick notes by medical condition (UK)

Source data: Shiels C, Gabbay M Scandinavian Journal of Public Health, 2007

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Patients % Time off Work

Other

Injury and poisoning

Nervous system/sense organ

Circulatory and Respiratory

Musculoskeletal

Mental ill health

Modified from: Dunstan D, Covic T, Aus Occ. Therapy J 2006

Work Injury

Physical pathology

Pain Disability

The Biopsychosocial Approach

Cause – effect or “Biomedical Model”

The Biopsychosocial Approach

Social and environmental factors

Illness, pain, disability

Physical factors (pathophysiology of

injury)

Psychological factors (thoughts and

emotions)

Modified from: Dunstan D, Covic T, Aus Occ. Therapy J 2006

Regards health as a function of the interplay between the individual (biology and psychology) and their context (social environment).

An alternative to the traditional biomedical focus on physical health parameters caused by genetic weaknesses or an external pathogen.

Accommodates multi-cause/multi-effect pathways arising from psychological and social as well as physical sources.

The Biopsychosocial Approach

Biopsychosocial Implications

Risk prevention will not reduce risk as expected.

Requires ‘interdisciplinary’ collaboration.

Interventions collectively addressing biological, psychological and social factors will be more effective than ‘magic bullet remedies’ focusing exclusively on one set of factors.

Resources should be directed at better understanding the role of psychosocial factors in causing and sustaining occupational illness.

Managing the Return to Work

Being off work - Most patients don’t like taking time off work. - Cite guilt, missing the structure of work, financial implications, unable to be productive.

Ready for Return - Most patients say they are ready to return when they feel physically comfortable and mentally ready. - Some expressed difficulties, especially where there is pain.

Satisfaction with physician interaction - Most felt satisfied with their interactions with physicians and other healthcare professions.

Company Pressures - Most did not feel pressure from the employer to return.

Workplace Accommodations - Workplace accommodations are helpful for employees, but those available varied. - Some employees mentioned their coworkers were not supportive

Workers’ Compensation Process - Experience of workers’ compensation varied.- Those with guidance and assistance found it easier, others found it was stressful.

Return to work process* All physicians have experience with patients returning to work, but a minor part of their work. * Cases with a reluctance to return to work are stressful and uncomfortable.

Resources for the physician * Environment/community where the physician works affects accessibility of resources. * Some physicians said they would like more support in occupational health issues.

Communication with employers* Most physicians don’t communicate with the employers directly. * Most also felt the workplace environment is important in the patient’s return.

Workers’ Compensation Process* Physicians found the paperwork restrictive* Most would like to be educated on the workers’ compensation process. * Most noted communication deficiencies with workers’ compensation.