Tactical to Practical

Concepts and Examples of Navigating the Interface between Medicine and

Workplaces

OEMAC Edmonton, Sept. 28, 2014

John Brennan M.D.

Conflict Disclosure Information:

Presenter: Dr. John Brennan

Title of Presentation: Tactical to Practical-Concepts and

Examples of Navigating the Return to Work Interface

I have no financial or personal relationships to disclose

Dr. John Brennan

• B.A.Sc. (Chemical Engineering), M.D., C.C.F.P.,

Dip. Sport Med.

• Medical Director Honda of Canada Mfg. (5000

employees)

• Family Medicine, Emergency Medicine,

Hospitalist Medicine Parry Sound, Ontario

• Assistant Professor Northern Ontario School of

Medicine

Process vs. Content

• Content in medicine is subject to a half life of

between 5 and 7 years and therefore 50% of

what is learned today will have to be

relearned within 5 to 7 years.

• Process in medicine changes very slowly

• This talk will focus on some examples of the

process of navigating the return to work

interface

Example of Medical Knowledge half

life

• The following is from The American

Electricians Handbook (1942) A Reference

Book for Practical Electrical Workers. Terrell

Croft, consulting engineer. McGraw Hill Book

Company, Inc, New York and London 1942

Testing electrical circuits

• Electricians often test circuits for the presence of voltage touching the conductors with the fingers. This method is safe where the voltage does not exceed 250 and is often very convenient for locating a blown-out fuse or for ascertaining whether or not a circuit is alive. Some men can endure the electric shock that results without discomfort whereas others cannot. Therefore, the method is not feasible in some cases. Which are the outside wires and which is the neutral wire of a 115/230 volt three wire system can be determined in this way by noting the intensity of the shock that results by touching different pairs of wires with the fingers. Use the method with caution and be certain that the voltage of the circuit does not exceed 250 before touching the conductors.

Testing voltage

• The presence of low voltages can be determined by testing. The method is feasible only where the pressure is but a few volts and hence is used only in bell and signal work. Where the voltage is very low, the bared ends of the conductors constituting the 2 sides of the circuit are held a short distance apart on the tongue. If voltage is present a peculiar mildly burning sensation result, which will never be forgotten after one has experienced it. The taste is due to the electrolytic decomposition of the liquids on the tongue which produces a salt having a taste.

Testing voltage #2

• With voltages of 4 or 5 volts, due to as many cells of a battery, it is best to test for the presence of voltage by holding one of the bared conductors in the hand an touching the other to the tongue. Where a terminal of the battery is grounded, often a taste can be. Care should be exercised to prevent the 2 conductor ends from touching each other at the tongue, for it they do a spark can result that may burn. detected by standing on moist ground and touching a conductor from the other battery terminal to the tongue

What happens when things go

wrong?

• Thankfully the Occupational and emergency

medicine people of the day did a chapter in

this same book on how to resuscitate

someone should they have an electrical shock

CPR in 1942

Dr. Frederick Koliz

• 1st. Lay the patient on his back,

• 2 Move the tongue back and forth in the mouth by seizing it with a handkerchief or the fingers, while working the arms to induce respiration.

• 3. Don’t pour anything down the patient’s throat

CPR 1942

• . 4. Try to cause the patient to gasp by

inserting the first and second fingers in the

rectum, and pressing them suddenly and

forcibly toward the back.

• 5. If possible, procure oxygen gas, and try to

get it into the lungs during the efforts at

artificial respiration

CPR 2014

• Yao L, Wang P, Zhou L, et al. Compression-only

cardiopulmonary resuscitation vs. standard

cardiopulmonary resuscitation: an updated

meta-analysis of observational studies. Am J

Emerg Med 2014;32(6):517-523.

CPR 2014

• Meta-analysis: outcomes of compression-

only CPR = standard CPR

• Clinical question

• Are the outcomes of out-of-hospital standard

cardiopulmonary resuscitation better than the

outcomes of compression-only

cardiopulmonary resuscitation?

CPR 2014

• Bottom line

• The outcomes of cardiopulmonary

resuscitation (CPR) are abysmal; compression-

only CPR and standard CPR have equivalent

survival rates and equivalent favorable

neurologic outcomes. This simplifies things for

bystanders and simplifies instructions

emergency workers can give to bystanders

CPR 3014

• A friend of mine has described a scenario

1000 years into the future when

anthropologists find our writings and videos

and imagine a bizarre death ritual in which

complete strangers jump onto the chest of a

dying person during the final minutes of his

life, violently press his chest and breathe into

his mouth, and then say farewell. (LOE = 1a)

Madrid 2014

How to Create or Avert Needless

Work Disability:

Implications of New Models for

Practice, Policy & ResearchJennifer Christian, MD, MPH

President, Webility Corporation

Founder, Multi-Dimensional Care Consortium

© Copyright Webility Corporation – reprinted with permission

Result: Needless Work Disability,

Job Loss, Withdrawal from Workforce

Delay

Uncertainty

Delay

Uncertainty

Medical Offices Workplaces

“Not mine:

This IS medical”

“Not mine:

NOT a medical issue”

The Gap: Whose Responsibility Is It?

19

Critical Definitions

• 1. Health

• 2. Work

• 3. Impairment

• 4. Disability

Health

Health Definition 1

World Health Organization

Health is a state of

complete physical, mental

and social well-being and

not merely the absence of

disease or infirmity.

Health Definition 2

Dr. Johann Aufreiter (psychiatrist

U.W.O.)

• 1. The ability to like

yourself.

• 2. The ability to form

relationships

• 3. The ability to work.

• = BRILLIANT (defined in

three abilities independent

of diagnoses!!)

Work

• Physical or mental effort or activity directed toward the production or accomplishment of something

• Note that this is positive definition of work whereas generally in society ‘work’ often has a burdensome tone or implication

** The truth is that being away from work for prolonged periods is a significant health risk!!

Impairment

• impairment /im·pair·ment/ (im-pār´ment) any

abnormality of, partial or complete loss of, or

loss of the function of, a body part, organ, or

system.

* Note this definition does not have ‘context’, it

is often measurable and can be agreed upon

by multiple independent people

Disability

• How a real or perceived impairment

negatively affects an individuals occupational,

personal, or social functioning

• In the return to work setting it is how the

medical impairment affects the persons ability

to do the intended work (has context) and is

open to some interpretation or ‘negotiation’

© Copyright Webility Corporation – reprinted with permission

Result: Needless Work Disability,

Job Loss, Withdrawal from Workforce

Delay

Uncertainty

Delay

Uncertainty

Medical Offices Workplaces

“Not mine:

This IS medical”

“Not mine:

NOT a medical issue”

The Gap: Whose Responsibility Is It?

26

© 2008 Copyright 60 Summits Project, Inc. All rights reserved

Time Is Of The Essence

0

20

40

60

80

100

0 4 8 12 16 20 24 28 32 36 40 44 48 52

Time away from work in weeks

% EVER RTWAt 12 weeks, employees have only a

50% chance of ever returning to

work.

The employer (when there is one) plays

a powerful role in determining the

outcome. . . .

. . . . By deciding whether to manage the

employee’s situation actively, passively,

supportively, or hostilely;

. . . . And by deciding whether to allow

on-the-job recovery or make permanent

adjustments to the job (“reasonable

accommodations”).

28© 2011 Copyright Webility Corporation – reprinted with permission

© 2012 Copyright Webility Corporation – reprinted with permission

Doctors and other clinicians have a

powerful influence on a situation. . .

. . . . . By providing factual information

and advice that will either encourage /

support or discourage / obstruct efforts

at SAW / RTW.

29

Injured or Ill Employee

Financial Risk

Statutory Obligations

Labour Relations

Medical Case Management

Claims Administration

Benefit/Claim Process

Return to Productive Work

Integrated Disability Management Model

•Medical Reviews &

Recommendations

•IME’s, FCE’s, Diagnostic

testing

•Graduated return to

work plans

•Legal Compliance

•Re-employment Obligations

•Duty to Accommodate

•Cost Containment

•Cost Avoidance

•Cost Recovery

•Form Processing &

Submission

•Claim Correspondence

•Communication

•Co-operation

Tactical to Practical

Six Concepts and nine examples of

navigating the interface between

Medicine and Work

Concept #1

• Workplaces have distinct cultures, with

distinct policies, procedures, human relations

etc and we (health care professionals) are

guests in that culture. Please be a good guest

at all times! To do otherwise only prolongs an

absence or aggravates the situation

No Involvement of family doctor, MTO,

Medical Department, rehab

Concept 1 Example 2

• “It is a complete waste of my time writing notes stating that a patient has a medical reason to urinate”

• Worker that was spending more than one hour per day (in addition to breaks) on washroom breaks.

• Remember we are in a texting universe and most workplaces do not allow most workers to text etc on the job.

Concept 2

• A workplace is a workplace and not a hospital

or social welfare agency

Concept 2 Example 1

• “Patient followed here and with a psychiatrist

on a regular basis. Unable to return to work

pending workplace accommodations to

ensure:

• 1. Stable work shift placement.

• 2. No work shifts coinciding with her ex-

husbands schedule”

Outcome = Termination of employment

Concept 2 Example 2

• “The above worker needs to work at her own pace and be allowed to take mini breaks whenever needed. Additionally she needs to ice her back for 15 minutes every hour while at work”

• Outcome = Worker and physician told no such accommodation was reasonable or possible and she returned to full duties within weeks.

Concept 3

• Patient Advocacy does not extend to

misrepresenting the truth

Concept 3 Example 1

• “This person has been my patient for ten years

and needs to teach a straight grade 5 class (no

split classes) with no more than 21 students at

a school within walking distance of their

home”.

• Context = ‘anxiety’, loss of drivers license for

impaired operation of motor vehicle.

Concept 3 Example 2

• “The above patient needs to work light duties

on steady days for the next three months”

• Context = pitcher for Junior Baseball team

whose coach told him to get a note from his

doctor so that he could attend all the games

and ‘save his arm’ for pitching.

• Outcome = Termination of employment

Concept 4

• If you write a medical note make sure that the

condition is being fully investigated and

treated and do not just accept the patient

request for a note at face value.

Concept 4 Example

• “This is a ludicrous and a waste of my time. Mr B

has a number of medical conditions and when he

has to go to the washroom I suggest you let him”

• Context= 58 year old worker going to washroom

every 30 minutes. Further history also waking

every 30 minutes at night! Threatened Human

Rights complaint

• Outcome = PSA 12 (under investigation now)

Concept 5

• Avoid Pejorative Diagnoses (those that assign

blame)

• “Repetitive Strain Injury” and “overuse

syndrome” are pejorative and not helpful

either in clinical management or work

accommodation.

• Think instead of “Impaired Adaptation

Syndrome “(Brennanism #1)

Concept 5 Example

• “This worker has repetitive strain injury and

needs to be retrained to another line of work

or assigned permanent office duties”

• Context= sore wrists and first visit to Family

Doctor. Disgruntled employee

Brennanism #1

• Repetitive Strain injury is a horrible and pejorative diagnosis and should be renamed “Impaired Adaptation Syndrome”

• Why?

• The natural state of man is to adapt. Things go wrong where there is a failure to adapt.

• In workplace issues the diagnosis rarely predicts recovery accurately because the perception of blame and harm delays recovery. Do not feed this cycle!!!!

Impaired Adaptation Syndrome

• 1. Individual Factors (age, sex, smoking, general health, general fitness, attitude, culture, perception of blame)

• 2. Workplace factors (culture, production demands, seniority, dispute resolution mechanisms, human resource policies, co-worker conflict, industrial relations, unions, change, force, repetition, span of control, postures)

• 3. Social Factors (eldercare, childcare, divorce, legal issues, underemployment, overemployment, deer season)

Concept 6

• Nobody ever gets better if they listen to their lawyer or union rep more than they listen to their doctor. They will be prone to ‘solicitogenic disability’ (Brennanism #2)

• “It is not possible to get better if you have to keep proving you are not” Dr. Norton Hadleron how insurance companies, litigation, and compensation systems delay recovery.

Concept 6 Example

• Abbreviated version of Keays v. Honda settled

at the Supreme Court of Canada

• I was asked to review a file of a worker that

was missing time with ‘chronic fatigue’.

• I could find no formal diagnosis according to

CDC criteria, worker changed doctors five

times in 10 years.

• No consents on file to get medical information

Keays v. Honda cont’d

• I asked to meet with worker to figure out

overall diagnosis and management.

• Worker agreed after talking with Family

Doctor

• Worker declined after talking with lawyer

• Cycle repeated itself several times without

resolution

• Worker terminated

Keays v. Honda cont’d

• Lawsuit in Ontario

• I testified for nearly five complete days including four

days of cross examination

• I never met the worker until I walked into the

courtroom

• I relied heavily on the CDC definitions of CFS

• I relied heavily on the CMA Return to work document

• Largest employment damages assessed against Honda

and trial judge made the following conclusions:

Keays v. Honda cont’d

• Dr. Brennan had a ‘hardball approach’

• Dr. Brennan participated in a ‘corporate conspiracy’

• Dr. Brennan did not need consents to contact the various doctors and discuss his case

• The requirement to have the employee/patient see Dr. Brennan was “as benevolent as leading a lamb into the wolf’s den”

Keays v. Honda cont’d

• That my testimony on CFS was wrong and he

overrode my testimony himself by doing

research on the internet since no other expert

witness testified

• Appealed to the Supreme Court of Canada

and overturned with the following comments:

Keays v. Honda cont’d

• “The trial judge made palpable and overriding

errors of fact and law”

• “there was no corporate conspiracy”

• “Dr. Brennan did not have a hardball approach

but was quoting the best available evidence

and return to work practices”

• Costs were awarded against the plaintiff

WHY

• “the national ME/FM Action Network has applied

to the Court Challenges program for case

development funding for the Network to challenge

the Disability Tax Credit (Form T2201) in court. As

you know, applying for this tax credit has been

causing our ME/FM people many difficulties. The

Court Challenges program will therefore assist us

with the cost by way of a recently approved grant.

WHY

• this will permit us, with the help of our lawyer, Hugh Scher, to develop arguments for a proposed challenge to Section 118.4(1)(c) of the Income tax act on the basis that this section discriminates against persons suffering from Myalgic Encephalomyelitis/Chronic Fatigue Syndrome and Fibromyalgia……….it will be necessary to identify suitable plaintiffs that might be able to carry forward a court challenge of this kind……we are now looking for persons who have been denied the disability tax credit for reason either that they do not comply with the definition contained in the act of disability or they have been denied

WHY

• we are now looking for persons who have

been denied the disability tax credit for

reason either that they do not comply with

the definition contained in the act of

disability or they have been denied the tax

credit because they do not have

ME/FM………..” (Fall 1999)

Keays v. Honda epilogue

• I believe to this day that if Mr. Keays had

listened to his doctors he would either be

employed or on some form of disability

benefit now instead of being without work,

without benefit, and with large legal bills.

• Solicitogenic Disability

Letter to Professor John Nash

Nobel Laureate(A Beautiful Mind)December 3rd, 2008

Dr. John Forbes Nash

Princeton University

Senior Research Mathematician

Fine Hall,

Washington, Road

Princeton, New Jersey

Dr. Nash,

I am the medical director for Honda in Canada and I am faced daily with issues that are not explicable on purely medical grounds. I will try to explain. I have a duality of interests and training in Sports Medicine and Occupational Medicine.

In my sports medicine world a person with a given diagnosis may recover quickly whereas a worker with the same diagnosis may recover slower or not at all. Medical and ergonomic studies have failed to explain this type of duality and soft factors such as job satisfaction, involvement of lawyers, or having a spouse on disability become larger predictors of soft tissue or work recovery than does the degree of injury. We all believe that it somehow has something to do with secondary gain or compensation issues. Sometimes injury will put a person in a preferred job or a preferred shift where they would not normally be.

This is a struggle for prediction of recovery and I am wondering if there are mathematical based theories or models that may be applicable to a situation like this to help explain the duality that we know exists.

I am asking this as an individual physician with an academic interest in such things since we cannot intervene for the good of people if we do not understand the root causations.

Thank you very much,

John Brennan

B.A.Sc.

M.D.

Medical Director

Honda of Canada

John Forbes Nash Response

Dear Dr. Brennan,

Your letter of 3 Dec. 2008 arrived here today.

As I see it, the issues of interest to Honda that arise in connection with the speed or the slowness of the recovery of employees who experience

disability events are apparent enough (from an economic perspective).

Recently it was "discovered" (or brought to wider public knowledge

through newspaper stories) that the employees of the LIRR (Long Island Railroad, a part of "metropolitan transit" in the NYC area) were, almost all of them, retiring as "medically disabled". Is there a mystery? Not really, if one has enough of cynicism in relation to politics and things arranged through political means and in relation to economic considerations

To help Honda, in relation to the problem of health benefits costs problems that have widely affected the automobile industry in general (like particularly Ford and GM) would be simply a matter of materially beneficial aid to a materialistically defined objective.

I could not see myself as a VOLUNTEER scholar and thinker working

for such a cause or objectives, but work as a paid consultant would

be conceivable. (However I, personally, have no recognized status as a "labor economist"!)

Sincerely Yours,

John F. Nash, Jr.