M. K. Schweigert MD,
D. McNeil
JE Sleeth Hon. B.P.&.H.E., B.Sc.P.T.,
Dawna McNeil B.Sc.RN
The aim of this paper is to understand the treating physician’s perspective with respect to the barriers that their patients face returning to work from injury and illness.
Methods The methodology used was focus groups conducted in Southern Ontario with treating physicians.
Results The main barrier identified by the treating physicians in the return to work process was the lack of accommodated work. The main areas identified for the use of additional resources was facilitated investigations, assessments and treatments for their patients and education and training for treating physicians. With respect to communication, physicians indicated that they wanted to know more about the work to which their patients were returning.
Conclusions Treating physicians believe that the most significant barriers for the timely return to work for their patients exist in the workplace, specifically related to lack of knowledge about appropriate modified work. The treating physicians’ role in the return to work process is demanding due to insufficient time to deal with return to work issues, lack of training, not enough of the appropriate information and the treating physicians’ role ambiguity.
Key words Disability management; focus groups; qualitative research; return to work.
Introduction
Studies from various disciplines have indicated that timely return to work improves restoration to normal health [1]. National and provincial medical associations and worker compensation boards have recognized this [2–5]. There are economic benefits associated with a timely return to work for the employee (full wages) and the employer (decreased disability costs and improved productivity) and society (a more productive workforce). Labour groups are generally supportive providing the return to work is appropriate in timing and form. Presumably the treating physician, who is interested in a successful functional outcome, will have insight into the difficulties that their patients have in the return to work process. This article describes the work by a group of employers, labour organizations and health professionals in Southern Ontario working with local treating physicians to understand the barriers that impede timely return to work. In Ontario, payment of disability benefits is contingent on the treating physician completing a form certifying disability. The province pays for physician treatment in a fee-for-service arrangement, but nominal fees are often charged to the patient for form completion. In cases where there is insufficient information provided or there are inconsistencies in the information, third party physicians paid for by insurers may be utilized. Occupational health physicians do not provide treatment and are generally paid by employers to make determinations of fitness to work in the workplace.
The impetus for the formation of the group was the difficulty experienced by a particular employer in the region as they attempted to shorten the length of disability of their workers. It was accepted that the treating physicians who are intimately involved in the treatment of patients, completing of insurance forms and advising the employees should be canvassed for their perspective on barriers in the return-to-work process. One of the authors (L.D.), an occupational health
physician, was contacted by the employer to work with the community treating physicians. The expanded group of employers was organized by two of the authors (D.M. and L.D.). Other health professional consultants, physicians with affiliations with the Ontario Medical Association and the Ontario College of Family Physicians, representatives from the provincial and local labour groups were invited to join to provide a broader perspective. This group chose the name Lakeshore Workplace Initiative (LWI) to indicate their location (near Lake Ontario), and the focus of patient in the context of the workplace.
Methods
Treating physicians who completed a high number of employee sickness and absence benefits claims were invited to attend focus groups to discuss barriers in the return to work process. Invited physicians were encouraged to bring interested colleagues. Nearly all of the participating physicians were family medicine physicians as identified by their disability claim submission forms. Physicians were given a small honourium for their attendance independent of their level of participation or views expressed. Structured questions were developed by consensus from the LWI participants following an initial unstructured focus group occurring in November 2000 that identified issues of concern (see Table 1). The structured focus group interview consisted of three formal questions listed in Table 2. Six structured focus groups were conducted from October 2001 to January 2002. The size of the focus groups ranged from 6 to 12 participants. The moderator of the discussion was one of the LWI committee members and his affiliation with the participating employers was stated. The invited physicians were encouraged to speak freely. The conversations were not electronically recorded so as not to inhibit the discussion. Responses were transcribed on either a laptop computer with a projector or on a paper flip chart. The discussions lasted ~60–120 min.
The transcribed responses were tabulated by one of the authors (M.K.S.) for each of the three questions for all six sites. The specific issues were then categorized for each of the questions. Tables 3–5 contain for each of the questions the totals for each specific issue and category. The categories and tabulations were reviewed with the LWI committee for clarification and discussion.
Results
The most cited barriers to return to work were related to the workplace—lack of accommodated work and differ- ences in how work versus non-work-related absences were treated.
Physicians identified issues relating to treatment, including themselves, as potential barriers in that their role in the return to work process was not clear, that they have a lack of occupational health training, that they possess a lack of knowledge of specific work issues or that they are overwhelmed with too much or inappropriate information at times.
Issues identified related to the treatment process include conflicting information, lack of objective information and lack of health care access for their patients. Forms for disability benefits were identified as a barrier in that they were too complicated, or that the forms for each employer, private insurance provider or Workplace Safety and Insurance Board (WSIB) were different and time consuming. Other barriers that were identified included lack of communication among the interested parties, employees’ dislike of their jobs and lack of clinical practice guidelines.
The most common suggestion as to where new resources could go is to facilitate investigations, assessments and treatments related to restoration of function, providing a company case coordinator or advocate, and adequate physician remuneration for time required dealing with return to work issues.
Communication-related issues included the physicians’ need for information related to jobs or modified work opportunities and written consents to discuss health issues. Physicians felt that the workplaces needed to be more aware of the Canadian Medical Association (CMA)’s policy discouraging certification of disabilities of <5 days.
Table 1. Responses from the original unstructured focus group
• The issue of complicated forms (content and structure) increase the level of frustration by the physician and directly relate to form
completion.
• The more complex the issue (medical or political) this has a direct pressure on the relationship between the GP and his/her patient. They do
not want to lose the patient (customer).
• It is in the nature of the physician/patient relationship not to question the validity of the patient’s complaints/concerns.
• The underlying ‘mental module’ is for the physician to believe his/her patient.
• Forms and the completion of forms are seen as the driver for the doctor’s time on an issue.
• Physicians raised the perception that employers are more concerned with the patient on WSIB insurance versus Sick and Accident insurance.
This inconsistency provides confusions as to the employer’s intention.
• The issue of ‘medical confidentiality’ is of concern to the physicians and they are unsure which workplace party they can trust.
• Physicians indicated that if employers could help expatiate the access to ‘Specialist’ they see this as a positive move on behalf of their patient.
• Physicians discussed the issue of cases of ‘workplace stress’ should be returned to work as soon as medically possible, not left at home. It was
generally felt leaving the employee/patient at home could make the situation worse.
• One employer was seen as having the more difficult employer/employee relationship impeding return to work.
Table 2. Focus group questions developed for structured focus groups
Barriers What barriers have been identified by your patients or that you have observed which impede a safe and timely return to work?
Resources What resources are needed to make the return to work process more successful?
Communication How can communication between the employer and the physician be improved in order to facilitate the physicians’ understanding of the
workplace in the context of a return to work plan?
Discussion
Of the workplace barriers, the most noted single issue was a lack of accommodated work. Typically, accommodated work refers to work that is not the employee’s regular job—whether it is another regular or modified job to allow the employee to return safely to the workplace. Given the concern that treating physicians have for their patients, it is not surprising that a perceived lack of safe accommodated work would be seen as a barrier. The perceived difference of how work-related versus non-work-related injuries were treated in the workplace was a concern. For non-work-related injuries or illnesses, the Ontario Ministry of Health provides funding to physicians to provide patient care out of general tax revenues. For work-related injuries or illnesses there is legislation pertaining specifically to duties of the employer to return workers injured in the workplace back to work in a timely manner. Treatment for work-related injuries is ultimately reimbursed by the WSIB. The WSIB is funded by premiums levied on employers’ payroll. Thus, there are legislative and financial considerations to return workplace-injured workers back to work. Employee motivation has been identified as a significant factor for return to work in other studies [6,7]. However, it was not identified as one of the more important barriers in this study which might reflect that
Table 3.
Question 1—Addressing the barriers to return to work[] Issue total Group total[] Workplace Lack of accommodation/modified work/RTW 28
Union issues/coworker 3
No injury prevention 2
Supervisors not aware of company policies 1
No receiver on site of confidential medical 3
Concerned about WSIB vs. non-WSIB attitude 7 44
Insurers Insurers are the barrier 2 2
Treatment Lack of healthcare access 7
Conflicting information/not objective 9
Not appropriate ER/FMD use 2
Lack of continuity of care 1 19
Treating physician Lack of training (FAEs, etc.) 4
Lack of workplace knowledge 4
No confidence/trust in employer 2
Too much/not appropriate information 4
Lack of time 3
Role not clear/not appropriate 7
No access to family doctor 1
Remuneration of family doctors 3 28
Employee Hate job 1
Do not trust employer 1
Expectations/concerns/attitudes about RTW 3 5
Communication Lack of communication 6
No informed consent 3 9
Forms Too many/complicated/different 14 14
Medical knowledge Lack of research/guidelines regarding RTW 3 3
Not categorized Category not clear 7 7
Total 131
Table 4. Question 2—addressing the resources required
Issue total Group total
Workplace Job info/PDAs 3
On site case manager/worker advocate 4
Remove workplace stressors 1
Screening of employees 1
Injury prevention 1
RTW policy 1 11
Treatment Facilitated specialist/care/FAE/investigations 17 17
Treating physician Need to resolve role conflict 4
Remuneration for time 5
Training 1 10
Communication Communication with workplace 3 3
Forms Consistent form 3 3
Medical literature Guidelines 2
General research 1 3
Not categorized Not clear 6 6
Total 53
Table 5. Question 3—addressing what needs to be communicated
Issue total Group total
Workplace Job info/PDAs 4
On site case manager/contact 5
Modified work/RTW opportunities 3
Supports are at work (e.g. EAP) 1
Work status (i.e. suspended) 2 15
Treating physician Treating physician role 1
CMA role regarding notes/unfit notes 6 7
Consent Written 4
Informed 2 6
General Not specifically identified 7 7
Total 35
the physicians’ perceptions with regards to their patients’ motivations are biased by their treating role. The continuing role ambiguity of the treating physician
in the return to work process suggests that more needs to be done to promulgate existing provincial and national medical associations policy statements [3,8]. This role definition and need for dialogue among the interested parties has been identified elsewhere [9,10]. Information that was deemed useful to be sent to the
work place was the CMA position and policy regarding notes for fitness to work, which discourages notes for medical certification of work place absences lasting for <5 days [11].Given the request for such notes, employers do not seem to be aware of the CMA policy. There are several potential shortcomings of focus groups. These include first, that collection of information is anecdotal, subject to selection and methodological bias; and secondly, that it lacks reproducibility and thirdly that it lack external validity. Nonetheless, these issues were addressed to minimize the shortcomings of this study design and there is literature to support the use of focus group design studies for health professionals [12–14]. Mays and Pope [15] provide a useful framework for
improving rigor in the course of conducting a qualitative study. A recent article by Harris et al. [16] found value in the focus groups to assess quality of care given in the occupational setting. This paper demonstrates that treating physicians are motivated to take time to participate in focus groups to discuss barriers in the return to work process. Employers, labour and health professionals with their varied interests demonstrated that they could work together to address a
common problem. Several opportunities for further study were identified. One specific weakness of this study is that the perceptions of the treating physician were formed to a large extent by their interaction with their patients. As such, they are subject to observer bias and would require further study to determine the validity of the physicians’ responses.
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