Earlier in my medical practice career, I joined a predominantly busy medical practice and family medicine practice in a “bedroom community” setting. There wasn’t much occ med or workers’ comp business, but the owner of the practice, one of my early mentors, encouraged me to become the “occmed specialist” for the practice. At the time, I didn’t really have that much inclination or knowledge about occmed, besides taking care of workers comp patients for several years. This mentor ran this practice in a “patient centric” manner long before anyone was coining such terms or talking about the patient experience. He felt that workers should be treated just as well as our “regular” or “private” patients, while at the same time meeting the needs of our client employers.
I would later come to acquire this practice, added to my other clinic that was 70-80% occupational medicine with over 400 clients. By that time, I had finished a stint as the corporate medical director for a 14 clinic chain in the northeast that was sold to a physician practice management company. One of my projects there was to open and operate an occupational/workers’ comp clinic for municipal and county workers, which included a physical therapy department and one of the first “Workers’ Comp PPO’s” I knew of. We had created this panel so it would be comprised of docs who could effectively and efficiently treat these injured employees to get them back to work in a timely manner, and to provide an enhanced level of communication to the employer so they knew what was going on and patients/workers weren’t in “limbo.”
So, now I was completely immersed in occupational medicine. Although, I was not formally trained as such. But, after 30 years of caring for injured workers, communicating with clients, countless CME courses, and a “mini-residency” of sorts through membership in ACOEM, I finally became that “occmed specialist” my early mentor had envisioned. At least in the context of a medical practice. I had even gone back to my alma mater, the Medical College of Wisconsin, to pursue the distant learning MPH OccMed credential, but had to stop at the point where they wanted me take a year off of my busy practice to do a “practicum year.” Haven’t I already been doing “practicum years?” Well, I sold all that to Concentra a few years ago, and spent a year helping them train their ER doctors to do occupational medicine, performed quality audits, chart reviews, and assisted with clinic operational efficiency and troubleshooting. Another area I naturally “fell into” is DOT Exams.
One of our clients was a large truck driving school with multiple locations, not near our clinics. So we set up 5 DOT-only clinics at their locations and staffed them with PAs to keep costs down. But, we had to train these PAs to follow the DOT regulations early on, way before there was an NRCME. So, I set up a training course for them, and as questions or issues would come up with these student drivers, they’d call me and I’d pore over the regs and answer their questions and added to the training manual as we went along. Later, I hooked up with NADME, the National Academy of DOT Medical Examiners, and became the medical director— one of the hats I currently wear. We’ve trained over 7,000 practitioners online! So, I’ve learned a few things about occupational medicine practice in the real world.
Here are some tips about treating workers’ comp patients: Physicians do a disservice to patients with work related injuries by not understanding basic return to work practices. Given the same injury, patients who go back to some type of productive work as early as possible have less long term disability, are more productive, and happier than those who are kept out of work. In her article "7 Signs Your Injured Worker is Treating with a Physician Who is Not Employer Friendly," Rebecca Shafer makes some excellent points about physicians treating workers’ comp injuries. Her article is geared towards the payor side, so I'll add some comments that treating physicians/providers need to consider when treating these patients. (Although this is a huge topic and we can only just touch on some basics here.)
Placing the patient off duty. As Ms. Shafer states, if a patient is off duty, it means they are totally disabled, as in the hospital, going directly to surgery or absolutely can't move. This is rarely the case. Often times the patient will tell the provider "there's no light duty at my job." I generally explain to the worker that they'll get better faster if they return to some type of productive work today. I explain that I will first determine what their job duties are, then determine if the injury prevents them from doing the essential elements of the job. If they can return to full duty with only "first aid" level care, the injury may not even be OSHA recordable, which will help your clients (the employer) immensely. If they can not do their regular duties, write specific restrictions on what they can or cannot do in terms of stand, sit, walk, lift, carry, push, pull, climb, crawl, reach, grasp, etc., and how many pounds for what period of time--occasional, frequent or continuous. Any physician providing workers comp services should have some type of form on which you can indicate these restrictions.
Follow up after the first visit, in my opinion, should be in just 2 or 3 days. Many times the injury will be significantly improved and the patient can be returned to full duty. Other times the patient will complain they are worse. When this happens, you must not "knee-jerk" take them off duty, rather focus on their demonstrated level of functional ability in order to determine work status, not subjective complaints. Always write the restrictions based on examination of their ability to function, and always explaining that it is in their best interests to continue to work to this level of ability. My subsequent follow ups are generally weekly.
Medications If there is a minor injury with the worker returning to full duty, treat the injury as "first aid", to avoid an OSHA recordable. Prescribing OTC NSAIDs at OTC strength is generally fine for most minor injuries. Remember if you write Motrin 600 instead of 400 it is going to be recordable. If you are not completely familiar with what is or is not considered first aid regarding OSHA recordability, <<click here for my article on OSHA recordables>>
Physical Therapy Yes, PT can be easily abused, but also mandatory for injuries showing a functional deficit. If the worker cannot return to full duty within a week or so, or if off duty and not in the hospital, I am aggressive with PT to restore mobility, function, and also importantly, confidence and motivation. I personally like a close working relationship with the therapist so we are a team working to get the patient functional as soon as possible. I did not have a PT department in my last Medical Practices, but would if I had the space. You don't have to over-prescribe PT to have a successful and effective PT department.
Specialist Referrals Obviously if there is a surgical problem, the patient needs to be referred right away, and be careful to not allow them to go into "limbo" with no duty prescription or excessive lost time waiting for the specialty appt. If the patient is not progressing, e.g. showing signs of improvement in function, with progressive lightening up of work restrictions within 2-4 weeks, generally a specialist should be consulted.
Communication Yes, notes, restrictions, meds, PT, diagnostics, referrals and follow up plans, as well as expected date of maximal medical improvement (MMI) or prognosis should be legible and reported at each and every visit.
Treating injured workers effectively requires an understanding of proven return to work practices and strong cooperation and communication among providers, employers, adjusters, payers, and patients.
Lawrence Earl, MD
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