Return-to-work evaluations -- no easy answers

It would be great if health care providers were able to standardize the care, including determination of work status, of all workers suffering from similar injuries or illnesses. It would be beneficial to the employer and would make the busy doctor's job easier. However, medicine remains "an art," often subject to decisions based on subjective information received from a patient. While medical technology certainly has made tremendous advances, evaluating injuries and an employee's ability to return to work still remains an individual process.

This area of occupational medicine may be one of the most controversial among employers, employees and the physician. A manager will see one employee return to work in a very short time after a shoulder injury, while another worker remains off for several months with the same injury, then returns to light duty. The manager doesn't understand why the second worker didn't return in the same length of time. Is the employee faking the pain that keeps him off of work? Is the physician dropping the ball?

Undoubtedly, a small minority of employees will falsify medical information simply because they don't want to return to work or because they are seeking a workers compensation settlement. However, the majority of people are honest and want to get back to work as soon as they can. So why the discrepancy?

Although two injuries may appear to be identical, every injured worker will respond to the injury and treatment in a different way. The pain threshold for some is higher than for others. Motivations differ with each person. Some individuals have a higher capacity for healing because of a healthier lifestyle, better general health and conditioning or any number of reasons. There are no quick, easy answers when evaluating a patient's ability to return to work.

Probably 50 percent of a determination regarding work activity is based on the medical history received from the patient. While often very subjective in nature, this information cannot be discounted. A good health care provider will pay close attention to everything a patient describes and relates.

A thorough physical examination should be performed each time a patient is treated for an injury and before that person is released to return to work. This will generate objective findings that the physician can use in making a decision about work status.

Ideally, an individual would have no complaints and nothing would be revealed from the physical to cause concern. At that point, a worker can be returned to regular work without worry.

When a physician has a patient who continues to have subjective complaints with no objective findings, this creates a dilemma in evaluating return-to-work status. The employer is ready to have the worker back on the job. The worker is saying he or she is not ready. At this point, second opinions, preferably by appropriate specialists, should be obtained. Functional capacity evaluations are also an option, and independent medical evaluations can be performed, usually as a last resort.

As technology advances, possibly some day we'll be able to run a few simple tests and make "cut and dried" decisions about work status based strictly on those tests. Until that happens, health care providers must continue to work closely with patients and their employers to achieve a fair and consistent evaluation system that protects the worker and the company.

Dr. Richard R. Morgan is the medical director for the St. Anthony SCORE wellness program. St. Anthony Hospital is a member of SSM Health Care.

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