Ubc webinar feeling+disabled+by+disability


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Ubc webinar feeling+disabled+by+disability

  1. 1. 2/27/2013 Feeling Disabled by Disability?: How to Better Support Your Patients’ Return to Work Disclosure for Dr. Chris Stewart-Patterson: Nothing to Disclose. Chris Stewart-Patterson MD, CCBOM, FACOEM Occupational Physician Program Director Harvard Medical School “Survey Says” We asked: When are expectations for Return-to-Work (RTW) discussed? • 32% of Injured Workers1 versus 64% of Physicians2 surveyed said RTW was discussed at the 1st visit What do you hope to learn by attending this webinar? 2 Most common responses to the survey were: • Improve form completion • Improve management of patients’ RTW • How to perform a functional assessment/which assessment tools to use • How to determine a realistic prognosis/recovery time What are your challenges in regards to preventing and managing disability? 2 Most common challenges highlighted in the survey were: • How to support my patients’ RTW: improve motivation • No guidelines to follow • Too many forms! • Giving a recovery timeframe/prognosis 1IPSIS Occupational Medicine REED Survey Dec 2012; 2Pre-Webinar Survey Feb 2013 Photo by: Charles Hercules Ebbets, Sr 1
  2. 2. 2/27/2013 Original image URL: http://www.flickr.com/photos/rent-amoose/5510408914/ Title: lavagna_gabri Photo credit: rent-amoose / Foter.com / CC BYNC-SA RTW can be Complex Multiple psychosocial factors beyond MD’s control Original image URL: http://www.flickr.com/photos/diamondmountain/2943172757/ Title: The World Needs Ditch Diggers Too Photo credit: diamond mountain / Foter.com / CC BY Ditch Digger to Nuclear Physicist Polling Question #1 • workplace relationships • economic factors like secondary financial gain • compensation process • employer policies • social policies Can Fam Physician 2011;57:202-9 Is Timely RTW Important? Workmen’s Compensation Board: Vancouver, Canada (1986, unpublished data) 2
  3. 3. 2/27/2013 Waddel & Burton 2006 Report • “Strong evidence base showing that work is generally good for physical and mental health and well-being” • Worklessness is associated with poorer health • The proviso is that jobs should be safe and accommodating • Overall, the beneficial effects of work outweigh the risks of work, and are greater than the harmful effects of long-term unemployment or prolonged sickness absence Waddell, G., Burton, A. K., (2006). Is work good for your health and well being? London, The Stationery Office. CMA RTW Statement Prolonged absence from one’s normal roles, including absence from the workplace, is detrimental to a person’s wellbeing The Physician’ Role in Helping Patients Return to Work After an Illness or Injury (UPDATE 2000): CMA Policy Similar endorsements by multiple medical associations internationally • OEMAC, AMA, ACOEM, American Psychiatric Association, AAOS “First, Do No Harm” RTW too early • Exacerbate symptoms to point of further impairment • Relapse with failed RTW • Safety sensitive work concerns But RTW too late… • Negative health effects of not working on: • daily structure & activities • social contact • self esteem • financial stressors Let’s Get This Dialogue Started! • The role of MDs is to incorporate a timely RTW into the care plan for their pts. • Early in the course of treatment, the MD should discuss expected recovery times as well as an early, graduated increase in activity. • MDs should encourage a pt’s RTW ASAP provided that RTW does not endanger the patient, coworkers or society The Physician’ Role in Helping Patients Return to Work After an Illness or Injury (UPDATE 2000): CMA Policy 3
  4. 4. 2/27/2013 Physician Skills & Tasks Polling Question #2 Routine physician tasks & skills • History, examination, investigation • Diagnosis & treatment Additional RTW physician tasks • Early focus on safe RTW expectations • Focus on function!!! • Activity prescription • Set limitations & restrictions • Review the job demands Impairment vs. Disability Current Symptoms Impairment is about Inability of a function Disability is about Duty (role or job) Case: Physician fractures an arm Impairment: Strength, ROM, pain Disability: Surgeon Yes! Medical lecturer No! Are the symptoms impairing? • Severity • Intensity • Frequency • Duration • Effect on functioning • Perceived work barriers 4
  5. 5. 2/27/2013 Focus on Function! Assessing Function • Self-reported tolerances • Current life roles • Description of a typical day • Adaptations to impairment • Observed functioning • Physical examination • Imaging and investigations Original image URL: http://www.flickr.com/photos/tambako/4526323236/ Title: Huskies and sunset Photo credit: Tambako the Jaguar / Foter.com / CC BY-ND Physical Examination Signs related to impairment • Joint: reduced range of motion • Skin: swelling & redness • Neurological: Strength, sensory, reflex 1 Minute RTW questions “What impact is the problem with your…going to having your ability to do the job in a regular way?” Pain behaviors “Have you figured out the way to work around this so you can stay at work while you recover?” Observations of function • Sit, stand, crouch, bend… “Are you going to have any problems with your boss or co-worker with that?” Questions provided by Dr. Jennifer Christian, MD 5
  6. 6. 2/27/2013 3 MD Forecasts of Function • Out of commission • Confined to bed or staying in the house • OK to resume ADLs • But with perhaps with some limitations • Back to normal functioning • Back to normal does not necessarily mean all symptoms free may have permanent loss of function and have a “new normal” RTW is Tx! Activity Rx • What patients should be doing for recovery and preserve well-being • What patients should not do because of medical risk (harm or a hazard to others) • What patients can and cannot do given their functional ability due to the medical condition • Whether or not they are willing to tolerate the activity • ACOEM position statement The Personal Physician’s Role in Helping Patients with Medical Conditions Stay at Work or Return to Work 2008 Information provided by Dr. Jennifer Christian, MD S.M.A.R.T. Rehabilitation Goals • Specific • Measurable • Achievable • Relevant • Time bound Clin Rehabil April 2009 vol. 23 no. 4 352-361 Risk factors for delayed RTW • Maladaptive beliefs around pain • Reinforcement of pain behaviors by family members • Heightened emotional reactivity • Lack of social support • Job dissatisfaction • Compensation issues • National Advisory Committee Guide to Assessing Yellow Flags in Acute Low Back Pain. New Zealand, Ministry of Health, 1997 6
  7. 7. 2/27/2013 RTW Motivation No Graduated RTW Available? The Obstacle Question • What is specifically the obstacle preventing you from working today? Think alternate activities equal to or close to demands of the GRTW plan: • Increase lifestyle physical activity • Specific home rehabilitation exercises • Daily walks • Volunteer work • School & upgrading courses The Mole Hill Sign • When an apparently minor health condition having a major affect on daily life and function, there maybe a motivational issue. Information provided by Dr. Jennifer Christian, MD Fibromyalgia & Lifestyle Physical Activity • Nightly recorded their # of steps and zeroed their pedometer • In a diary, categorized the types of LPA’s they engaged in • Over 12 weeks, LPA group increased the mean of daily steps from 3,788 to 5,837 (± 1,770) • LPA group reported significantly less perceived functional deficits & pain Basics: Work Fitness Terms • Capacity • Limitations • Restrictions • Tolerance • Accommodation A Physician’s Guide to Return to Work, 2nd ed. (AMA) Fontaine et al. Arthritis Research & Therapy 2010, 12:R55 7
  8. 8. 2/27/2013 Limitations or Restrictions • Sit, stand & walk • Lift & carry • Stoop & crouch • Heights & ladders • Overhead or repetitive reach • Shift work • Concentration & memory “Mom & Pop Shop” Question If he or she owned his or her own mom-andpop grocery store, would they be able to find a way to work safely? Question provided by Dr. Jennifer Christian, MD RTW & Safety Sensitive Jobs • Danger to self • Danger to work mates • Danger to general public • Pre-placement examination • Periodic examination • Fitness to return to work Medical FTW Guidelines Available online: • CMA Driver’s Medical Fitness Guidelines • Railway Association of Canada medical guides Book: • A Physician’s Guide to Return to Work 2nd edition (AMA) 8
  9. 9. 2/27/2013 Temporary or Permanent? If temporary restrictions or limitations… • How long? • Need reassessment? If permanent… • Are they at Maximal Medical Improvement? “The condition has stabilized and is unlikely to change substantially in the next year…” Employer Responsibilities • To provide a safe workplace • ‘Duty to Accommodate’ • To make ‘Reasonable • Accommodation’ up to ‘Undue Hardship’ • Provide Bona Fide Occupational Requirements (BFOR) (Rondinelli 2008) Confidentiality • “Physicians should ensure that they have received the employee's consent to provide information to the employer or its insurer” • “Physicians should take care not to disclose more information than is covered by the employee's consent or is required by the employer's request” • “Diagnosis and treatment information is not normally required” RTW Tool Kit • Set the stage for reasonable RTW early on • 1 minute RTW screening tests • Activity Rx • “Mom & Pop Shop Question” • Mole Hill Sign CPSBC Guideline “Medical Certificates” 9
  10. 10. 2/27/2013 RTW Assessment Review 1. 2. 3. 4. 5. 6. 7. Diagnosis Evidence of significant impairment ? Is work absence medically required? Describe any limitation Describe any restrictions Is there a job demands mismatch? Are there non medical barriers? 10