Clarifying my message re: doctors, RTW coord, etc.

Jennifer Christian MD

To those of you who wrote me worried notes:    I apologize for causing confusion/misunderstanding.  I am NOT recommending we “medicalize” disability.  I AM pointing out the reality that in order to PERSUADE doctors to take on responsibility for doing their part in the SAW/RTW process, they need to SEE it as a successful outcome of the healing process – as the finale of their MEDICAL work.  Thus, they need to see the COHE as part of the healthcare system, and its services as part (an extension) of their “caring” process.   

That doesn't mean the other stakeholders need to see the COHE / RETAIN the same way.  We must have descriptions / messages that are meaningful, relevant and attractive to EACH major player whose participation is needed.   

I hope that the two slides pasted below (and attached) clarify the nature of the gap in the social fabric we are trying to patch with RETAIN.  I’ve also pasted below (and attached) a one page Work Disability Prevention Manifesto I wrote that describes the nature of the problem AND the nature of the opportunity (solutions) in words.  

At the point the RETAIN program begins – a few days or weeks after the worker first seeks care from a physician for a new health condition  – the worker, the physician and the employer ALL see any workplace absence as DUE to an unresolved MEDICAL problem.   In fact, almost ALL health-related job losses BEGIN with a worker seeking care for “a new medical problem.”  As provided by law and usual business practice, doctors play a critical role, especially during the first few weeks/months.  Their words to the patient and on disability / RTW forms are powerful; they set expectations.  Employers and claims payers expect doctors to make determinations (expressed on forms) that say whether workers may work and if so, doing what.   Doctors thus play a major role – and can START the process of SAW/RTW.  The COHE then communicates with other parties who must pick up the baton and run with it.  Most importantly, the employer decides whether or not to provide work within the workers’ altered capabilities.  If things get stuck, the payer or the government (workforce system) can come in to provide practical assistance to the employer or worker. 

TRY TO SEE THIS THROUGH THE DOCTOR’S EYES:   Physicians are professionally committed ONLY to the practice of medicine --to diagnosis, treatment, relieving suffering, and assisting healing.  Period.  So the SAW/RTW process needs to be positioned in THEIR EYES as an important milestone in the healing process IN ORDER for the doctors to BUY IN.   (I have been working to improve things at the healthcare-workplace interface for 30 years.  It is impossible to get doctors to care about an “administrative” or “benefits” or “employment” or “legal” program involving their patients.  Those things are simply “someone else’s job – not mine”.   Getting doctors to pay attention even to stuff they DO see as MEDICAL is tough enough.  Think “herding fretful cats.”)

Diagram #1 shows today’s gap between the doctor’s office and the workplace.  Today, neither the doctor NOR the employer feels responsible for DRIVING a healthcare episode in an employed person towards a good concrete outcome:  the minimum possible life disruption and protecting the worker’s job.  Diagram #2 shows the maze that an affected individual has just entered.  Who will help them get through to the other side?  Diagram #3 shows that neither the private sector as a whole nor the public sector as a whole has felt responsible for this issue.   

RETAIN is an effort to get all parties to recognize that the solution is TEAMWORK – and to start learning how to COLLABORATE across stakeholder boundaries.  Each stakeholder group must feel responsible and take professional satisfaction in the eventual SAW/RTW outcome, like it’s part of THEIR job.  In other words, preventing needless work disability must be a SHARED responsibility, with each party contributing what they can – and making an extra effort at problem-solving if necessary  – to make sure newly injured or ill workers actually get the support they need to stay functional and keep their jobs.

See the two slides and the text of the Work Disability Prevention Manifesto below and attached. I hope this is helpful.

Jennifer Christian, MD, MPH
President / Chief Medical Officer
Webility Corporation
Wayland, MA 01778
Office:  508-358-5218 (preferred)
Mobile:  617-803-9835
Email: jennifer.christian@...





 Preventable job loss demands our attention!              

  • Millions of American workers lose their jobs each year due to injury, illness, or a change in a chronic condition.
  • A new medical problem that also threatens one’s ability to earn a living creates a life crisis that must be addressed rapidly and appropriately. Most people are unprepared to handle this double-headed predicament.  It can overwhelm their coping abilities.
  • Loss of livelihood due to medical problems is a very poor health outcome, second only to death.  Worklessness is harmful to people’s physical and mental health, as well as to their family, social, and economic well-being.
  • Preserving people’s ability to function and participate fully in everyday human affairs, including work, is a valuable health care outcome.  People who must learn to live with chronic conditions or impairments will have much better quality of life if they can keep their jobs or find new ones and remain economically self-sustaining.
  • When medical conditions occur or worsen, especially common ones, most people are able to stay at or return to work without difficulty -- but not all.  Many cases of prolonged work disability covered by private- and public-sector benefits programs began as very common health problems but had unexpectedly poor outcomes including job loss. Those cases frequently began as musculoskeletal pain (especially in the low back), depression, or anxiety.

Why do such poor outcomes occur?

  • Medical conditions by themselves rarely require prolonged work absence, but it can look that way. Both medical treatment and time off work are often considered benefits to be maximized, rather than tools to be used judiciously.   The harms of over-treatment and needlessly long periods of life in limbo are not usually recognized.
  • Professionals typically involved in these situations (health care providers, employers, and benefits administrators) do not feel responsible for avoiding job loss.
  • Unexpectedly poor outcomes are frequently caused by a mix of medical and nonmedical factors. Diagnosed conditions may be inappropriately treated; others (especially psychiatric conditions) may be unacknowledged and untreated. The employer, medical office, and insurance company (if there is one) often operate in isolation, with little incentive to collaborate.
  • Without the support of a coordinated team focused on helping them get their lives back on track, people can get lost in the health care and benefits systems. With every passing day away from work, the odds worsen that they will ever return to their job. After a while, they start to redefine themselves as too sick or disabled to work.   
  • After people lose their jobs and do not find new ones, most of them barely get by on disability benefits.  They also become vulnerable to the other detrimental effects of worklessness.

How can we fix this problem?

  • Good scientific evidence exists about how unexpectedly poor outcomes are created, how to avoid them, and how health care and other services can protect livelihoods. 
  • Health-related work disruption should be viewed as a life emergency. Productive activity should be a part of treatment regimens.
  • When work disruption begins, it can be both effective and cost-beneficial to have a coordinator help the individual, treating physician, and employer communicate and focus everyone’s attention on maximizing recovery, restoring function, accommodating irreversible losses, and making plans for how the individual can keep working, return to work, or quickly find a more appropriate job.
  • Helping more people with significant medical conditions keep their jobs or quickly find new ones will benefit them and their families, as well as our society as a whole.
  • We must urgently establish accountability for work disability and job loss in our workforce, health care, and disability benefits systems and build nationwide capacity to consistently deliver services—just in time, when needed—that help people stay at work or return to work.

Now is the time for policymakers in government and the charitable sector, as well as private sector employers, insurers, and health care delivery and related organizations to commit to developing solutions to this national problem.

Rick Denning

Thank you.  Unless we see the many pieces as a integrated system the outcomes will not improve.  (Ref: W Edwards Deming)

Rick Denning
Shelter Island Risk Services
New York