NOTE: This document is provided for historical purposes only.
Presentation by Brad Evanoff, Washington School of Medicine
DR. EVANOFF: I am head of the section of Occupational Environmental Medicine at Washington University in St. Louis. I will be chairing the panel today, along with Dr. Becky Moreland and Dr. Kurt Hegmann.
We plan on having three presentations of approximately 20 minutes each, with time for a few questions after each presentation. We are trying to protect a full 20 to 30 minutes for the end of the session for the purposes of a panel discussion and addressing questions and issues that you have. So if you find me cutting off your questions at the end of someone's talk, you will get another chance at the end of the session to address questions to any of the panelists.
The topic today is Health Aspects of Ergonomic Programs, otherwise known as medical management issues. And I will be providing a general overview of medical management issues, focusing on the things that employers can do to work best with the health care professionals. And then Drs. Moreland and Hegmann will be addressing specific experiences in industry relating to different aspects of medical management programs.
So I bring, I think, three different perspectives to the issue of medical management. The first is as a physician in an occupational medicine group practice, which treats employees from approximately 1,500 small- to medium-size companies in the St. Louis Metro area. The other is as Medical Director for a large hospital, and then the third is as a researcher in the prevention and treatment of work-related musculoskeletal disorders.
And in the talk today, I will be relying more on the perspective as a treating physician seeing patients right off the shop floor, and to a lesser extent on that of a medical manager responsible for reducing total lost time within a company.
So, what is medical management and when does it kick in. I think it is important to stress that the main effort of employers should be on the primary prevention of musculoskeletal diseases through the reduction or elimination of workplace risk factors. And this has been a primary focus of many ergonomics programs and, I think, of many of the discussions that you will hear over the ensuing two days.
Medical management is what you need after your prevention efforts fail, and so in a certain sense, every employee who comes to see me represents a failure of a primary prevention effort. No matter how good a primary prevention effort is, there still are injured employees. And the medical management attempts to reduce the functional impairment and disability in people who become symptomatic. It can also be thought of as medical treatment.
The goals of a medical management program should be to reduce or eliminate symptoms in employees who have suffered an injury, to prevent the progression of musculoskeletal disorders from early stage easily treated disorders to expensive late stage almost impossible to treat disorders, to reduce the duration and severity of any functional impairments that an employee might suffer; and to prevent a reduced severity of disability, including time loss, in employees who have suffered a musculoskeletal disorder.
This is a satirical slide from Dean Lewis. This is the sort of medical management program you would like to avoid, which unfortunately is extremely common. The symptomatic employee sees the plant nurse, gets referred to the plant physician, gets treated with wrist splints, returns to the same job with no modification, symptoms return, is referred to the specialist.
They get an operation, they return to work at the same job with full clearance to return. Symptoms return. They are out of work for a long time. They get involved in the workers' compensation system. They get a lawyer at least in Missouri. Now they are involved with the rehab nurse. There's now a case manager from the insurance company. They get sent to another referral, M.D., ad nauseam, ad nauseam.
This has also been referred to as the vortex of disability or other metaphors involving spirals. I think we see this all too commonly in patients who are referred to us who have been caught up in the system. What I would like to address today are some ways to break this cycle early and avoid having your co-workers or employees caught in this spiral.
What are the essential elements of a comprehensive medical management program? One is surveillance. This is defining problem areas using either data that you already have or collecting data specifically for that purpose. Dr. Moreland is going to address this area in much more detail. Early recognition and treatment is vital.
As a treating physician, I would much rather see a patient very early in the course of their problem when I can probably return them back to work with no lost time, with minimal modifications and very inexpensive treatment. The problems come when we have people who have had symptoms for two, three, four months without seeing a health care provider, and then you have a much harder job ahead of you.
In a few minutes, we will talk about access to appropriate health care providers, and about what makes a good health care provider. Job evaluation and job modification has to be an integral part of any medical management program. It is unrealistic to think that I as a physician sitting in a clinic five miles distant from your worksite can magically fix your employees and send them back to doing a job that caused the problem in the first place, unless there are some changes, at least in the majority of cases, some changes in the way that work is done.
It is also important for me to diagnose whether a medical condition is related to the worksite or not. Unless I get information about what the work involves, I can't make that diagnosis, and I can't make appropriate treatment.
Conditioning and rehabilitation programs are necessary for employees who have more severe or protracted musculoskeletal disorders. Follow-up is something that I think almost everyone doesn't do well enough. Even programs which provide good case management and follow-up, almost all will stop the follow-up the day the employee returns back to their regular job. If you look, however, at what happens to people who have had time off and return to a job, a large number of them, six months later, a year later, have had recurrence of symptoms and are out of work again. I think once you have had an employee with a significant musculoskeletal injury, even after they are back at work, you need some way of following up to see if symptoms recur and you intervene at a very early stage and avoid having a more protracted problem.
And then finally coordination with primary prevention efforts. And hopefully you are putting this medical management program in place in a plant that has some efforts at changing the underlying risk factors. And if you are trying to affect the work for your healthy employees, it is all that much more important to try to make changes directed at those employees who have had a problem. And if you see some of the follow-up and coordination, this comes back up to surveillance and early recognition.
And the last page of your handout shows a diagram that we will get to at the end of the talk, really showing how these different elements ought to be thought of as a connected group of concepts and not broken up into separate noncommunicating programs.
So how do you choose a health care provider to see your injured co-workers or employees. You would like to find someone who has some specialized training or experience in ergonomics and/or the treatment of work-related musculoskeletal disorders. And this really involves a working knowledge of the industry and the specific work that employees do. And by working knowledge, I mean willing to obtain information and work with it, to talk with the employer, talk with the employee, and try to use the information about the worksite in the diagnosis and early treatment. And it is very difficult, again, to treat an injury if you have no idea what the person does.
Your health care provider should be willing to communicate with the employee and the employer, not in cryptic dictums from on high, like a scribbled prescription that says "light duty," which is extremely common. You need to find someone who is willing to make specific recommendations regarding the nature and duration of any changes in work status. In my opinion a work prescription that says only "light duty" is almost worse than useless.
Finally, you would like to get someone who is willing to consider conservative therapy and not hustle the employee quickly off to see a surgeon.
If you have found this paragon of a health care provider who is willing to communicate with you and willing to get information about the job and use it in treatment, how can you make this provider familiar with the job. Well, walk-throughs are best. The best way is for the health care provider to actually be physically present at the worksite and see what a specific injured employee is doing, or at least employees in that class.
For large employers, for companies that have in-house medical, this should be really the standard of care. For small- or medium-size companies this is more difficult to attain. Again our group serves 1,500 different companies. Unless I would go to 7 or 8 companies on a walk-through every workday, I couldn't see them all in a year. So if you aren't able to get a health care provider out at the worksite to see the specific job, there are a number of other ways to communicate: check sheets, detailed descriptions of a job, or videotapes are a very good way to communicate about jobs. And many physicians who see work-related diseases have a videotape player in their office, and we use ours fairly often. So the more information you can give your health care provider, the better job they can do with diagnosis, the better job they can do with treatment.
And, finally, if you have found this provider who is willing to communicate with you, you need to facilitate communication with them by providing someone at the worksite who is familiar with the jobs and who can facilitate or actually make decisions about alternate duty and can provide the necessary conduit of information back to the physician.
And I think often when you see cases that have gone on for three or four months, we see that the communication has consisted of memos which arrive a week or more after the episode of care, so everyone is communicating back and forth by memos that have a week- to two-week lag time on what is actually happening. And it is much easier if I can pick up the phone and I know who to call at your company. And things can often be resolved extremely quickly that way.
So, as I mentioned, a mainstay of treatment of work-related musculoskeletal disorders is reduction in the exposures, relevant exposures, posture, repetition, and vibration. What if you were to go to see a physician for tennis elbow that was caused from being a slug all winter, then hitting too many balls over a couple of weekends, and all the provider did was say, "Here's a splint, here's some pills, play as much tennis as you like." If the physician didn't talk about the amount of your tennis playing or your tennis technique, you would probably find another physician pretty quickly.
By the same token, if you had a work-related disorder that was contributed to by the work, it is often unrealistic to think that a physician has wonderful treatments that can fix that and yet the person can keep doing exactly the same job that contributed to the problem in the first place.
In treatment, particularly of chronic musculoskeletal disorders, some sort of permanent job modification, temporary job modification, or, if all else fails, removal from work may be necessary. Here is where you can guide the physician in telling them what options are available for different types of work or different modifications so that the physician doesn't just jump right to giving people time off.
By far the best option is modifying their current job, making some permanent change to the job that eliminates the relevant risk factor or markedly reduces the relevant risk factor and allows the employee to go back to work. This is the least disruption to the company and the employee. And, as you will hear in the primary prevention talks or the other talks during the few days, there are often very cheap and easy ergonomic solutions -- raising a table, lowering a table, raising a chair, changing the height of a keyboard -- that can be done for low cost or under $50.
And it also amazes me that employers are willing to pay for visit after visit to me, visit after visit to a physical therapist, but aren't willing to spend half as much money as one visit to me costs to buy their employee a tool or make an adjustment that might make the problem go away completely.
Temporary modifications, such as reducing speed, reducing overtime, restriction of certain tasks that may not be essential to the job, are also effective. I think less desirable but often necessary is a temporary job transfer, moving someone to a different job. It is important, of course, to screen the new job to make sure it doesn't have the same risk factors that the old job did.
And for workers who have been out of their usual job for some period of time, particularly if that job involves a lot of force and repetition, you should consider a gradual re-entry into their normal job.
Least desirable, of course, is time loss. In the case of acute or severe injuries, short-term time loss is useful and necessary, but you should work hard to avoid long-term time-loss for a variety of reasons, remembering that "the longer someone stays off work, the longer they stay off work." It is almost inconceivable that there is not something useful that can be done at your worksite by someone with almost any conceivable physical limitations.
I think the Americans with Disabilities Act has provided something of a prompt for employers to find these accommodations for people who don't have work-related injuries. I think that same process can work for people with work-related injuries. There is a fair bit of evidence that bringing people back to work early in some capacity is helpful in getting them back to their permanent job, avoiding long-term disability, avoiding the attendant expenses in litigation that long-term disability settlements bring.
Let me switch now to an example of some results from a medical management program. These are injury data from a large urban hospital in St. Louis, 6,000 employees. Like health care institutions across the country, there is really a high injury rate within several of the departments. In particular, transporters or orderlies, LPNs or certified nursing assistants, and housekeeping workers have injury rates that are compatible with those in construction sites, steel foundries, and other places that we think of traditionally as heavy industry.
The situation at this hospital in 1990 was that they had a lost day rate of 94 lost days per 100 full-time workers per year. They did not have any medical management program and were sending their employees to a variety of different providers, none of whom had any background or experience in work-related diseases.
The major change that they made in 1991 was to switch providers and start sending all initial injuries to a multi-physician group that specialized in occupational health care. Over the next three years, there was a pretty dramatic reduction in lost days. You should note that this was occurring in a setting actually of an increasing injury rate, not a decreasing injury rate. Part of this increase was probably an artifact, because at the same time they started keeping their injury records a little better, and I am sure there was significant undercounting in the early years.
Note also that they had almost no restricted days related to some administrative issues that you may face as well. In 1994, restricted duty was introduced in a limited way by a few departments. In 1995, they did more. I can tell you that 1996 looks pretty much like this, more of a decrease in lost days, an increase in the proportion of restricted days.
Again, these results were obtained just by doing one aspect of medical management. This hospital is just now starting to do primary prevention efforts, and we foresee a further reduction in these numbers as time goes on.
Since I am from the "Show-Me State", I have to tell you there are some things of which you should be skeptical. There is no technological quick fix that is going to solve all of your workers' comp problems yet in any trade meeting or publication, you can many vendors making such claims. I think it is ludicrous to think that in a system that is so complicated, bringing in one piece of equipment or one programmatic element is really going to change things completely.
In my opinion, the most successful programs have an integration between prevention programs which seek to minimize the risk of injury, treatment programs which seek to manage injury, and rehabilitation programs which seek to minimize disability in cases of an injury. When these three elements are working in a coordinated manner, you see the best change. Again, this diagram is in great detail on the last page of your handout.
