There are pressures in today’s healthcare environment to ensure injured or sick workers return to duty, but this must be balanced against their needed recovery time.
It takes a delicate combination of compassion and skepticism — and no small amount of detective work — to make the right call, Leslie Cadet, MD, MPH, an occupational health physician at Loma Linda (CA) Medical Center, said during a webinar hosted by the Association of Occupational Health Professionals in Healthcare (AOHP).1
It must be clear most healthcare workers report injuries or illness honestly, and only a small percentage in any field try to game the system.2
Why do they do it? “Often, the person honestly feels sick, so as to remain consistent with this exaggerated belief,” a psychologist noted. “The cause of this active avoidance, using pain as an excuse, is that pain is a more acceptable justification vs. ‘I don’t feel like it.’ Feigning illness is not lying, although it is deceptive — [it is somewhere] between hysteria, magical thinking, and the white lie. Psychosomatic medicine is sometimes hard to understand.”3
Complicating the matter, healthcare workers are among the most injured employees in any profession. The Department of Labor reported that in the first year of the pandemic, “U.S. healthcare workers experienced a staggering 249% increase in injury and illness rates. In fact, workers in the healthcare and social assistance industries combined suffered more injuries and illnesses than workers in any industry in the nation.”4
With all they have been through, there could be some sympathy for healthcare workers taking breaks from work. But the counterintuitive answer is missing work for a prolonged period is a negative experience on many levels.
“If we don’t tell our patients what to expect [regarding return to work], they’ll fill in those gaps for themselves,” Cadet said. “We’ll end up prolonging the amount of time it takes for them to return to work, increasing absenteeism rates and worsening clinical outcomes because the worker is inactive.”
Cadet characterizes this as “iatrogenic disability” because occupational physicians and the employee health department are “enabling” the adverse effects of prolonged leave from work.
“Healthcare costs increase, but perhaps the most impactful for the worker is the loss of their social relationships with co-workers, the loss of their [work] identity component — what they do for a living,” Cadet said. “The loss of their self-respect that comes by now having to rely on other people or government assistance. This does not do anything to increase their self-worth.”
Insult to Injury
Cadet recalled a case that amounted to a tough lesson before she started applying her techniques of setting expectations and keeping a timeline. It involved a 43-year-old nurse with low back pain sustained while bending to help a patient. A CT scan showed some degenerative disease at discs L4 and L5, the two lowest vertebrae of the lumbar spine. The scan also revealed a narrowing of joint space caused by a disc bulge. At the time, Cadet did not realize this was, at least in part, the result of a patient-handling injury five years earlier.
“Two days later, she comes to occupational medicine, asking for a wheelchair to move about the clinic,” Cadet said. “She says she didn’t feel safe driving her car. Sitting makes her pain much worse. Her exam is objectively normal. Only some subjective pain with palpation. We continue conservative care, we give her work restrictions to not lift more than 10 pounds and to stand mostly.”
As the nurse continued to report high levels of pain, Cadet recommended physical therapy (PT), but agreed to the nurse’s request for aqua therapy.
“Over the course of her care, it became known to us that the worker had a previous workers’ comp claim five years prior for a low back injury,” Cadet recalled. “At that time, she said she was doing repetitive reaching, twisting, and bending while caring for a patient. An MRI performed at that time showed a disc protrusion.”
The radiologist reported no nerve impingement or displacement of the cerebrospinal fluid because the disc is sitting in the correct position.
“Over the next several months as I treat her, the worker continues to complain of low back pain with minimal improvement, despite NSAIDs [non-steroidal anti-inflammatory drugs], the completion of aqua therapy, followed by multiple rounds of traditional PT,” Cadet said. “The nurse then requested to be evaluated at the neuropathic pain center, complaining of decreased sensation in her right leg. This included all dermatomes of the upper and lower leg, which was not consistent with her previous MRI. She said that her pain was so severe, she could not bear weight, and felt as if her right leg was weak. I ordered an electromyography [EMG], which showed no evidence of lumbosacral radiculopathy, plexopathy, or peripheral entrapment neuropathy.”
A new MRI was compared to the original from five years before. “According to the radiologist, in the more current MRI, it could be argued that that disc protrusion was less prominent,” Cadet said. “Practically no change. Neurosurgery sent the patient to their physical therapy spine team and referred her to pain management, where the worker declined steroid injections.”
The worker resisted full removal of work restrictions and a return to full duty. Then, quite literally, the nurse added insult to injury. “At her five-month follow-up, she tells us that she recently came back to the United States after visiting her family overseas for one month,” Cadet said. “Her complaint did not affect her ability to travel internationally for a month. She was able to carry heavy luggage, stand, and sit for prolonged amounts of time. You all know how it is in the airport, and riding in an airplane overseas.”
The nurse announced she had found another job as a diabetes educator, and she was discharged from occupational health.
“With these types of cases, it’s good to take a moment to reflect and ask yourself, ‘What went wrong?’” Cadet said. “No. 1, I didn’t set expectations of the return-to-work timeline. She said she injured her back while bending over to assist a patient don their undergarments. The mechanism of action makes strain most likely, and that would have been expected to resolve within a few weeks.”
Do Not Let Injured Worker Drive Care
Admitting she did not establish a firm timeline, Cadet said she left too many things open-ended. “I let the worker drive care,” she noted. “First, it was ‘I don’t want traditional PT, I want aqua therapy.’ Then, it was ‘Now, I want 30 sessions of PT, and now I want the neuropathic pain center. Now, I want neurosurgery.’ Realistically, these specialty referrals were not necessary, because there was a lack of objective evidence on exam. There’s no nerve impingement on imaging, and her EMG says her nerves and muscles are fine. Her description of whole-leg numbness does follow a strict anatomic distribution, and so is deemed invalid according to the American Medical Association guidelines to the evaluation of permanent impairment.”
The other problem was lack of awareness of the nurse’s previous back injury and workers’ comp case. “I didn’t adequately data-mine my chart before my initial visit with her,” Cadet acknowledged. “I went into the room blind, and therefore, I was more easily carried away with all of her requests and reports of pain. I should have set expectations that a simple muscle strain should resolve within two to three weeks. I’ll even give you six to eight weeks, max.”
What is the average time away from work for various injuries? Cadet cited a study5 that gave the average work loss for the following injuries:
• Back problems: 51 days;
• Sprains and strains: 41 days;
• Musculoskeletal: 54 days;
• Connective tissue disorders: 51 days;
• Lower limb fractures: 62 days;
• Upper limb fracture: 57 days;
• Anxiety disorders: 41 days.
Once Fooled, Twice Vigilant
Now, Cadet looks for “red flags” in workers presenting with injuries that may result in leave time and a workers’ comp claim. For example, healthcare workers frequently present with shoulder injuries, a common and legitimate harm as a result of manually lifting patients, for example. But Cadet is in the “trust but verify” camp. She may ask some workers holding their shoulders in pain to lie on the exam table and please remove their shirt.
“They say they have severe shoulder pain, and they can’t work, and then they take off the shirt with no issue,” Cadet said. “Sometimes red flags are apparent on intake.”
A patient transporter visited her clinic with a chief complaint of cough after exposure to propane fumes. “As I take the full history, he says, ‘I had to wheel a homeless woman into the ER who arrived by taxi,’” Cadent recalled. “She had been burned because the propane tank she was using to warm her encampment exploded.”
The transporter started coughing and was sent to employee health for possible exposure to propane fumes. “His cardiopulmonary exam was normal,” Cadet said. “He was no longer coughing. I had seen this patient in clinic before, and could tell he was the type of worker that didn’t necessarily want to be at work. I comforted him in the fact that he was now asymptomatic, and he was more than likely well enough to go back to work. There had been no exposure to propane fumes.”
Any employee nurse probably has seen what Cadet calls “frequent flyers,” staff members who report frequent injuries or ailments.
“I’ve had patients engage the healthcare system at least twice per week for over a year for a variety of musculoskeletal injuries,” Cadet said. “Some of those are work-related, some are not work-related. This raises a red flag in my mind that they are a ‘power user’ of the system. It causes me to examine their presenting complaint more closely, to look for any indication that there’s an alternative motive behind their presentation to occ med.”
In such cases, Cadet maintains her calm, professional bedside manner, inferring no blame — and certainly not leveling any accusations to the worker. “Bedside manner is everything,” she said. “Good bedside manner conveys care and respect. Patients are more likely to hear you when they feel heard and respected. They’re more likely to trust your advice when they know that you care about them. They’re more likely to accept your ‘no’ because you’ve explained to them that this is not a personal attack.”
The most important aspect of managing healthcare worker injury and recovery is setting clear return-to-work expectations and a corresponding timeline. Most workers who are out six months or more are not likely to return.
“This can be a very hard conversation to have with workers because it can feel like we are telling them that they are not going to get what they want,” Cadet said. “We’re telling them that they don’t get to be off of work for eight months. In general, we want our patients to like us, and we want them to feel better. But sometimes, we’re not able to make them feel completely better, and to confess that seems like a reflection on the type of doctor or nurse practitioner we are. Many of us don’t like confrontation. We don’t want to deal with the patient’s negative emotions when they don’t get whatever it is that they want.”
When providers effectively manage a worker’s expectations of the return-to-work timeline, they can improve patient outcomes in productivity, save healthcare costs, report greater patient satisfaction, and gain a reputation as a value-based provider, Cadet noted.
Animal Lab Tech
In another case, a research animal tech worker reported hurting her back while bending over to open cages and pick up the animals. She still complained of back pain at week six, and an X-ray of the lumbar spine showed no acute or degenerative processes.
“I emphasize that sometimes the pain does not go away as we had hoped, but pain is not an indication to keep indefinite work restrictions in place, especially when there was no objective evidence of an injury” Cadet said. “I introduce the concept of tolerance. At our week eight follow-up, [the worker] says her symptoms are improving, but she still has pain. I empathize with her — we’re not heartless robots.”
Still, Cadet told the worker that due to the lack of objective findings on imaging or exams, work restrictions must be lifted. A third round of PT will be ordered but may not be granted by the insurance carrier because the previous rounds resulted in little improvement.
“As you know, utilization review is a process insurance companies use to verify the medical necessity of treatments ordered by providers,” Cadet said. “If they find there’s no medical necessity, they will deny payment for the treatment.”
The worker understood this because the expectations of treatment and duration have been emphasized.
“At her final follow-up, she had completed 18 sessions of PT and she was tolerating full duty,” Cadet recalled. “She even made moves to change her job, deciding ultimately that she couldn’t tolerate the discomfort she felt as a result of being an animal tech assistant. This isn’t a common outcome, but when it does occur, it’s a good thing. If workers feel that they can’t tolerate the pain, they can find a position that does not cause that discomfort.”
REFERENCES
- Association of Occupational Health Professionals in Healthcare. Managing worker expectations of the return-to-work timeline. April 4, 2023.
- Cullen L. The myth of workers’ compensation fraud. Frontline. May 29, 2000.
- Daitzman RJ. Feigning illness to avoid tasks: Making sense of psychosomatic illnesses. Psychology Today. July 26, 2021.
- U.S. Department of Labor. As workers’ injury and illness rates soar, US Department of Labor urges healthcare facilities, providers to employ effective safety, health programs. Feb. 8, 2022.
- Zaidel CS, Ethiraj RK, Berenji M, et al. Health care expenditures and length of disability across medical conditions. J Occup Environ Med 2018;60:631-636.
There are pressures in today’s healthcare environment to ensure injured or sick workers return to duty, but this must be balanced against their needed recovery time. It takes a delicate combination of compassion and skepticism — and no small amount of detective work — to make the right call.
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