Guidotti, Tee L. MD, MPH, DABT
Section Editor(s): Schwerha, Joseph J. MD, MPH; Department Editor
Dr Guidotti is an international consultant in health, safety, environment and sustainability with Medical Advisory Services, Rockville, MD, www.mas.md. E-mail: firstname.lastname@example.org. Dr Guidotti is a former President of ACOEM
The Occupational Medicine Forum is prepared by the ACOEM Occupational and Environmental Medical Practice Committee and does not necessarily represent an official ACOEM position. The Forum is intended for health professionals and is not intended to provide medical or legal advice, including illness prevention, diagnosis or treatment, or regulatory compliance. Such advice should be obtained directly from a physician and/or attorney. Inquiries and contributions to the Forum should be forwarded to Joseph J. Schwerha, MD, MPH by e-mail at email@example.com.
The short answer is by educating them over time, both in face-to-face sessions talking with them and by making every case a teaching moment. For some reason, the literature on this topic is very scanty. Nevertheless, some good tips are available from material on the internet, especially from institutions in the United Kingdom.1,2
If a worker's performance is slipping, could there be a medical problem? Is a worker fit for duty after a long recovery from a nonoccupational injury? Is an accommodation required for a disabled worker? Should a worker be offered help through an employee assistance program? Is a given workplace or exposure safe for a worker who is pregnant? Can a worker's care for a chronic disease, such as diabetes, be managed in the workplace to prevent frequent unnecessary absence from work? Does an employee qualify for retirement or disability pension on the basis of a chronic medical condition? Are special immunizations needed for this worker's duties? Is a worker's ill health possibly due to exposure at work?
Referrals to the occupational medicine service or a consulting occupational physician in the community are often vague, and the reasons for referral of employees are often unclear. Whether it is an internal referral from an operating unit in a company to their health/safety/environment department's occupational medicine service or an external referral to an occupational physician on contract or in the community, managers can get more out of the referral with a little preparation.1
Insurance companies learned this a long time ago, and referrals for independent medical evaluations are usually very specific and accompanied by the information the physician actually needs. On the other hand, internal referrals or referrals to an outside consulting occupational physician are less well organized and, frequently, the physician has to ask the worker “Why are you here?” That is not ideal, for anyone concerned.
It is particularly disheartening when supervisors or managers use the medical department as a form of punishment or threat, telling workers that they will have to undergo a medical evaluation if they do not improve their performance or attendance. Human resources departments are often the worst offenders because they sometimes use the medical department as a dumping ground for complicated cases or expect the occupational physician to create a medical justification for an action that should be a personnel decision. (No reference provided—you will not find this written down in many places!) The occupational medicine service should be a resource for problem solving, mutual benefit, protection, and prevention, not coercion or discipline.
Most managers simply do not know what questions to ask, where the lines are, and are unclear why the referral is being made, although they are the ones making it. The occupational medicine service or the occupational physician needs help to answer the questions that matter and to use time effectively—the time available for the encounter and the time the employee spends away from the job. Expectations of what the referral is intended to accomplish can be very different. Both are better served if the reason for the referral is explicit and understood by both sides.
Referrals by managers to the occupational physician are only appropriate when there is a management decision to be made. If the manager or supervisor is concerned about the individual's health for their own sake, it is preferable to suggest that the worker see their personal physician or a physician in their community in whom they have confidence.
Think of the referral as like being called into consultation by another physician. What is the essential question? What can be offered in terms of analysis of the problem (never the clinical diagnosis!)? What is the appropriate management of the problem? What solutions are available for particular problems?
Three elements are key to a satisfactory referral: professionalism, information, and communication.
* Professionalism. The manager must understand that the physician will respect confidentiality and abide by ethical standards. The manager is not entitled to information on the diagnosis of a condition or to the medical record of the worker. (See the ACOEM Code of Ethics, the ICOH International Code of Ethics for Occupational Health Professionals.3)
* Information. The manager cannot expect the physician to work in a vacuum and provide a useful consultation. The physician needs to know why the worker has been referred (an absence problem, suspected occupational disease, fitness for duty?), what occupational hazards there are on the job, and the specific job duties. The request needs to be accompanied by as much documentation as the situation requires.
* Communication. Without violating confidentiality, the supervisor or manager and the physician need to be free to discuss fitness for duty (Is the employee fit, unfit, or fit with certain accommodation?), what accommodation might be possible, when an employee is likely to be able to return to work, and what hazards might be present in the workplace.
Communication should be in both directions. The client manager has to articulate what is needed, and the occupational physician or other health profession has to provide an informative and useful consultation. This is much easier when proper vocabulary is used by the medical department. For example, a request for a “medical” is not appropriate, even if a “medical” is the colloquial term for an evaluation. “Medical” can mean anything. The physician should use correct terminology in conversation, such as preplacement evaluations, periodic health surveillance, etc, because in the long run, the correct terminology will be picked up by managers and, eventually, everyone will start talking the same language. Using correct language also impresses on managers that our field has its own logic, structure, and principles and that these services are not casual or made up.
It is too much to expect managers to know exactly what they want all the time. It is more important for managers simply to tell the medical department what they need and what the problem is than to specify a particular service by name. However, managers must be encouraged to provide the medical department with the basic information we need. The best way to do this is with a single window of contact and a form, which if at all possible should be on-line. The form, of course, should be treated as part of the confidential medical record.
Table 1 lists the essential information that should be captured before a referral. The National Health Service in the United Kingdom has a similar set of information items in their procedures for managers to use, when referring their employees for work-related questions.4 It has been known for many years, also from work in the UK (specifically Newcastle upon Tyne, where much of the best literature on this subject comes from), that early referral for long-term sickness absence results in better outcomes, closure of cases, and earlier return to work for those workers who are ultimately fit for duty.5
The form should be as simple as possible or busy managers will not use it. It should be optional, because many managers simply will not accept having it imposed on them, but the medical department should insist on at least a telephone request at which time the same form can be filled out for internal use. Whoever takes the information should be trained to capture the basic information and some sense of the agenda. Abusive practices, such as trying to find medical grounds to push somebody out the door, can often be prevented by simple education and a question or two that makes it clear that this is not an acceptable practice.
Having a referral system that is transparent, unambiguous, policy-driven, and documented leads to better medical opinions and protects all concerned. The occupational physician has a difficult task as it is in finding the essential balance between the interests of the worker and those of the employer. Anything that compromises trust in the physician or that creates confusion makes it that much harder to do the right thing. Anything that interferes with the timely delivery of an appropriate medical opinion, protective of confidentiality but responsive to the management question, makes the occupational physician less effective and erodes confidence in our services.
3. Guidottil TL. The Praeger Handbook of Occupational and Environmental Medicine. Santa Barbara: Praeger; 2010.
4. Harrison J, Woodhouse J, Dowson AJ. The management of occupational health by NHS trusts in the north of England. Occup Med (Lond). 1999;49:525–533.
5. Malcolm RM, Harrison J, Forster H. Effects of changing the pattern of sickness absence referrals in a local authority. Occup Med (Lond). 1993;43:211–215.