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Commentary and Perspective

“What We Have Here Is a Failure to Communicate”

Commentary on an article by Jan Eric Vanderhooft, MD, FAAOS: “Ineffective Communication: The Uninformed Injured Worker”

Talmage, James Byron MD1,a

Author Information
The Journal of Bone and Joint Surgery: October 6, 2021 - Volume 103 - Issue 19 - p e77
doi: 10.2106/JBJS.21.00721


In this article, Dr. Vanderhooft publishes his series of 556 injured workers seen for either an independent medical examination or a permanent impairment rating in the Utah Workers’ Compensation system. He reports that very few (3.6%) of these injured workers understood the legal principles underlying their Workers’ Compensation claim, despite a state mandate that each injured worker be given or sent a pamphlet explaining these principles.

Although this is an important issue, readers need to assess the generalizability of any research publication. In this article, selection bias precludes generalizability.

Dr. Vanderhooft acknowledges that the study is limited in that this case series is composed entirely of claimants in the Utah Workers’ Compensation system and includes only those with a more serious injury that required a second opinion or permanent impairment rating. The author notes that each state has its own Workers’ Compensation system with varying statutes and rules, and there are also several federal government Workers’ Compensation systems. A recent review1 highlighted the variability in Workers’ Compensation systems in America.

In addition, in this series of more complex injury cases, only 7 (1%) of 556 claimants in Utah were represented by an attorney; this is an unusually low rate. Tao et al.2 reported the experience of a single nationwide American employer with 13% of all “lost-time” claimants (not just those with more complex claims) having an attorney in states where the employer cannot direct medical care and 17% to 24% of claimants in states where employers have at least some choice of the treating provider. Attorneys typically believe that it is their role to advise clients of their legal rights (principles) under Workers’ Compensation law and that this is not a physician role. Thus, Utah’s experience does not likely generalize to the situation in most readers’ practices.

Workers’ Compensation systems typically expect physicians to diagnose and treat injured workers and to respond to questions posed by employers, insurers, and state agencies based on medical issues. Neither of the summaries3,4 of Workers’ Compensation written for physicians suggests that informing injured workers of the legal principles underlying their claims is a physician role.

Although this report of one physician’s Utah experience is interesting but does not generalize, it does point out one of several reasons for the literature-documented difference in the surgical outcomes of patients with Workers’ Compensation compared with the same surgical treatment of the same diagnosis under general health insurance. Although Dr. Vanderhooft has cited 4 references on this topic, there are hundreds of publications and several systematic reviews5-7 that cover this issue.

There is no validated instrument if an orthopaedist wishes to screen patients for confusion about their rights under the Workers’ Compensation system. However, if the confusion resulted in anger in the injured worker, there is a validated simple questionnaire to screen for anger hindering recovery that is available in many languages and that, according to a Google Scholar search, has been validated in many cultures. This would detect both anger directed at the employer over the circumstances that led to the injury and anger directed toward the Workers’ Compensation system with its statutes, rules, and principles. It would not detect workers confused by the system who were not angry. Dr. Vanderhooft describes a few workers who were angry enough to displace their anger onto the examining physician.

In summary, this article reminds us all of the quote often attributed (perhaps falsely8) to Sir William Osler, “It is more important to know what kind of patient has the disease than what kind of disease the patient has.”


1. Taylor TK, Mueller KL, Blink RC, McKinney DW, Silverman W, Das R; ACOEM Work Group on Workers’ Compensation. Workers’ Compensation elements in different jurisdictions in the United States. J Occup Environ Med. 2020 Dec;62(12):e760-1-2.
2. Tao XG, Leung N, Kalia N, Lavin RA, Yuspeh L, Bernacki EJ. Is employer-directed medical care associated with decreased Workers’ Compensation claim costs? J Occup Environ Med. 2018 May;60(5):e232-1-2.
3. Bible JE, Spengler DM, Mir HR. A primer for Workers’ Compensation. Spine J. 2014 Jul 1;14(7):1325-1-2. Epub 2014 Jan 23.
4. Daniels AH, Kuris EO, Palumbo MA. The role of the orthopaedic surgeon in Workers’ Compensation cases. J Am Acad Orthop Surg. 2017 Mar;25(3):e45-1-2.
5. Harris I, Mulford J, Solomon M, van Gelder JM, Young J. Association between compensation status and outcome after surgery: a meta-analysis. JAMA. 2005 Apr 6;293(13):1644-1-2.
6. Cheriyan T, Harris B, Cheriyan J, Lafage V, Spivak JM, Bendo JA, Errico TJ, Goldstein JA. Association between compensation status and outcomes in spine surgery: a meta-analysis of 31 studies. Spine J. 2015 Dec 1;15(12):2564-1-2. Epub 2015 Sep 30.
7. Fujihara Y, Shauver MJ, Lark ME, Zhong L, Chung KC. The effect of Workers’ Compensation on outcome measurement methods after upper extremity surgery: a systematic review and meta-analysis. Plast Reconstr Surg. 2017 Apr;139(4):923-1-2.
8. Quote Investigator. It is quite as important to know what kind of a patient the disease has got as to know what kind of a disease the patient has got. Accessed 2021 May 31.

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