The fetish of the objective finding

The structure and process of workers' compensation systems and the role of doctors: A comparison of Ontario and Québec

BACKGROUND

This study sought to identify impacts of compensation system characteristics on doctors in Québec and Ontario.

METHODS

(i) Legal analysis; (ii) Qualitative methods applied to documentation and individual and group interviews with doctors (34) and other system participants (31); and (iii) Inter-jurisdictional transdisciplinary analysis involving cross-disciplinary comparative and integrative analysis of policy contexts, qualitative data, and the relationship between the two.

RESULTS

In both jurisdictions the compensation board controlled decisions on work-relatedness and doctors perceived the bureaucratic process negatively. Gatekeeping roles differed between jurisdictions both in initial adjudication and in dispute processes. Québec legislation gives greater weight to the opinion of the treating physician. These differences affected doctors' experiences.

CONCLUSIONS

Policy-makers should contextualize the sources of the "evidence" they rely on from intervention research because findings may reflect a system rather than an intervention effect. Researchers should consider policy contexts to both adequately design a study and interpret their results. Am. J. Ind. Med. 59:1070-1086, 2016. © 2016 Wiley Periodicals, Inc.

Pain and Prejudice: Does Collecting Information From the Standpoint of Exposed Workers Improve Scientific Examination of Work-Related Musculoskeletal Disorders?

The meaning, feasibility, and importance of scientific objectivity have been debated among public health scientists. The debate is particularly relevant to occupational health, because of frequent opposition between employer and worker interests. This article suggests that the concept of standpoint (J. Eakin) may be more useful than that of objectivity in framing discussion of work-related musculoskeletal disorders. Studies done from a "worker" standpoint can, for example, investigate and characterize environmental risk factors for work-related musculoskeletal disorders, while studies from an "employer" standpoint may concentrate on identifying individual workers likely to report work-related musculoskeletal disorders or those for whom consequences of work-related musculoskeletal disorders are more severe. Within "worker" standpoints, a distinction between "high-prestige worker" and "lower-prestige worker" standpoints can be identified in the current scientific debate about the health costs and benefits of prolonged standing vs prolonged sitting at work. Contact with workers, particularly lower-prestige workers, is critical to developing and sustaining a worker-based standpoint among researchers in occupational health. This contact can be facilitated by formal collaborations between universities and unions or other community groups.

Medical Evaluation of Work-related Illness: Evaluations by a Treating Occupational Medicine Specialist and by Independent Medical Examiners Compared

Treating physicians' and independent medical examiners' (IMEs') opinions were compared to identify differences of opinion and to develop a basis for understanding the differences. Twenty-three patients of an occupational health center (OHC) who had been examined by an IME were studied. OHC and IME opinions regarding diagnosis, work-relatedness, treatment recommendations, and disability assessment were categorized by degree of agreement. There was agreement on all four issues for only one patient. Opinions were most divergent with regard to disability assessment and least divergent with regard to diagnosis. Disagreement was unidirectional: the IMEs made fewer diagnoses, deemed fewer illnesses work-related, made fewer treatment recommendations, and assessed lower levels of disability than the OHC examiners. The results suggest that differences in opinion between the OHC and IMEs are due to differences in perspective, rather than skill or training.

More than meets the eye: social, economic, and emotional impacts of work-related injury and illness

The impact of an occupational illness or injury on an injured worker can be severe. This study assessed several dimensions of the impact on a group of 50 injured workers, all patients at an Occupational Health Center. The dimensions assessed included aspects of access to health care, support from treating physicians in obtaining Workers' Compensation benefits, financial impacts, the role of attorneys and "Independent Medical Examiners," and the impact on mental health. Many reported that their treating physician did not want to become involved in Workers' Compensation, despite indicating a belief that the health condition was work-related. The financial impacts of a work-related diagnosis were particularly striking, with respondents reporting that they were burdened both with costs directly related to the medical care of their condition, and with coping with ongoing general expenses on a reduced income. Many respondents reported depleting savings, borrowing money, taking out retirement funds, and declaring bankruptcy in efforts to cope. Emotionally, respondents almost universally reported their diagnosis and related issues were associated with depression, anxiety, and loss of identity and self-worth. This study demonstrates how a work-related injury or illness can extend far beyond the physical impact for injured workers. Existing systems fail to adequately compensate or rehabilitate injured workers, leaving them to their own devices to deal with their losses, medical or otherwise.

Occupational medicine: the case for reform

The specialty of occupational medicine is in peril, in large part because of its reliance on financing by industry, which has powerful incentives to limit costs and to favor physicians who are useful to their employers. Occupational physicians generally practice within the framework of the workers' compensation system. Serious flaws in the incentive structure of workers' compensation constrain objectivity in their practice. Under present law they are unavoidably subject to perverse influences from employers and insurance companies. A fundamental reform of workers' compensation law and practice is urgently needed to separate occupational physicians from the control of employers and workers' compensation insurers, whose interests should not be allowed to override the physicians' integrity or to compromise the specialty.

Occupational medicine: toward a worker/patient empowerment approach to occupational illness

Clinicians practicing occupational medicine are increasingly confronted with patients who have complex illnesses with chronic nonspecific symptoms. Most clinicians use the traditional tools of biomedicine to diagnose and treat the illness, determine etiology, and assess disability. This article argues that the biomedical approach is inadequate to effectively evaluate and treat occupational illness. After reviewing several critiques of biomedicine, including biopsychosocial, feminist, class, and critical theory/postmodern perspectives, the author offers an alternative approach that builds on aspects of these perspectives as well as the "popular education" work of Paulo Freire. Constraints on, and possibilities for, the development of an alternative approach that attempts to build patients' capacities for transformative action are explored.

Occupational injury and illness surveillance: conceptual filters explain underreporting

Occupational health surveillance data are key to effective intervention. However, the US Bureau of Labor Statistics survey significantly underestimates the incidence of work-related injuries and illnesses. Researchers supplement these statistics with data from other systems not designed for surveillance. The authors apply the filter model of Webb et al. to underreporting by the Bureau of Labor Statistics, workers' compensation wage-replacement documents, physician reporting systems, and medical records of treatment charged to workers' compensation. Mechanisms are described for the loss of cases at successive steps of documentation. Empirical findings indicate that workers repeatedly risk adverse consequences for attempting to complete these steps, while systems for ensuring their completion are weak or absent.