adverse health outcomes, and many GPs are reluctant to take on
workers compensation cases — the system is clearly in need of improvement
Stress is a normal part of everyday life, but it can lead to psychological strain
and difficulty coping with life's demands. Although a variety of non-specific
symptoms such as headaches, disturbed sleep, depression, anxiety,
irritability or substance misuse may result when individuals are stressed,
there is generally little evidence that such symptoms are a direct result
of particular stressful events. Rather, they are non-specific and can be
precipitated by a variety of other causes, including other stressors to
which the individual may be exposed.
The issue becomes more complex when stress occurs in the occupational
arena because of issues of confidentiality and the sometimes competing
interests of patients, insurers and employers. In addition, organisational
problems related to work stress, such as high absenteeism, high staff
turnover, industrial disputes and poor quality control (leading to inferior
products and reduced competitiveness for the organisation) may further
complicate matters.
In this issue of the Journal, the cross-sectional survey of Western Australian
general practitioners by Russell and Roach (page 367) attempts to start
gathering information on the variety of approaches taken by GPs when
faced with symptoms of anxiety which are apparently caused predominantly
by occupational stress.1 Obviously, the article has been written in the
context of a political agenda in Western Australia, with a desire by
some to consider accreditation for general practitioners in managing
work-related stress claims. This was clearly opposed by about 70%
of respondents to the survey.
The findings of Russell and Roach suggest that GPs with experience
in the practice of occupational medicine are less likely to recommend
time off work. Additionally, those who had knowledge of the specific
requirements for lodging a work-related stress claim (which is likely
to include those with experience in occupational medicine) were more
likely to recommend initiating a claim.
Many of the GPs surveyed were concerned about practising medicine
in a workers compensation environment, and the implications this has
for patient confidentiality. Many also reported reluctance to get
involved in the workers compensation system. Some of the reasons for
this include a lack of confidence in their knowledge of legislative
requirements for opening workers compensation claims and concerns
that such an approach has the potential to further compromise their
patients' health.
In Australia, whether a claim is eligible for compensation is determined by
the relevant insuring authority. While some jurisdictions have the option of
allowing payment of medical and rehabilitation expenses and reimbursement
of salary while claims are being determined, until a claim is accepted no
benefits are technically payable, and, if reimbursements have been paid, these
may have to be repaid if the claim is subsequently rejected. Thus, incurring
treatment expenses while the claim is being determined can have
substantial financial complications for an already stressed worker.
This is further compounded by the sometimes significant time delays in
the determination of some stress claims. For example, in South Australia
(which is the only jurisdiction from which I was able to obtain data),
500 claims with stress as the primary cause of injury were lodged in the
1998–99 financial year. It took an average of 77 days to determine whether
a claim was compensable or not; 223 claims were initially rejected,
but 88 of these were eventually accepted after litigation (H Woznitza,
Program Manager – Education, WorkCover Corporation SA, personal
communication).
There is no reason to expect that this sobering picture is substantially
different in other jurisdictions. Obviously, this uncertainty and tardiness
cannot assist the mental health of someone who already has a stress-
related illness.
As Russell and Roach note, guidelines support a therapeutic benefit from
early return to work,2 although the evidence for this is scanty. There is
some support for the benefits of early return to work in the South
Australian data. For claims lodged between July 1996 and 30 June 1998
in cases of occupational stress where there was an early return
to work the likelihood of patients requiring long term ongoing support was
reduced. However, these data need to be treated with caution because they
are not controlled for severity of illness.
Stress claims for which salary reimbursements were received from the
South Australian WorkCover Corporation between 1 July 1996 and
30 June 1998*
In contrast, there is good evidence to suggest that people who are injured
and claim compensation for the injury have poorer health outcomes than
those not involved in the compensation process.3-5
A recent report produced by the Australasian Faculty of Occupational
Medicine of the Royal Australasian College of Physicians highlighted the
deficiencies in knowledge in this area.5 In particular, research into causes
of poor health outcomes for individuals in the compensation system is
limited and inconclusive, and not enough is known of the effects of different
types of schemes or methods of case management.
Not so long ago in the Journal, Cameron outlined some of the technical and
ethical problems doctors face when working within the workers
compensation system framework.6 Issues of role confusion (gatekeeper
versus patient advocate), objectivity in the face of coercion, and patient
and insurer mistrust all contribute to many practitioners shying away
from workers compensation cases. These concerns were reflected in the
issues perceived by the GPs in the survey by Russell and Roach as barriers
to effective management of patients with work-related stress.1
So, what messages can be drawn? Given the recognised adverse health
outcomes that commonly occur after lodging a compensation claim, and
the obvious stress involved in the process, it is not surprising that many
general practitioners elected to temporise rather than immediately
commence a compensation claim.
However, patients have rights under workers compensation legislation
to receive benefits for work-related illness and injury. These benefits are
more generous than those available under the Medicare system
(eg, the payment of treatment from a psychologist is able to be
reimbursed through workers compensation). Indeed, claiming benefits
from Medicare for a workers compensation injury is specifically precluded.
There is also a need for systems that enable treatment to occur with
certainty of reimbursement of costs while claims are being determined
and disputed. Obviously, practitioners would benefit from increased
education and skills, and the proposed Western Australian accreditation
system may be one way to assist this process.
Increased education and skill sharing of all participants (including consumers
and the legal profession) in the compensation system may address some of the
concerns about the adversarial system. Another approach may be to change
the system itself, particularly by reducing its adversarial nature so that more
time and effort is available for patient care. Exploring solutions that recognise
"work stress" as a multifactorial problem, often with some of its origins outside
the workplace, may be a worthwhile approach. This would necessitate a
collaborative approach to managing work-related stress, with all
stakeholders contributing their particular skills and perspectives.
Finally, confidentiality issues in workers compensation stress claims remain
significant barriers in the minds of medical practitioners and their patients.
Clearly, there is a need for appropriate research strategies to examine and
address these issues systematically to optimise health outcomes in a
cost-effective way.
Refs:
Ian D Steven and E Michael Shanahan, MJA 2002; 176 (8): 363-364
Russell GM, Roach SM. Occupational stress: a survey of management in
general practice. Med J Aust 2002; 176: 367-370.
The Royal Australian College of General Practitioners WA Research Unit.
Stress, compensation and the general practitioner. Perth, Western Australia:
Workers Compensation and Rehabilitation Commission, 2000.
Cassidy DJ, Carroll LJ, Cote P, et al. Effect of eliminating compensation
for pain and suffering on the outcomes of insurance claims for whiplash
injury. N Engl J Med 2000; 342: 1179-1186.
Atlas SJ, Chang Y, Kammann E, et al. Long-term disability and return to
work among patients who have a herniated lumbar disc: the effect of
disability compensation. J Bone Joint Surg Am 2000; 82: 4-15.
The Australasian Faculty of Occupational Medicine, Royal Australasian
College of Physicians, Health Policy Unit. Compensable injuries and
health outcomes Sydney: RACP, 2001: 19-21.
Cameron SJ. Workers' compensation – what role the doctor?
Med J Aust
1996; 164; 26-27.
31 Jan 2002
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