Designated Guessers

Talked the other day with a doctor who works for a large workers' compensation carrier.  He's been asked to design and teach a course for physicians on how to set work restrictions and limitations.  He hesitated and stammered a bit and then confessed that he's realized that the emperor has no clothes in this area  -- that in fact no doctor (not one) REALLY knows how to do this accurately (in advance) because there is little or no evidence-based science on this topic, nor are there any studies supporting any of the specific estimates that the doctors make about work capacity.   In fact, the few studies there have been either refute or fail to address the predictive accuracy of the methods in common use.

So, the doctor from the insurance company and I laughed ruefully, and I found myself describing the doctors as "designated guessers."  Someone's simply gotta give advice to workers, to their employers, to benefits claims adjudicators and sometimes the courts about what an injured or ill person should avoid and what they can do safely.  I suppose it's actually better to have doctors doing the guessing than carpentry supervisors or benefits clerks.  At least the doctors have been trained in anatomy, physiology, and they have watched lots of people get sick and then heal and get better.   Orthopedists and occupational physicians (those who treat lots of work-related injuries) are more practiced at making these SWAGs (scientific wild-**sed guesses) than most other doctors are.  But they are still making guesses.  What's really weird is how quickly these guesses become the "revealed truth" written in stone.

Bluntly, doctors are being asked to predict the future, and to predict performance based on fragmentary knowledge of objective medical/physical factors only in an area where motivation, cultural and personal beliefs, individual tolerance for discomfort and fatigue, environmental and emotional suppport, skill/training/expertise, natural ability, and many other non-medical factors play a major role in what actually happens.  Realistically, the best way to tell if someone can do a job safely and comfortably is to let them try doing it, assuming they want to succeed.  Sadly, retrospective advice is not what is usually required, and not every worker wants to succeed at the tasks.   And, the fact that someone has been safe/comfortable "so far" is not a guarantee that they will continue to be so.

Studies have shown that doctors' advice tracks more closely with their own beliefs about the value of work, how to behave when ill, and the hazards of activity in general than with any factual information.  And, in the lone study of which I am aware that addressed the issue of the predictive ability of functional capacity evaluations (FCEs), they were found NOT useful in predicting people's actual ability to perform successfully at work. 

Things will get better if we start from the reality that the doctor is guessing.  How can we help the doctor make the best quality guess? 

Wouldn't you think that the best way to figure out what workers can do is to ask them?   But what about medical risks in the situation that the workers can't anticipate because they don't understand the process of wound healing or the side effects of their medications or overestimate their stamina or length of recuperation?  This is where we really do need medical expertise, but the problem is that almost all doctors have never been taught either a logical or a standard method for figuring these issues out (and there IS no generally-accepted method yet).  Also, as pointed out on page 11 of the new ACOEM Guideline on Preventing Needless Work Disabiltiy by Helping People Stay Employed, there is NO authoritative and comprehensive resource available that lists the medical risks for workers with particular diseases or in particular work environments or trades.  (The new book A Physicians Guide to Return to Work by Talmage and Melhorn from the AMA Press is the closest approximation available.)

Another reason why employers/payers don't want to ask the workers what they can do is that they don't trust the workers to be truthful.   This is where things REALLY get complicated.  Unfortunately, the doctors' ususal reaction to being put on the spot is .. . . . to ask the workers what they can do!  So what good did it do to put the doctor in the middle?

If we assume for the moment that ill-prepared doctors around the country (and world, for that matter) are being pressed into service as the "designated guessers", then it seems to me that it would make sense:

1. to train as many of them as possible how to think through these situations, and to develop some standard models to teach them.  I've been giving basic lectures on this topic to clinicians who laugh with relief when I acknowledge that we're all making guesses, then pay rapt attention and are grateful for the material -- they feel awful about having to make these decisions day in and day out without any conceptual or clinical model to rely on.  Remember, these are people who went into their chosen profession because they like feeling expert and masterful.

2.  for the other parties with personal knowledge about the situation to help the doctor as much as possible -- to contribute the data and background information they have, to point out aspects of the situation that are of concern or seem pertinent, etc. 

3.  to treat the doctor's advice as a tentative first cut, instead of the truth written in stone.  If the doctor's opinion seems off base to others with personal knowledge of the situation or experience in giving guidance in similar-seeming situations, then provide that data in a helpful manner to the doctor and ask for a re-thinking in light of the additional information.  Or, even better, have a conversation and work together in dialogue instead of sending formal missives back and forth to resolve the issue.

If we all start thinking of the stay-at-work and return-to-work process as a team sport with team members in different sectors of society, and if we have compassion for the doctors who are doing their best with an impossible task, and start collaborating on putting together a complete picture of the situation, the decisions that get made will at least be (a) based on richer data about the actual situation at hand and (b) more credible to all parties because they have all played a role in developing it.

Comments

[Anne Cherry]

Oh Jennifer - this is SPOT ON! Had me laughing out loud!

I spend inordinate amounts of time trying to explain SWAGs and Designated Guesser roles to employers, insurers and injured workers. Can I use these terms? (correctly referenced to you, of course!)

Totally agree with you - let's work together as an expert TEAM rather than "bag" (Australian slang for "bad mouth") the experts when they are unable to respond to questions outside their expertise!

Expect to see a large number of 'hits' to your blog from Australia!

[David Milecki, MB,BS, Dip. Occ. Hlth., Principal, Injury Net]

Great piece Jennifer. When justifying work certificates and looking me in the eye, I usually feel that that the treating doctor is looking rather anxious wondering if anyone will pick them up on the "bluff" that is their medical restrictions. Signing a document with an MD does not make the contents in any way scientific or even reaasonable.

Regards,

David