Australian Doctor 3rd November 2023 3rd Nov 23 | Page 37

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Box 2 . Chance of returning to work

• If a person is off work for : — 20 days , the chance of getting back to work is 70 %. — 45 days , the chance of getting back to work is 50 %. — 70 days , the chance of getting back to work is 35 %. Source : Australian and New Zealand Consensus Statement on the Health Benefits of Work . Position Statement : Realising the Health Benefits of Work 2011 3

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The health benefits of work are also impacted by the way that GPs provide medical sickness certification .

However , in the medicolegal environment , medical practitioners need to be confident that the recommendations they make about an individual returning to work or , alternatively , recommending short- or longer-term medical restrictions , will be safe and in the best interests of their patients .

Over the past few decades , there has been a shift to a more positive view of work and health . Table 1 outlines several ways to alter thinking for both the GP and worker . 4

WHEN MAY GPs BE ASKED ABOUT THEIR PATIENTS ’ FITNESS FOR WORK ?

THERE are an increasing number of situations in which GPs may be asked to comment on their patients ’ fitness for work ( see box 3 ).

CONSENT

THE issue of informed consent ( see figure 3 ) is of critical importance . When providing or communicating an opinion on an individual ’ s medical fitness for work , aspects of that individual ’ s medical history , or at least the GP ’ s opinion on how that medical history may impact the individual ’ s work capacity , is typically being given to a third party , such as an insurer or employer .

In these cases , all the principles of informed consent ( see box 4 ) when releasing medical or personal information about a patient need to be followed . It is vital that the GP documents discussions about consent . In more complex situations , seek input from your medical indemnity insurer .

Garnett and Tobin authored a guidance note for GPs on providing patient information to employers , but it is the responsibility of the doctor to confirm that any advice is up to date and relevant to their jurisdiction . 5

WHAT IS FITNESS FOR WORK ?

THERE are various ways in which fitness for work may be defined and assessed . Patients , employers and treating GPs may have concerns about fitness for work in a variety of contexts . There may be concerns about the risk of further injury to the patient , how a patient may cope at work in the context of a chronic condition , or whether an individual ’ s illness or injury may present dangers to co-workers or members of the public .

One approach that has been proposed to characterise an individual patient ’ s work ability employs the concepts of risk , capacity and tolerance . 7

Under this model , risk is described as the chance or likelihood of injury or other harm to the patient or other individuals , were the patient to undertake

Figure 1 . Individuals may come into contact with hazardous substances at work .

Table 1 . A fundamental shift in thinking about work and health Current thinking

Symptoms mean injury or disease and incapacity for work

Work is a ‘ risk ’ and ( potentially ) harmful to health

Common health problems often lead to long-term incapacity

Therefore

Cure depends on healthcare ‘ Protect ’ worker / patient from work :

• Advice to stay off work until ‘ recovered ’

• Sick certification

• Risk assessment

Source : Waddell G , Aylward M 2010 4

particular work tasks or activities . For example , consider the case of an individual with uncontrolled seizures who works as a driver . In this situation , while the patient may physically be able to perform the task , there is a risk associated with sudden incapacitation ( these are known as safety-critical tasks ). In this case , such an individual should be restricted from performing these duties .

Capacity relates to what an individual is physically able to perform at a given time . For example , if an individual has adhesive capsulitis and is physically unable to lift their arm above chest height , then they do not have the capacity to perform a role which requires them to operate overhead controls . As capacity relates to characteristics such as strength and endurance , it is important to note that this is not a static concept and may change with training or deconditioning .

Change to Symptoms do not necessarily mean disability

Common health problems should be manageable

Work is generally healthy , therapeutic and the best form of rehabilitation Most common health problems can be accommodated at work Recognise the risk of long-term worklessness

Therefore

Advice and support to remain in work or return to work as soon as health condition permits ( even if there are still some symptoms ) and Safe , healthy , accommodating work

This requires all stakeholders onside

The notion of tolerance is more challenging . In this context , tolerance refers to a situation where an individual has the physical capacity to perform a role and the performance of that role does not result in any increased risk to themselves or others . However , the individual reports that work tasks result in symptoms such as pain or fatigue . These symptoms are complex , multifactorial and associated with biopsychosocial experiences ; there is rarely a way to objectively measure them or how they impact our patients .

Different practitioners have varied approaches to work certification . Some argue that formal work restrictions should not apply in cases where there is no demonstrable risk of injury and no lack of capacity . Others may certify work restrictions based upon self-reporting of tolerance . There is no correct answer , so consider an individual ’ s circumstances in each case .

Box 3 . Situations where a GP may be asked to comment about a patient ’ s fitness for work

• The request may come directly from the patient :

— They may attend requesting a medical certificate certifying them as unfit for work because of a temporary illness or injury , or may request a ‘ clearance certificate ’ at the cessation of a period of temporary ill health .

• Insurers may request information where a patient ’ s medical condition is being managed as a work-related condition , or under an insurance claim ( such as workers ’ compensation , income protection or compulsory third party ( CTP ) insurance ): — Such requests typically require medical practitioners not to simply state if a patient is fully fit or unfit for their usual work role , and also ask for an opinion as to what sorts of alternative or restricted duties the patient can perform .

• Requests for information may also come from a patient ’ s employer :

— Such requests may relate to a worker ’ s compensation claim , or a nonwork-related injury or illness that a patient has flagged is impacting their ability to perform their role .

— As with requests from insurers , these requests often seek the doctor ’ s opinion on appropriate alternative or restricted duties , and a prognosis for return to full duties ( see figure 2 ).

— As risk management is central to business structures , GPs may commonly be asked to provide an opinion as to whether there is a risk of a patient sustaining further injury or illness if they return to their previous role after their recovery . Many GPs find this situation extremely challenging , and it is a core part of the practice of occupational and environmental medicine .

MEDICAL STANDARDS AND JOB DESCRIPTIONS

THERE are several industries with legislated medical standards that all individuals in the industry are required to meet . In this situation , both the assessing GP and the worker have clear guidance on medical conditions that are considered acceptable or unacceptable in a given situation . Such legislated medical standards exist for industries including commercial ( and private ) vehicle drivers ( see figure 4A ), rail safety workers ( see figure 4B ), aviation safety workers and maritime workers . 8-11

There are also industries that do not have legislated medical standards but have industry-based guidelines . For example , many resource companies have developed these for individuals working on certain projects . They provide some guidance to the GP and the patient .

Box 4 . The principles of informed consent

For valid consent in a healthcare setting :

• The individual must have legal capacity .

• The consent must be voluntary .

• The consent must be specific .

• The consent must be informed ; that is , given with enough information about the risks and benefits , any alternative options , and they must have an opportunity to ask questions

Source : Australian Commission on Safety and Quality in Health Care 2020 6

There is a third situation , where there are no specific documented medical standards for the role . Employers may provide a job task analysis or job dictionary to assist the GP . These attempt to set out