Professor Ian Harris, an orthopedic surgeon and researcher from Sydney, led a team in reviewing the impact of compensation on surgical outcomes.  

The team looked at all the research papers assessing outcomes from surgery that noted whether the patient was treated under a compensation system or not. Across the 200 or so relevant studies, there was information on approximately 20,000 patient results. Approximately 7,000 were treated under a compensation system and 13,000 were not. 

Across the 20,000 cases they found that patients in compensable circumstances had about 4 times the chance of having a poor outcome as patients in non-compensable situations. Recovery after surgery was classified as satisfactory or unsatisfactory, based on the patient’s satisfaction and pain levels, on specific injury outcomes, and on the patient’s general health and function after surgery. Patients in compensable circumstances were less likely to report benefit from the surgery.

The results were consistent regardless of the type of illness or injury leading to the surgical intervention. It did not seem to matter whether the surgery was for a shoulder problem, a back injury, or for other conditions such as carpal tunnel.

The authors could not identify why outcomes were worse. However, we know from other studies that there are a number of factors that may influence the situation:

• Blame makes it hard to recover, so if you blame your employer for the situation the outcome is less likely to be satisfactory.
• Bureaucratic processes or an employer unhappy about having to accept responsibility for the costs of a case can set up a negative reaction and so reduce the success of surgical procedures.
• Compensation systems formalise return to work, and this can be at the expense of flexibility. When the employee and their supervisor trust each other and can work things out, simple conversations deal with issues that arise. When they don’t feel confident to do this, minor issues become problems. Employees are then more likely to stay off work, or if they are back at work, go off work. 
• Expectations about recovery have a major impact on outcomes. People in compensable are often concerned about their ability to return to work. They have less control over the whole situation, and it may be that their expectations about having a good outcome are lower, reducing the chances of successful recovery following surgery. 
• Delays in the employer or insurer agreeing to surgery may make a difference to outcomes, setting up a cycle with patients who are unhappy to start with, and less likely to report that they are satisfied later on. Having to prove that you have a condition emphasises the problem, and may influence the patient’s view of their condition.
• Health practitioners may treat people in compensable situations differently. We know that surgeons who have spinal surgery themselves return to work much more quickly than their patients. While they may return to work within a month themselves, they often mark patients off work for many months. And this is longer for compensable patients.  
• Medical practitioners often have a negative view towards a third party’s influence on the situation, and that can interfere with the treatment of the patient. Delays in treatment or denying coverage of treatments can have the doctor siding with the patient and keeping them off work (perhaps with the erroneous thought they are assisting the patient).
• Some specialists with excellent track records refuse to treat workers’ comp patients. If we are missing out on top specialists treating compensable patients, successful outcomes may be diminished.
• A desire to secure a lump sum payment may lead patients to report negative surgical outcomes. The larger the potential settlement of a case the greater the incentive to report that surgery has not helped.

Of the above factors, there are things we can do and things we cannot do to alter the situation. We can:

• Minimise bureaucratic delays in approving surgery.
• Give patients valid advice about what has contributed to their condition to minimise the chance that they will inappropriately blame their employer and thus jeopardise their own recovery.
• Provide a supportive environment that reduces frustration.
• Refrain from blaming the employee for developing the condition that necessitated surgical intervention. This is best achieved by training supervisors and other relevant workplace figures about the nature and treatment of musculoskeletal problems.

You would think it is in the interest of the system to encourage top surgeons back into the field but in many jurisdictions that seems a long shot.