“So many out-of-the-way things had happened lately,” Lewis Carroll tells us in his mind-bending children’s classic, “that Alice had begun to think that very few things indeed were really impossible.”

As an occupational SuperDoc, I can sometimes identify with poor old Alice in Wonderland. I assess people with work injuries. It’s not always easy. Some days, I have a run of people with straightforward conditions. When this happens, they – and the system – need clear advice about what can be done to help them rehabilitate effectively and efficiently, and I’m happy to oblige.

Other days are not so straightforward. In fact, I sometimes feel as though I’ve tumbled straight down the rabbit hole, into a topsy turvy land where the laws of logic have gotten twisted, and the characters I encounter simply do not behave as expected.

A few days ago, I saw several people who had been within the compensation system for eight to ten years. Two of the people on that day were overtly hostile to the system, describing their experience as being on a merry-go-round – and they didn’t mean that as a compliment. My job was made difficult because they were reluctant to provide information about their circumstances.  Based on past experiences, there may have been legitimate reasons for this reticence, but that doesn’t help me help them. RTW is a collaborative process, and every SuperDoc needs a side-kick!  When the patient just won’t spill the beans you try your best, but it’s difficult. Which puts me in a speculative frame of mind…

Sometimes, as I listen to people’s stories and observe their behaviour, I start to wonder about the events and experiences that have contributed to their ill-health. 

Recently, I saw a 45-year-old with back pain and anxiety. He was outside the compensation system but was attending for an assessment regarding incapacity benefits.   Despite receiving significant support from family members, he had struggled for five years with disabling anxiety. It was hard for him to put a sentence together. He seemed to have come from a good family, and there was no obvious experience that had caused his anxiety. By the end of the consultation, I was completely bewildered. How could a person’s life get to that point? How could an individual struggle like that for no clear reason?

As fate would have it, the next person I saw was a woman who had had a back problem for eight years.  From a medical perspective, there was little out of the ordinary about her back condition.   Her claim had initially been investigated. Brief return to work trials had been unsuccessful.  She had been seeing a psychologist for four years and was seeing a masseur twice a week, as well as an osteopath. The treatment helped for a day, but the benefits quickly subsided. She was also being provided with four hours of home help a week, as well as fortnightly gardening services. 

Three years ago she’d requested a new mattress which was provided after the matter went through a dispute resolution process.   More recently, she had requested an electric recliner chair to assist her move from the seated to the standing position, as well as a high backed chair for the dining room table. Quite a wish-list, isn’t it?! 

Again, I left the assessment bewildered at how the situation could get to that point, for a relatively uncomplicated back problem. 

Most of the time, I remind myself that patients who are asked to come for an assessment are the ones who are not doing well. It’s those who are not getting better, or those who remain in the system who are asked to come for review.  

These patients, at the most difficult end of the spectrum, are major challenges. How, I ask myself, can their treating doctors, claims managers, or those around them, alter the course of the path they are travelling down? How can we stop them from falling down the rabbit hole?