Every month or so, I see a new patient who has been referred to a particular spinal specialist. I’ll typically become involved in cases like this when an insurer or company wants an independent opinion on the diagnosis, and management and input on the person’s work capacity.

As soon as I see this particular specialist’s letterhead at the top of the patient’s scan report, my heart sinks. Despite all my best intentions, I know this has turned into a game. Rehabilitation endeavours are going to be a waste of time.

Though he no longer performs surgery, this spinal specialist has a wide referral base from around Melbourne and Victoria. His reputation is well-known to those who work in the field.

His pattern of cases has a remarkable consistency. They usually involve middle aged males from manufacturing environments. The injured person is generally off work, but if they are back it’s only for a few hours a week on very light duties. There are no signs of positive return to work occurring and the employee frequently declares their unhappiness or resentment about how they have been treated by someone from within the workplace.

Here’s what usually happens: the patient presents with a back complaint, so immediately the specialist sends the patient for further investigations. In the past, that involved a discogram - even though at the time other practitioners had stopped doing them about a decade ago. In the last few years it has become an MRI scan.

Then, patients are generally advised that they have a severe back problem, are counselled against doing anything manual and are told their back problem is as a result of their job.

There is no connection between medical evidence about back problems and the advice given. In fact, the advice given is about as far from best practice as you can get.

Why does this happen?

The most likely scenario is that patients are told by others, or their lawyers, that this is the doctor to go to if they want to pursue a legal claim. There are only a handful of doctors in this vein, yet a handful in each jurisdiction is enough to compromise the entire compensation and rehabilitation process. Some systems have tried hard to weed these practitioners out, but vested interests have continued to win the day.

How should dedicated return to work professionals deal with this situation? How will the system win?

The damage done is broader than the difficulty in dealing with a single case. It is demoralising for all involved and derails the entire process of rehabilitation. We docs lose credibility as a whole every time a practitioner such as this works against the spirit of the system.

Once you see a person attending this doctor, you essentially know you're wasting your time. Perhaps the person has a path which has been predetermined and is simply being supported by the specialist's certificate or letter. Perhaps the specialist has influenced their thinking. It makes me wonder when the diagnosis of disc damage is provided a little too early and with a bit much over-confidence by the patient.

How can we win?

The first and most evident answer is to prevent the problem in the first place. If a disgruntled employee is the type to find a doctor to support their chosen path, the best approach is to avoid the person becoming disgruntled in the first place.

The second option is to gather evidence to support good practice. Set up an excellent rehabilitation programme and gather evidence on its success, so that the quality of the rehabilitation programme and good communication is clear for all to see. Persuade potentially problematic employees that rehabilitation is the best outcome for all involved.

Finally, if the case is moving down the legal path, find an aggressive barrister who understands what appropriate management of back problems is. Make sure the doctor's out of date, inappropriate advice and opinion is put under intense and aggressive scrutiny. Toxic doctors have no place improving the rehabilitation and return to work process.

“It’s much more important to know what sort of person has the disease than what sort of disease the person has.” - Sir William Ostler, 1896.