I am a company doctor, working in a practice in a highly industrialised area of Melbourne with tourism, service, tertiary and manufacturing all booming on my doorstep.

The patients I care for are all from the local industry. When they develop a medical condition or sustain an injury whilst engaged in their work, I am engaged by the company. I specialise in dealing with musculoskeletal injuries and the vagaries of occupational rehabilitation.

Despite the best intentions of occupational health and safety professionals, the likelihood of injury in the course of employment is high, just as it is in life in general. It is therefore wise for an employer to have a contingency plan in place for dealing with injuries.

As a company doctor, I’m local, available and able to visit the workplace when the need arises. I’m certainly no less competent nor caring than the worker’s own choice of general practitioner. 

The party line sold to the uncertain worker is that their employer would be happy to work with me, settle my account promptly and would heed my opinion on matters concerning their worker’s condition and future return to the workforce. 

As altruistic as that may sound, a large proportion of my clientele first attend an appointment with me under great duress. There is a perception that I am a whistle-blower, a hired gun, and that I value the financial burden of the employer on a level that’s equal or greater than the well-being and wishes of the patient before me. Above all, I am not their chosen treater.

At a time when emotions are more than likely fresh and raw, it is sometimes very easy for a recently injured worker to allow their fears of manipulation by the system come to the fore. In short, they fear losing control of their own situation. That very basic human emotion is recognisable and understandable.

I (and the small smattering of other occupational physicians with whom I am familiar) are as proud of our work as any other doctor may be. We are driven by good outcomes and personally speaking I do not rest until I have done my utmost to achieve results that are the best that I can manage, within all that I can control.  The (few) failures, where despite my best efforts the injured worker doesn’t return gainfully to their occupation and/or their recreation, weigh heavily.

In occupational medicine, optimal outcomes can be unclear. There are many variables in play and many masters to serve. What complicates the occupational medical consultation for the doctor is the curse of hindsight. It may also take a long time to get to know a patient and to understand the degree to which they take responsibility for themselves.

If the worker sustains a medical impairment unrelated to their work, whilst recuperation does not always follow a predictable path, there is at least a great clarity about the surrounding issues. A condition is diagnosed, treatment is prescribed and there is generally sufficient sickness leave available to ensure that taking time away from work is a relatively uncomplicated experience.

If the workplace is implicated in the onset of a condition or injury, the dynamic changes tremendously and the occupational doctor is simultaneously responsible to at least three, and sometimes more, interested stakeholders.

Needless to say, the Hippocratic Oath still applies first and foremost, and I am often at great pains to reinforce to workers that they, as my patient, are my priority. They are also part of any decision-making process which involves them. 

In occupational medicine, more than in any other circumstance, the opinion of the doctor is subject to scrutiny. If I cannot justify recommendations that I make, then the decisions may be taken away from me, to the detriment of the worker.

During the initial injury management consultation with a new patient, ten minutes is invariably given over to a frank explanation of the worker’s compensation system. I try to explain what it means for them in a practical sense, and how it influences the decisions we must make together.  Although it may sound like a disclaimer to some, I assure them it isn’t. 

I try to gain an understanding of what their role at work actually entails, both in normality and in extreme circumstances. Details about the injury itself are of course important, but they are primarily to help me give a diagnosis and formulate a plan. Determination of liability is only a very minor consideration. 

I’m presently in a privileged position in that I’m usually able to take a little more time than a GP is afforded in my first meeting with an acutely injured worker. As such, it’s usually possible to discuss many of the issues pertaining to their injury and what may need to happen for their previous function and role to be restored to them. We may also discuss their wishes and fears, as well as addressing any questions which may have arisen. 

It often becomes clear at this early stage what attitude this injured party has to their job. This is often, but not always, a direct reflection of the culture at that particular employer.

UNWILLING PATIENTS

Some people who would not normally attend a health provider of any nature come hell or high water. They insist that they can work through their injury and it will most likely improve to normal without any intervention at all. They dislike fuss and hate to cause consternation. 

To the casual observer they would appear to be a dream-ticket for the occupational doctor to manage, but in reality they often require an advocate far more than those who feel far more comfortable in complaining. 

Many of the conditions we are considering in physical, primary or manufacturing industry work result from repetitive overuse. They tend to manifest early with warning symptoms, at which point it is vital to intervene to prevent progression to structural tissue damage which can then only be treated with surgery. 

Occupational doctors appear to stand in the way of those who feel able and have old-school values of diligence and hard work. This situation requires the greatest skills of negotiation and communication on the part of the company physician, in order to avoid the perception that there are hidden agendas.

WILLING PATIENTS

Surprisingly few patients show the polar opposite traits. These workers range in presentation from the merely entitled, through to the furious and litigious who will appear to stop at nothing in order to gain redress. 

Some believe it my duty to put their wishes above any other matter. When they learn that it is very rarely my opinion that the worker is unable to complete any task at all, they may employ various mechanisms to compel me as certifying doctor towards what they would most like to happen. This is often to have paid time away from their employment, whether medically justifiable or not. 

The most common ploy is to observe “…there’s nothing there for me to do…” and of course it’s easy to have sympathy with this position. Most people, I believe, genuinely like and feel passionate about their job. Indeed most specifically chose it due to the satisfaction derived from performing their role with competence. 

Ultimately, it is the task of the employer to interpret my recommendations as they see fit, as long as the employee is meaningfully occupied. Among the least gratifying of my cases have been those workers who appear to have been ‘put out to pasture’ once a restriction is introduced, fanning the flames of distrust in a workplace. 

Often a worker will introduce some moral leverage at this point, stating “…well, MY doctor would give me time off…you can’t be much of a doctor, if you won’t.” 

It can be very hard to stand for rules and standards that ultimately leave both parties dissatisfied. I have found that the trick is to engage in honest and responsible negotiation, ideally with all stakeholders present. 

In almost all cases, I have found that what injured workers want most of all is a plan of action. It is often possible to make a decision which the patient initially finds unpalatable, if I can explain and justify to them why it is ultimately best that they do attempt to continue working. I am accountable for this decision, and put a contingency in place for escalation, in the unlikely event that their condition deteriorates. 

The employer is also factored in to the equation. One of the tools I have at my disposal, if my recommendations are not being adhered to, is to recommend unfitness. I would implement this if I believe remaining in the workplace is detrimental to the worker’s condition. This, unsurprisingly, is often quite motivating.

MOST WORKERS

Most workers I encounter inhabit an area somewhere between these two extremes, mixed in with idiosyncrasies unique to their culture, their personality, their experiences and personal beliefs. 

Planning a return-to-work which is likely to succeed can be dependent upon taking account of the small details that contribute to satisfaction in the workplace. The occupational doctor is well-advised to explore these in as much depth as possible. This can counter the failed progression in duties and hours of work which can result in a loss of faith in the doctor’s opinion, both from the employer and the injured worker alike. It is vital that medical consultation never be rushed or viewed as a chore. 

After establishing a treatment plan, I will recommend that we make contact with the designated contact person from the employer, to discuss the condition and its impact. Almost any matter that might otherwise be assumed to be trifling can present itself as a significant bone of contention, so emotive is the matter of employment to some people. The molehill can become the mountain, but communication can make it plain. 

Some situations are simply beyond redemption and cannot, for love nor money, be rectified, but most troubles can at least be addressed and improved through skilled mediation, eyes that are open and an ear that is willing. Time must be taken to address concerns and take them seriously. 

SUMMARY

So in summary, I cannot (and never do) promise employers an immediate cure of their workers condition, nor a return to work that is unrealistic in timescale, fraught and likely to fail. 

On the contrary, I often remark to the attending return-to-work co-ordinator that “…I feel as your preferred medical provider, I represent you and am engaged to provide you with advice that it accurate and realistic…” 

Sometimes, the injured worker will not have the capacity to undertake their work, it is as simple as that. I never promise to make recommendations that are, simply put, unethical. But what I do guarantee is that I will be decent, responsible, available and above all, will stand for the medicine.

The occupational doctor is a negotiator, facilitator, advocate, educator and confidante. They are also hopefully a skilled, dedicated and compassionate physician. 

It’s a little known and (I think) under-appreciated role….and I wouldn’t swap it for anything.