Ian is an orthopaedic surgeon who became an academic, keen to research the impact of compensation on recovery from injury.

He noted that good things result from compensation and that good can also result from legal involvement in cases, as lawyers can help with the complications in the process. He found however that in his work as an orthopaedic surgeon, compensable patients were remarkably slow in their recovery.

He gave the example of a woman who had a picture frame fall on her leg. She had photographs of the two lacerations on her leg, and did not require hospitalisation at the time of the injury. By the time Ian saw her, he had trouble finding the location of the injury. The patient’s husband attended the interview with her and was being ‘supportive’. 

There were reports of the patient being unable to sleep and that her life had been deeply impacted through the injury. Ian felt that the woman’s feelings of pain were genuine, but the woman had been going through the compensation process for ten years. He believes that the length of time involved in the case is a major problem.

He believes that if the woman had had the painting fall on her in her own home, she would have been able to cope much better than if she was blaming someone else.

In another case, a woman had been through eight operations and at the end was worse than when she started.

During his thesis research, he looked into some historical cases. One of these was steel nib syndrome. It made it easier for people to write, but muscle cramp sometimes resulted. Doctors couldn’t work out the cause. Telegrapher’s cramp was similar. Then along came computer keyboards and RSI, with biopsies resulting. Ian believes that it was not the keyboards causing harm, but the systems causing harm.

Ian began with a meta-analysis on The Association between Compensation Status and Outcome after Surgery. He found that “Compensation status is associated with poor outcome after surgery. The effect is significant, clinically important, and consistent.”

He also looked at back pain, neck pain, psychological distress and general health after a motor vehicle accident or orthopaedic trauma. He found that the strongest predictors of a poor outcome were “making a claim and legal involvement” (either separately or together).

One argument is that these people are more injured and therefore more likely to make a claim, however Ian’s argument is that “these people perceive themselves to be more injured because of the situation that they’re in, and therefore are more likely to claim.”

He also found that the biggest predictor of making a claim or involving lawyers was socioeconomic status and NOT injury severity or pre-injury health. Further, all outcomes were worse for the compensated group, despite similar injuries.

He commented that the pain clinics are full of people with neck pain who are under the compensation system. People who are not under compensation are either, “suffering there in silence or they’re coping better.”

In NSW several years ago, workers compensation ceased covering people travelling to and from work. As a direct result, his personal income from his medical practice “plummeted”. Now however, “people are so much easier to treat. We just put the nail in and they go back to work. Sure, they might need to get a lift to work because they can’t drive the car but they’re happy to go to work. They seem happy to me. It was a nightmare getting people to work before. They would never return to work until they were 110% fit.”

A paradox exists between the aim of the compensation system (to help people) and the effect of the compensation system. Compensation certainly needs to be proportional to injury, but when this occurs there is an incentive to “up the injury”.

Of the “perverse incentives,” Ian believes that back pain is number one, and lumbar fusion surgery is increasing. Increases in direct costs and increases in compensation also provide an incentive. After treatment with back fusion, levels of impairment tend to go up by 20%. In fact, in research conducted in NSW on 500 patients who undertook spinal surgery within the workers compensation system, less than half returned to work in two years. 3% returned to pre-injury duties. 80% were still being treated with physiotherapy and opioids two years after the surgery.

At present, the rates of verifiable physical injury rates are falling, while non-verifiable, subjective ‘injury’ are rising. The compensation systems are spending more on whiplash than on quadriplegia. More is being spent on loss of libido than loss of limb. Ian believes this to be a waste of money and “it’s making people worse.”

While he doesn’t believe that the entire system should be dismantled, perhaps some parts should be. It may be worth looking at paying for results rather than treatment, and maybe compensate for initial and objective diagnoses only. The keys may be in reducing medicalisation through demanding evidence of injury and evidence that the treatment will work, and recognising and addressing harms and perverse incentives. While the system shouldn’t be dismantled, it can be made better.

The full ISCRR presentation can be found below.

Overview: Impact of compensation on the injured person - Professor Ian Harris, University of New South Wales from ISCRR on Vimeo.