I spoke to Paul Coburn about how he applies his background in physiotherapy to work disability management, an area he now has extensive experience in.  We met, during a half hour break in his busy schedule, outside the imposing building that houses the Transport Accident Commission and WorkSafe Victoria in central Melbourne.  Despite his time pressures, Paul was affable and passionate about sharing his experience in return to work management.  Like many in the field, he understands what works and what doesn't when treating workplace injuries and that if some simple practices were adopted it could prevent a lot of damage to people's lives and livelihood. 

Paul said he was working as a sports physiotherapist when he was recruited to join the WorkSafe's clinical panel by a colleague in the medical profession.    

“I wasn't really sure about it to start with, because it wasn't my base experience, my experience was much more in sport, but in fact…a lot of the principles were applicable…and it provided a different challenge in terms of managing patients with different types of motivation.”

The role of the WorkSafe Clinical Panel is ‘to conduct clinical reviews, provide clinical support to WorkSafe Agent claims staff, and professional support and advice to treating medical and healthcare professionals providing services to injured workers'.  When asked about the difficulties in engaging medical professionals in forward-thinking return to work practices, Paul distilled the wisdom of his many years' experience:

“We might discuss whether or not treatment is the most evidence based approach to the management of the patient, [or] whether the issues of return to work might be addressed in a different way.  In lots of cases the treaters… don't have the resources to deal with return to work, either they don't see a lot of return to work [patients], or they're not aware of what's available…return to work may make up only 2-3% of their patient population, so they don't necessarily know what the best thing to do is.”

“Primarily we start with the premise that treaters actually do care about the patients…but by the same token they're all quite busy.  They're under pressure, they don't really want to be told how to do their job because they are good at doing their job, so the way you've got to approach them is to…try and work with them in the management of the patient and not make it more complex or more difficult for them...but by the same token some of the treaters are practicing things that they were doing a long time ago, for lots of reasons, and things change… We really do need to work towards pushing them to adopt an evidence based approach”

“Most people think or feel that by removing someone from a dangerous environment or a dangerous source that you're actually doing something to help them…Treaters feel, as a carer, that they are helping people by removing them from the worksite.  What's missed is the detrimental effects on a person's health and wellbeing [caused] by not being at work and that you have to be quite specific in what you remove people from…Overall prolonged time off work, the evidence shows, is actually not in their best interest in terms of health, or wellbeing.  In a sporting situation…if someone gets injured, as much as possible you try to have them playing sport, but protecting whatever's injured, because for a sportsman not to be able to play their sport is distressing…you can manage people so that they recover and are participating in the workforce.”   

Changing beliefs in the community:

“Changing the community beliefs really involves using tools and methods that transcribe not just to patients, but to all stakeholders.  One means of doing that which we've used is a tool called the Clinical Framework for the delivery of services to injured workers (http://www.worksafe.vic.gov.au/wps/wcm/connect/WorkSafe/Home/Health+Care+Providers/Clinical+Resources/Clinical+Framework/).  The Clinical Framework basically talks about…the principles behind which you should be managing a patient.  We've used that tool not just with treaters, but also with patients, we've promoted it to agents…[and] people working in dispute management.  That's one form of broader management, but I think coupled with that you do need to talk to practitioners about individual cases…When you speak in generalities…people start to think about exceptions to the generalities, and its in application of those generalities to specific cases where people start to learn how [they] can be applied appropriately.”

Poor medical advice: the pointing of the bone:

“The most ridiculous treatment advice I've come across…is where treaters have viewed X-rays [and] told the patient that the X-ray…indicates that they have major damage in their spine and…[they] will be affected for the rest of their life.  Why that's ridiculous is we know that there is very little evidence for that in reality.  People can have…major…changes on their X-ray and have no impact on their function… The issue…is that once people have been told that they…tend to become worried that there is something wrong with them and it becomes a self-fulfilling prophecy.  It's a bit like the old story about Koori people having the ‘bone' pointed at them…Because the ‘bone' is pointed at them they then loose the will to live.  I think the X-ray is the modern day version of the ‘bone', and in fact the analogy is quite fitting because you're talking about the bones.  So you get the ‘bones' pointed at you and a lot of people loose the will to live.”

What's to be done?  What's the future of disability management?

“If employers accepted injuries and…work to communicate with both their employee and the treater then there'd be far less chronicity with injuries.  There's nothing worse for a patient who's got an injury [than] to feel like they have to prove that they're injured…Where we get to a point when treaters are 100% behind getting people back to work as soon as possible regardless of injury, being specific to the injury and realizing that there's so much a person can do, even if they do loose function in certain elements of their body they can still participate meaningfully…Finally, for workers and just the public in general to be a little more understanding of illness and injury…A lot of so-called illnesses are actually caused by inactivity and…as part of your rehabilitation you need to work through a degree of discomfort…With that sort of attitude they'll actually make good recoveries.”