Abstract
BACKGROUND:
Physicians working in a tertiary care injured worker clinic are faced with clinical decision-making that must balance the needs of patients and society in managing complex clinical problems that are complicated by the work-workplace context.
OBJECTIVE:
The purpose of this study is to describe and characterize the decision-making process of upper extremity specialized surgeons when managing injured workers within a specialized worker’s compensation clinic.
METHOD:
Surgeons were interviewed in a semi-structured manner. Following each interview, the surgeon was also observed in a clinic visit during a new patient assessment, allowing observation of the interactional patterns between surgeon and patient, and comparison of the process described in the interview to what actually occurred during clinic visits.
RESULTS:
The primary central theme emerging from the surgeon interviews and the clinical observation was the focus on the importance of comprehensive assessment to make the first critical decision: an accurate diagnosis. Two subthemes were also found. The first of these involved the decision whether to proceed to management strategies or to continue with further investigation if the correct diagnosis is uncertain. Once the central theme of diagnosis was achieved, a second subtheme was highlighted; selecting appropriate management options, given the complexities of managing the injured worker, the workplace, and the compensation board.
CONCLUSIONS:
This study illustrates that upper extremity surgeons rely on their training and experience with upper extremity conditions to follow a sequential but iterative decision-making process to provide a more definitive diagnosis and treatment plan for workers with injuries that are often complex. The surgeons are challenged by the context which takes them out of their familiar zone of typical clinical practice to deal with the interactions between the injury, worker, work, workplace and insurer.
Introduction
Provision of care to injured workers often occurs in a parallel funding system to the healthcare provided to the general population. For the most part, this is intended to provide equivalent access and quality of care for workers with injuries to that provided to the general population. The Workplace Safety and Insurance Board (WSIB) is a government agency that oversees workplace safety and training, disability benefits, and health care for injured workers in Ontario, Canada.
The WSIB has established several specialty clinics that are designed to deliver consultation and/or treatment services by expert clinicians to populations that have unique health conditions, or represent a particularly challenging problem from a case management perspective. The WSIB Upper Extremity Specialty Clinic at the Hand and Upper Limb Centre (HULC) at St. Joseph’s Health Care, London, is one of these. This clinic serves a large segment of Southwestern Ontario, where a largely industrial work environment contributes to a high prevalence of work-related injuries [1, 2]. At this clinic, orthopaedic and plastic surgeons diagnose and treat patients at the request of the WSIB. Because these patients often represent complex clinical dilemmas and have seen multiple practitioners with conflicting diagnoses or having failed traditional approaches [3], and because of the complexity of considering both clinical and return to work considerations, these clinical consultations represent unique and complex decision-making for surgeons.
Many physicians feel uncomfortable in the role of governing the patient’s return to work program [4, 5]. It is generally accepted that physicians are most comfortable when working within the scope of traditional medical training. This includes focusing on disease factors, anatomical pathology, and the range of treatment modalities that can ameliorate these. Active governance of return to work does not necessarily fall within this scope, nor is it the focus of most clinical encounters outside of this clinic. The surgeons at the HULC WSIB clinic are being asked (and paid) by an insurer to see patients and make decisions on both medical management and return to work. This is in contrast to other clinical settings in this region, wherein funding is provided through a single-payer government system, and the funding organization does not become involved in return to work decisions. Further, the medical specialty that is focused on upper extremity musculoskeletal conditions includes orthopedic and plastic surgery trained surgeons who have gone on to specialty training related to the upper extremity. The majority of focus in surgical training would be on upper extremity pathophysiology, surgical decision-making and techniques. Specialty trained surgeons are actually more likely to be involved in teaching and research, and less likely to be involved in ability-to-work evaluations [6]. The WSIB upper extremity specialty clinic places these surgeons in a unique situation where they must make decisions that draws upon their unique medical knowledge while balancing the potentially conflicting interests of the patient, insurer, employer and society.
The purpose of this study is to describe and characterize the decision-making process of the HULC WSIB surgeons when managing injured workers. Specifically, this study attempts to identify the methods and tools used by surgeons to assess and manage injured workers.
Methods
Participants
This study was approved by the University of Western Ontario Research Ethics Board. Nine surgeons who practice in the HULC WSIB clinic at the Roth McFarlane Hand & Upper Limb Centre agreed to participate in the study. All participants were fellowship-trained orthopaedic or plastic surgeons, with at least five years of practice experience, and varying areas of clinical interest and expertise within the upper extremity (Appendix 1). At the time of the interviews, the WSIB upper extremity specialty clinic was approximately three years old. Thus, all of the physicians interviewed had three years’ experience within this specialized environment.
Data collection and analysis
Data collection for this study consisted of two components. Initially, each of the nine surgeons was interviewed by one of the authors (AK) in a semi-structured manner. A common set of core questions was posed to all participants (Appendix 2); these were developed and selected by the authors through a process of consultation with multiple stakeholders, including surgeons, therapists, and trainees, who were familiar with the clinic and with the unique and challenging features of this practice environment. Follow-up questions were asked in order to further explore or clarify the answers given, and differed between participants. The interviews ranged in length from 15 to 75 minutes. Each interview was audio recorded and transcribed verbatim. Field notes were also taken by the interviewer and accompanied the transcripts in the data analysis process to allow for cross-linking and generation of themes as they emerged.
Following each interview, the surgeon was also observed by the same author in a clinic visit during a new patient assessment and additional field notes were made. This allowed observation of the interactional patterns between surgeon and patient, and a comparison of the process described in the interview to what actually occurred during clinic visits. All patients whose clinic visits were observed for research purposes also participated in an informed consent process. Each interview was conducted in the office of the surgeon being interviewed. Clinical observations took place in the setting of the WSIB specialty clinic, separate from the surgeon’s office where the interviews took place.
Data was collected iteratively. Transcripts were initially read for overall content, and were then analyzed by means of coding and key word indexing [7]. Initially, codes were applied to the interview transcripts and field notes for each meaningful unit. These codes were reflected upon and summarized the specific content of the data transcripts. This was done to reflect the thought processes behind multiple, unique decisions and scenarios. Strategies for theme generation included the simultaneous coding of all notes and transcripts by at least two members of the research team. Initially, two transcripts were each coded by three members in concert to ensure consistency and consensus. The members were in agreement in most cases, and all discrepancies were discussed until consensus was achieved. The overall methodology was guided by an interpretive description framework in order to generate themes surrounding this complex clinical situation [8]. Analysis and data collection was performed using rigorous, interpretive cross-comparison [9], and ceased when no significantly new themes were found within this sample of surgeons, despite the individuality of each surgeon’s approach.
Findings
While examining the reports from the interviews and accounting for the observation in the clinic, one central theme was isolated surrounding the unique decision-making of surgeons in the WSIB specialty clinic. A common theme expressed by all participants was the importance of comprehensive assessment to make the first critical decision: an accurate diagnosis. Two subthemes were found that reflected sequential critical thinking on the part of the surgeons. The first of these involved the decision whether to proceed to management strategies or to continue with further investigation if the correct diagnosis is uncertain. Once the central goal of diagnosis was achieved, a second sub-goal was highlighted; selecting appropriate management options, given the complexities of managing the injured worker, the workplace, and the WSIB.
Comprehensive assessment to establish a correct diagnosis
A specific disease-centered focus is used in the initial evaluation of the work injury, and relies on the biomedical model and the surgeon’s expectation of the pattern of symptoms and physical exam findings that result from a given injury. This reflects a general theme learned from this study, endorsed by most surgeons in interviews and observed in the clinic. The surgeon must correlate the examination with the clinical scenario and with the patient’s subjective symptoms. This comparison includes the degree of symptomatology and the location and pattern of symptoms in order to assess the respective contributions of physical and psychological factors. The surgeons stated that the complex medical histories that were reviewed in the files prior to the visits with the patients were often non-informative and conflicted with the clinical scenario.
The specialty training of fellowship trained upper extremity surgeons and specialized upper extremity therapists was critical to conducting an independent assessment that arrived at an accurate diagnosis. During clinic visits, all patients initially saw a therapist for evaluation and the results of the therapist’s evaluation were communicated to the surgeon prior to the surgical consult. The surgeons used this information, along with their own assessment, to establish a diagnosis. While the surgeon was the primary focus of the observations, some therapy assessments were also observed,. Therapists performed clinical examinations, but also included more objective tests such as strength or sensibility testing, and interpreted patient reported outcome forms. The results of these were communicated to the surgeons to inform their decision-making. During the interviews, surgeons specifically referenced the skills and experience of specialized upper extremity therapists as a valuable asset in the management of injured workers.
There was general agreement on the need for a complete clinical evaluation that included the patient’s health and overall level of functioning. Surgeons acknowledged that understanding the nature of work and the workplace was important to developing a management plan. However, they also acknowledged that this assessment largely relies on a patient’s ability to describe his or her usual tasks and insight into those that tend to relieve or exacerbate symptoms. As one surgeon stated, “Sometimes it seems obvious what workers can and can’t do. Other times it’s very hard to understand what they can and can’t do. So often I’ll have the patient help me as to whether they can or cannot do certain tasks. I get their advice as to whether they think they can do their job.”
The data from multiple interviews highlighted that the misfit of symptoms with those expected from a given anatomic pathology is possible in the WSIB clinic, and can complicate treatment planning. However, it was consistently reiterated by the surgeons in this study that a patient’s assessment of their own pain and functional impairment must be respected and trusted, as it is a subjective personal experience. One surgeon stated, “I always believe the patient”. He elaborated, “We look for treatable causes. But oftentimes they’re not treatable causes from our perspective of surgery. That doesn’t mean they’re not physiologic.” This was a common distinction since surgeons are trained to make a decision about whether the problem requires surgery or not; a binary decision. However, surgeons recognized that decisions in the injured worker clinic were more complicated. The fact that they did not need to intervene surgically did not necessarily mean the problem was not “real”, or did not have a physical pathophysiology.
Surgeons acknowledged that the patient’s place of employment can have a significant impact on their return from a work related injury. One surgeon stated that “work site visits and the work of the return to work coordinator can facilitate understanding the patient’s job.” Since a few surgeons had time to directly interact with workplace, they acknowledged the importance of having other staff on the team who would fulfil this role. Several of the surgeons interviewed identified feelings of invalidation experienced by injured workers, engendered by the need to “prove” their illness or injury to their colleagues and their employer. They acknowledged that this affected their clinical interaction, since patients may sometimes have amplified the severity or persistence of symptoms in order to facilitate this acknowledgement. This complicates both the initial assessment and management of the injured worker and return-to-work planning since it can be difficult to accurately establish a correct diagnosis.
Proceed to management or further investigation?
Every surgeon acknowledged the important role of imaging in diagnosis and management. They commonly ordered imaging modalities, including plain X-ray radiography, Computerized Tomography (CT) scanning, and Magnetic Resonance Imaging (MRI), to evaluate the integrity of bone and soft tissue structures. Other classes of investigations such as Electromyography (EMG) and nerve conduction studies for the assessment of entrapment neuropathies, and diagnostic block injections were perceived to be highly relevant in cases with potential neurological involvement.
Both positive and negative results of investigations were described as being very useful to the surgeons. Positive imaging results were useful as they frequently confirmed the clinical diagnosis; and in rare circumstances revealed unexpected pathology. Negative results allow a surgeon to effectively rule out surgically correctable pathology, a critical distinction that must be made in order to guide the approach to further therapy. Several of the surgeons interviewed commented on the utility of investigation results for patient education since negative imaging can be useful to reassure patients around the possibility of safe return to work. In fact, some surgeons noted that they ensure that all patients have the opportunity to view their imaging studies in order to better understand their injury. For example, one surgeon stated “I use the negative results of imaging investigations as part of a cognitive intervention to help people understand that they have no significant lesion. This might decrease patient anxiety regarding pending treatment and long-term prognosis, and assist with reshaping the patient’s perception of their condition, their response to the injury, and their prognosis.”
While imaging results can be useful, one barrier surgeons experienced in patient education is helping patients to understand the nature of their problem and how to return to work in the context where symptoms cannot fully be relieved. Surgeons acknowledged this particular challenge in dealing with patients who have low levels of health literacy.
Surgeons emphasized the importance of not considering diagnostic imaging in isolation, but to support or refute aspects of the clinical evaluation. One surgeon commented on imaging, stating that “confirming the diagnosis or make a new diagnosis is intent of these investigations. Any investigation – whether it’s positive or negative – you just use that to direct further treatment.” Additional investigations were seen as being particularly useful in cases of complex presentations with multiple symptom foci, in patients with chronic complaints, patients with multiple conflicting diagnoses, or with poor responses to previous therapies. Surgeons reported that they are also more likely to proceed to more sensitive and specific tests or ancillary investigations in these clinical scenarios.
The surgeons in this setting acknowledged that they often required a number of additional investigations, sometimes to repeat poorly done imaging from less specialized centres, and sometimes to provide more refined assessments not available outside of specialty upper extremity units. This need was related to both the diagnostic complexity of the case presenting to specialty clinics, and the need to establish that no rare or peculiar diagnoses were missed; as stated by one surgeon, “make sure I’m absolutely not missing anything”. Although surgeons were aware of the duplication of evaluations and additional use of resources, this was seen as critical to their clinical decision-making.
Incompatibility of clinical signs and symptoms with the anatomic pathology found on imaging was often used by surgeons as a potential sign of psychosocial factors complicating the patient’s presentation and their response to the injury. In these cases, surgeons often rely on other members of the multidisciplinary team for consultation and direction. One surgeon stated “Sometimes workers’ underlying concerns are more efficiently addressed by the interdisciplinary team, by expanding the focus beyond the physical ailments. The complexity of presentations frequently seen in the WSIB clinic necessitates interdisciplinary care in order to appropriately address all patient issues. These additional treatment options available increase patient confidence and foster a sense of complete care.” Conversely, cases where demonstrable pathology is congruent with patient symptoms were reported to increase the surgeon’s confidence in the provisional diagnosis, and seen to herald a better prognosis for response to surgical treatment.
Selection of appropriate management options
Surgeons acknowledged that they had to consider the worker, the work, the workplace, and the work injury, as well as provider factors, at all stages of the clinical interaction. Surgeons typically followed a linear process to establish a working diagnosis, determine if surgery is needed eminently or conservative management should be implemented; and if ancillary services are required for additional psychosocial barriers.
Nonsurgical management
One principle identified by the surgeons in deciding which therapy to pursue is that of the “intelligent minimum”. That is, the optimal treatment in any individual case is the simplest and least invasive therapy that is likely to be successful. All of the surgeons indicated that they usually attempt conservative measures before proceeding to surgical intervention. Exceptions include those injuries for which surgery is the only option likely to succeed, or where delay in definitive surgical correction was likely to lead to increased disability and other permanent deficits.
Nonsurgical management was considered a potential source of alleviating the problem without surgery, or when it was not curative it could be important for symptomatic relief. Adherence to therapy was seen as an important prognosticator for adherence to postoperative management. Management options that were commonly considered included watchful waiting, rest of the affected limb, job modification, therapy, orthotic or assistive devices, medical therapy, and injections.
The surgeons indicated that the occupational therapists and physical therapists involved on the multidisciplinary team were very important for both the assessment/diagnosis process and for ongoing nonsurgical management. Therapists routinely improve certain musculocutaneous disorders through therapeutic exercise, strengthening, appropriate orthotic management, adjunctive modalities, and patient education. Therapy often avoids the need for further invasive treatment in this clinic. The therapists in the clinic often evaluated functional capacity and made substantial contributions to decision-making surrounding return to work.
Psychological intervention was seen as an essential component of management of some patients, whether to deal with pre-existing mental health conditions, or to improve coping and treat associated emotional distress. While this intervention was reportedly indicated in a minority of patients, it was seen as a critical component of treatment in this group. Surgeons recognized that psychological assessment was outside their scope of training and had implemented a psychological screening questionnaire (the patient health questionnaire) completed by all injured workers to help determine who would benefit from a psychological consultation. Nearly all surgeons interviewed considered psychological wellness to be important for recovery and also readiness for surgery.
The surgery decision
Surgeons acknowledged that they are often trained to make binary decisions since diagnostic tests are often positive or negative; they decide whether an anatomic problem is present or absent, and whether surgery is indicated or contraindicated. This process works well for them in the acute care setting, but was more challenging in the specialty clinic. Surgeons felt that the contextual complexity complicated the surgical decision, but even where they felt surgery was indicated were uncertain if that intervention would accomplish a return to work. This context was recognized as being quite different than their training and typical clinic context.
Surgeons talked about integrating patient experiences, expectations, goals and perceptions into treatment planning. Response to prior interventions was considered an important prognostic factor. Additional patient factors identified by the participating surgeons important to consider when selecting considering surgical intervention include the patient’s age, surgical risk assessment, the patient’s risk perception and aversion, comorbid medical conditions, subjective response to pain, family status, and support structures. Many of the surgeons interviewed described some patients who preferred to live with and manage their present condition, rather than take the risk of surgery. While patient factors are rarely formally evaluated, all surgeons interviewed reported that they attempt to take these factors into account, and to engage in joint decision-making.
When the WSIB specialty clinic was initiated, the Surgeons estimated that only 20% of cases displayed pathology that was clearly amenable to surgery. They reported that their role was important for these complex recalcitrant cases with multiple diagnoses since they could sort out the subset of patients who were likely to benefit from surgery. Complex, unconventional or migrating symptoms were cited as a warning flag that often prevented them from proceeding with surgical intervention, since many surgeons had experienced cases where surgery worsened the symptoms of patients presenting with chronic pain syndromes.
Other findings unique to the WSIB specialty clinic setting
Return to work
Surgeons acknowledged that there was a greater expectation for dealing with return to work in WSIB clinic given the nature of the injury and the insurer. As such, it was considered important to address return to work very early in the management process. Surgeons saw an important aspect of the role being encouraging patients to improve their functional capacity. This is because it is often difficult to set meaningful, applicable work restrictions, and to adequately assess a patient’s functional capacity. This was widely considered by these surgeons to be the most difficult aspect of WISB practice. They echoed their reliance on patient description of their job and their tolerance of work activities, and the lack of evidence for assigning functional capabilities based on clinical findings. They also relied on their experience with a given injury or procedure to establish a likely timeline for return and appropriate restrictions. One surgeon noted, “we kind of work it through and find out what is painful about that activity and we can restrict that. I give them a timeline....With a rotator cuff repair, they will probably be on light duties for anywhere from 6 to 9 months. So they understand there’s a finite amount of time for this, and they can prepare for that.”
WSIB interaction
The surgeons of this clinic reported challenges in the clinic related to the insurance context. Policies and procedures exerted by the WSIB, require different levels of documentation and affected the clinical interaction. For example, there was a perceived pressure to avoid the use of the label of “permanent disability”. This was complicated by an expectation to resolve cases within a certain time frame, which can impinge on the usual convalescent time needed to adequately assess the patient’s response to treatment. The WSIB also does not allow surgeons to address other medical issues, such as pathology in other joints. The surgeons perceived that the pressure to establish an accurate diagnosis and assign a label was higher in the WSIB clinic because causality is an important issue. The need for clear documentation of the diagnosis in this context meant that they were more aggressive in the use of diagnostic testing. Finally, surgeons perceived a pressure to expedite care for WSIB patients.
The surgeon participants reported that they deal with these contextual challenges by continuing to focus on the patient, maintaining their usual process and approach as used in other clinical settings. Upper extremity surgeons generally function as independent practitioners, but perceived their level of independence differently in the WSIB clinic. Firstly, therapists were much more involved in the diagnosis and decision-making than a typical surgical consult. Secondly, many of the surgeons saw themselves as an intermediary between the patient and the WSIB. This role has been described as “an unbiased third party assessment”, which uses medical knowledge and expertise to “report recommendations and findings to the board”, while remaining unbiased by focusing on the results of the evaluations of each individual injured worker.
Discussion
Interpretive description was used in this study to develop themes related to the decision-making process of surgeons in the WSIB upper extremity specialty clinic. Decision-making was centered around one major theme – establishment of a correct diagnosis, while identifying the need for further investigations and implementation of an appropriate management plan were also at the forefront. Factors unique to this clinical setting play a background role in the decision-making process. These include high prevalence of complex and multifaceted problems; involvement of an interdisciplinary team; external pressures from the WSIB and the workplace; and a focus on successful and timely return to work as an important outcome. Despite these challenges, the surgeons in this clinic have become comfortable with managing the complexity and the WSIB clinic by drawing on their extensive experience.
The diagnosis of the work-related injury is the central event in the process of patient evaluation and management in the WSIB clinic, as in all medical practice. This is the primary focus of all patient evaluation, including the complete medical history, physical examination, and all investigations ordered [10]. This diagnosis then guides all management decisions, including that of surgical treatment, defines the expected outcomes for the patient, and can impact significantly on the likelihood of return to work. In keeping with this, many of the surgeon participants viewed establishing an accurate diagnosis as their primary role.
Despite the unique diagnostic challenges that accompany WSIB practice, most surgeons expressed confidence in their ability to expediently form an accurate diagnosis based on the patient’s history, physical exam findings, and investigation results. It was also noted that the determination of the source of the patient’s complaints does not always result in the formulation of a single diagnosis. Some patients will feature multiple foci of pathology. These may represent concomitant related or unrelated injuries, or may be causally linked. The participants emphasized the importance of establishing an accurate diagnosis including all disease elements that may be contributing to the patient’s symptoms and functional limitations. Furthermore, a definitive diagnosis is not always achieved in the setting of work-related injuries. This does not convey an assumption that the primary problem is simply psychological, rather that the true cause of the symptoms cannot be determined given the current status of investigative capabilities and the extent of medical knowledge.
Several surgeons in this study felt that the establishment of a diagnosis can have a positive impact on the injured worker. Similar to patient education using imaging results, a thorough explanation of the injury can allow the worker to understand the pathologic process, as well as their own response to the injury. A patient can also be educated as to which of their symptoms are directly attributable to the injury found. This provision of clarity can be satisfying to the ailing worker, even in the absence of therapeutic intervention. This type of collaboration with the patient has been shown to improve the decision-making process [11, 12].
Surgeons perceived their role as an unbiased third party who is focused on treating the patient, while still reporting findings to the WSIB and to the workplace. Communication between health care providers, employers, and insurance payers has been a barrier in previous work [13], however, active participation of the injured worker, early identification of barriers to return to work, and close communication with stakeholders have been shown to decrease loss of time from the workplace [14].
The patient’s objective functional status is very important for successful return to work, but is also augmented significantly by their perceived disability. In fact, the primary predictor of ongoing disability is likely the patient’s initial perceived disability at the time of injury [15]. The perceived return to work readiness on the part of the patient is considered to be critical for successful rehabilitation and increase in functional capacity [16]. There is also a significant presence of return-to-work anxiety and fear for the patient, as the WSIB, the workplace, and the worker themselves all place great emphasis on their ability to return to full work duties. This barrier can increase the longer an injured worker is away from work [17].
An emotional connection to the work and the workplace can improve patient motivation, and allows the patient to guide their own restrictions and return to work process. Return to work in a modified capacity is also considered and has been shown to be beneficial for success in the past [18]. Surgeons were aware of these complexities and the need to implement their own skill set in this context. They were well aware of that surgery might not fix either the clinical problem or could fix the clinical problem without being able to resolve other barriers for recovery and return to work. The “intelligent minimum” approach of using conservative approaches where surgical benefit was not a common theme which is important in this context since upper extremity rehabilitation can be both prognostic and interventional for recovery of upper extremity function that would support return to work.
This study had several limitations. The sample was highly specialized upper extremity surgeons, most of whom had several years’ experience. The fact that the sample was homogeneous and involved a specialized subset of medical professionals limits the external validity of our results to other groups. The contextual factors within this paper surrounding the worker, workplace, and insurer are also likely not transferrable to other contexts where these relationships may be vastly different. A final limitation is that the data collection was cross sectional, with an interview followed by a single clinical observation. Follow up interviews after the clinical observation may have led to more meaningful results, especially if clinical decisions made by surgeons during the clinical encounters were slightly different than discussed during the interview process. A longitudinal follow up may have also been beneficial to investigate how clinical decision-making changed over time.
Conclusions
This study illustrated that the upper extremity surgeons in this study were able to draw upon their specialized training to be able to distinguish the subset of upper extremity injured patients who would benefit from surgery. With a multidisciplinary team, they are able to support treatment plans for the majority who do not require surgical intervention. Upper extremity surgeons rely on their training and experience with upper extremity conditions to follow a sequential but iterative decision-making process to provide a more definitive diagnosis and treatment plan for workers with injuries that are often complex. The surgeons are challenged by the context which takes them out of their familiar zone of typical clinical practice to deal with the interactions between the injury, worker, work, workplace and insurer.
Conflict of interest
None to report.
Footnotes
Appendix 1
Research Participants
| Subject | Sex | Years of Practice (at time of interview) |
| 1 | M | 5 |
| 2 | M | 14 |
| 3 | M | 13 |
| 4 | M | 28 |
| 5 | M | 19 |
| 6 | M | 14 |
| 7 | M | 18 |
| 8 | M | 36 |
| 9 | M | 18 |
Appendix 2
I will be asking you some questions to understand how you manage injured workers in the WSIB injured workers clinic. What factors must be taken into consideration when deciding on a management plan?
What is the role of a multi-disciplinary team in managing injured workers? What value does the team add to the practice? What are the differences in your approach when seeing a patient in the WSIB clinic rather than a more acute, OHIP patient? How do you decide what investigations to perform or order?
What is the goal or intent of these investigations? How are these investigations then used? What factors must be taken into consideration when deciding whether or not to operate on a patient?
How do you go about developing and deciding on return to work restrictions? What factors would influence you to consider the classification of a “permanent disability”? How do you differentiate whether a patient’s condition is primarily a physiological/surgical problem, or is a chronic pain or a psychological problem?
Acknowledgments
J.C. MacDermid was funded by a Canadian Institutes of Health Research Chair in Gender, Work and Health and The Dr. James Roth Chair in Clinical Measurement and Knowledge Translation.