A group of occupational-medicine physicians has released a white paper on the issue of disability certifications for impaired workers, holding that doctors often keep workers off the job too long after an injury or illness and that the specialty should adopt a “Stay at Work/Return to Work Process” as its fundamental organizing model for treating disability. That process seeks to minimize the time workers spend off the job, which, the authors assert, would be beneficial in many ways:

We know that much work disability is not required from a strictly medical point of view. We see devastating psychological, medical, social, and economic effects caused by unnecessarily prolonged work disability and loss of employability. We also see wasted human and financial resources and lost productivity.

Finding better ways of handling key non-medical aspects of the process that determines if an injured or ill person will stay at work or return to work will improve outcomes. Until now, the distinct nature and importance of the stay at work and return to work process (SAW/RTW) has been overlooked. Improvements to that process will support optimal health and function for more individuals, encourage their continuing contribution to society, help control the growth of disability program costs, and protect the competitive vitality of the North American economy.

This may all be true, but it causes concern nonetheless. Without comment, these authors introduce multiple factors into their outcome evaluation which are not related to, and in fact may conflict with, patient welfare. They say explicitly here, and throughout the paper, that the benefits of encouraging workers to take less time off the job for disability-related reasons include, among other things, harm to the “economy” (GDP, presumably), “contribution to society”, reduced costs of disability treatments, and worker productivity. In other words, among the major drivers for doctors to determine the course of individual patients’ care are the contributions those patients can make to overall economic goals valued by their employers, third-party healthcare payers, or “society”, not the patients themselves.

To put that another way, these authors are openly encouraging doctors to admit external economic values (in addition to the many that already impact treatment decisionmaking) to directly influence their decisions regarding their patients’ recovery from illness or injury - values that run directly counter to the patients’ own. There may be a problem there.

It’s hardly news that much of healthcare decisionmaking in America (and elsewhere) is highly constrained by external economics. The predations of “managed care” are so pervasive and so well-known that it is tedious to recount them. Skinflint globally-budgeted governmental payment systems are no better. And it’s hardly unusual - or even objectionable, in broad stroke - to discuss healthcare policy from an overall economic perspective. We do spend too much on healthcare for what we get in return, in the US. It is important to control costs system-wide. But it is very dangerous to import industry-wide financial goals into clinical decision-making at the level of the individual patient. And that is essentially what these authors do.

They note that the current structure of the medical-disability system is somewhat counterproductive: doctors “certify” disability in individual patients with respect to their particular jobs; the doctors’ incentive is often to “make it easy” on patients by certifying long recuperation periods, and they have no particular incentive to think about costs to the employer, or the overall economic impact of lost productivity. They also claim there are significant harms to patients from excessive disability relief: lost wages and “employability”, the indirect costs of living in a reduced-productivity society, and the tendency to “adopt a new view of themselves” and desire to remain on disability rather than return to work. For all these reasons, they suggest, the disability process should be overhauled so that doctors do not “certify disability” but merely indicate what work the worker can still perform, with the expectation that almost all workers will return to the job immediately after an injury with some sort of modified duty.

Probably some of these concerns are legitimate, though to a large extent they smack of blaming the victim. The enobling value of the typically demeaning, crushing, exhausting, pointless, unengaging, and powerless dead-end job is somewhat over-romanticized as well, I think. But it is not their specific concerns or recommendations I am interested in. It is the general notion that the goal of medicine is to produce productive workers.

It may be that occupational medicine is a discipline inherently fraught with conflicts of interest. Certainly these authors have not succeeded in reducing those conflicts by recasting “certification” of disabilities - if anything, they have enhanced them by taking patient welfare almost entirely out of the goals-of-treatment equation. (In defining the treatment goal as returning workers to the job - and countering the tendency of workers to regard time off as contributing to their welfare and to their healing - they have made comfort, and probably healing time, irrelevancies, which I suspect no other medical specialty does. And since almost all sick people of working age are “workers”, this essentially means that the goal of every medical specialty should be to get recovering invalids back behind a desk - or machine, or vehicle, or whatever - as soon as possible without regard to comfort or the individual patient’s maximal well-being.) In doing so, they have taken patients themselves out of the treatment picture. They appear to be encouraging doctors to view patients as employers do - as cost-and-productivity units to be deployed for maximal benefit to the employer’s profit margin, or to “society” or “the economy”. They explicitly recommend financial incentives to doctors to keep workers on the job - a direct (but hardly unique) financial conflict of interest that they endorse for the purpose of splitting doctors’ own interests away from those of their patients. In these ways, they have cut the heart out of the ethics of medicine itself, changing an entire profession - not just one discipline - from a bulwark of individuals’ interests and benefits to a social tool for squeezing more labor out of more workers for others’ benefit.

I say again that large-scale economic considerations of this kind are not forbidden - but they are out of place in individual patients’ treatment plans. And to their credit, the authors above recommend many structural changes, including workplace support for recovering employees and attention to workplace factors - including morale - that contribute to on-the-job injuries, which would be highly beneficial to workers. But, just as the place to address workplace injuries is at the systematic level - with the kinds of workplace-safety revisions that the authors recommend - the place to address lost productivity is at the systematic level. In addition to comprehensive single-payer healthcare for all residents - not just grudging “workers’ comp” for those lucky enough to be employed - which would grant a huge economic benefit by cutting wasted overhead and profits out of the current system, we need a stronger ADA, better protection for injured workers, job re-training programs, and flexible work arrangements, which would all contribute to integrating impaired workers better into the work environment. We also need to abandon the notion of GDP as the overriding measure of economic health. Accepting lower GDP growth in return for more-human working conditions - a tradeoff virtually every other Western country has made - would itself reduce workplace injury and make injured worker recovery more possible. Then we can talk about recuperation times and modified duty.

But more than anything, we need to recognize the fundamental economic law of a capitalist workplace: worker welfare is in direct conflict with employer profit, as well as GDP, “productivity”, and cost-cutting. This fact is implicitly acknowledged in the white paper itself, in the claim that “excessive” worker welfare (time off to recuperate in comfort from injuries) is responsible for increased costs and for harms to “society”. But, perversely, the paper cites the Hippocratic maxim “do no harm” in support of its economically-driven analysis of worker recuperation times, declaring that “[a]n ineffective [stay at work/return to work] process causes damage at many levels.” As long as that conflict remains, any call for doctors to balance employers’ books on the backs of injured workers - whatever its pros and cons considered from other perspectives - must be a contradiction of the fundamental medical ethic of devotion to patients’ interests.

 Hat tip: May 4 Health Wonk Review at Managed Care Matters.