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Managing the greatest barrier to return to work: fear – Dr Sid O'Toole

Safe Work Month and Mental Health Week 2020

Speaker: Dr Sid O'Toole, Occupational and environmental physician.

In this session, Dr Sid O’Toole covers why even the best-made plans for rehabilitation and return to work can go wrong.

You'll learn about the foundation of the fears of each of the stakeholder groups involved in return to work, and ways to overcome these fears and break down the barriers to successful return to work.

Hi, everyone. It's Safe Work Month and I'd like to welcome you to another special presentation from Workplace Health and Safety, Queensland. It's about managing the greatest barrier to return to work that being fear. Our presenter this morning, or this afternoon will be Dr. Sid O'Toole. I'm Chris Bombolas and I'll be your emcee for today. Firstly, I would like to begin by acknowledging the traditional custodians of the land on which we meet today and pay my respects to the elders past present and emerging. I'd like to extend that respect to Aboriginal and Torres Strait Islander peoples watching today. Safe Work Month is held every October and is all about raising awareness of work health and safety. This year Safe Work Month looks a little different, but through these virtual events were able to deliver, safety and return to work information straight to your screens. Our speaker this morning, as I said is Dr. Sid O'Toole, an occupational and environmental physician and Joint Director of LIME Medicolegal and Phoenix Occupational Medicine. Sid has nearly 20 years experience in medicine and is passionate about the health benefits of good work. In fact, one of the things that drove Sid to start up Phoenix Occupational Medicine was so he could actively intervene in the early treatment of injured and ill workers. Whilst conducting independent medical examinations for insurers and solicitors, he has seen many poor outcomes which could have been avoided. Of the many barriers faced in the return to work sphere, there is one common element, that is fear. Today Sid will be sharing his knowledge and expertise as he explores just how fear can have impact and be overcome in the return to work process. Sid is very passionate about what he does and I'm sure you'll learn a lot from today's session and improve return to work outcomes. At the end of today's session, you'll be able to ask Sid questions. But to submit your question or even make a comment, please use the chat box that you can see on your screen over the course of today's event. All right, so over to you, Sid, talk to us.

Look, first I just really like to thank Chris Bombolas for that beautiful introduction. And today we're gonna have a brief rundown on what I consider to be the greatest barrier to return to work and that being fear. Now we all know about the importance of return to work and unfortunately I have to have a bit of a chat about stats 'cause that's my world. We all know 70 days away from work means there's a 35% chance of return to full-time duties ever. And that is a scary statistic and that is something we need to overcome because work equals better physical health and work equals better mental health, not just for the worker, but also for the family. So when we talk about the importance of return to work, we talk about routine. And return to work post-injury is all about routine. The body loves it. We have a circadian rhythm and this is how we control our interaction with the world. Getting up, getting out of bed, driving to work, screaming at drivers, coming to work and talking to your mates and having a bit of a whinge about the boss, that is all normal and we need to maintain this. We need to maintain using the muscles the way that they were being used in order to prevent deconditioning. And most importantly, returning to work reduces the likelihood of a secondary psychological injury. And with the pressures that we have on mental health on us right now with all of these external things that are happening in the world that are out of our control, anything that we can do to reduce the likelihood of mental health concerns should be addressed and a priority. So those of you who've been in the return to work sphere, have all heard about the flags. First off, we have the red flags, which were the physical signs that something wasn't going right. Then we had the yellow flags, which more those psychological concerns. And then we had to throw in the blue and the black flags as we extrapolated those out. Quite frankly, I get a bit confused by all of them. And so I think of things slightly differently. So I think about the worker things, the workplace things and caregiver things. And in those caregiver things, I break that down into your family and friends, the allied health workers and also the medical workers. So let's now talk about the worker things. Now, all of these are potential barriers to return to work. Primarily we have to talk about age. Honestly, older people do take longer to heal and that's just part of the natural degeneration process that blood doesn't get around the body as well as it used to. We can't get that immune system to the places it needs to be to recover. Younger people also may have less resilience and this isn't a blight on young people, this is because they haven't had the experiences that people who are older have over the time of their life. Therefore they're not as prepared to overcome issues as they come about. And both of these need encouragement. When we talk about the memory of the event or the mechanism of the event, that can actually be an indication there can be fixation on blame and blame is a huge barrier. These things do happen and it can be because of a fault, but fixating on that will actually slow the healing process. Now obesity and fitness, this sort of speaks for itself. The fitter you are the better blood's pumping around your body and the more quickly you're going to heal because you can get the healing cells to where they need to be. Obesity has a direct impact on your ability to heal. The more obese you are, the more drastic the event needs to be to cause an injury, a greater force is required and that therefore leads to requiring a longer period of time to recover and the body having to fight harder to do so. Now, ethnicity is always an area that we don't really talk about, but it's important to understand when you have the patient or the worker there in front of you. Different cultures hold different beliefs and those different beliefs extend not just to a religious belief or cultural belief, but also to healing and treatment practices and we need to be mindful and respectful of that. There is also some really good evidence to show that different cultures experience pain in different ways. And without acknowledging that and addressing it, we could be creating a barrier ourselves to the individual. The education status of an individual must also be considered. People who don't have the knowledge or the experience to be able to understand the complexities of an injury or the complexities of a diagnosis. In medicine, we're very, very good at coming up with really long, fancy sounding Latin terms to describe an injury pretty much 'cause it makes us sound very important, but if we can't explain that to the individual at a level they understand, then that is gonna create a barrier to them being able to take ownership and control of their rehabilitation. Now, obviously previous claims, there is good indication that the more claims that an individual has the worse of an outcome for each claim moving forward, and this can be part of a learned behavior, but it can also indicate an underlying level of decreased fitness or underlying illness. Smoking is often forgotten, but it is a significant contributor to delayed recovery. Again, when we smoke, it's those small blood vessels that close over over time, and it's often those small blood vessels that we need to be feeding the muscles or the bones or the parts of the body that are injured. And of course, other medical history, people who have conditions such as diabetes or heart disease are also going to be at a slight decrease in their capacity to be able to recover. So now let's talk about the actual workplace things, let's talk about the job itself. Are the physical and psychological demands of the job beyond the capacity of the worker in the first place. Did they actually hate their job? Now, these things may seem like I'm being judgemental, but it's really important to understand because if someone doesn't like their job, if they don't feel included in the workplace, then they don't have the motivation to go back. And we need to be aware of that at the start when we start to make decisions on alternate roles and suitable duties as people go forward. And when we're coming up with suitable duties and alternate roles, is that role we're up with meaningful? Does the person get purpose from doing that role or is it just merely sitting in a corner counting widgets and that's the whole purpose behind the health benefits of good work, the good component of work, for you to feel that you understand and feel that you belong, you have to actually do something that you feel productive in. Now, within the workplace itself, attitudes towards workers, compensation vary. There are many organizations and I hear from patients that are assigned to me are, I was told don't make a claim 'cause it's gonna stuff up our premiums or LTI numbers will go up. And if that's an attitude within the workplace that permeates through to the workforce, and that causes fear within the workers about standing up and saying something happened to me. That can lead to them not coming forward until it's often too late to be able to put in an interplay to stop them getting worse. How do people get along with the other people within their workforce? If ever everyone is constantly picking on this individual, if everyone sees this person is not pulling their weight, they are going to have a negative effect on the individual's recovery because they won't have the motivation to go back to an environment like that. We also have to consider, is there a dedicated return to work coordinator within the workplace? This is a specific role. It is a very important role for returning people back to work. And often, particularly in the smaller organizations, it's merely an add on role to someone's main permanent job. Often it's a HR person is also the return to work coordinator. And therefore they may not have the experience in doing the role, or they may be distracted from performing that part of the role by the primary duties that they have to do. And we have to understand, what's the hierarchy in the workplace? Who is actually in charge? Who is driving the return to work for this individual? And who's taking responsibility for it? Because without that, we're not going to get anywhere. Now we move on to the caregiver things. And as I said, caregiver things, I'm splitting into three groups and so we'll first look at family and friends. We've all had some form of injury illness in the past, and we've all had people talk to us about their injuries and illnesses, whether it be when your sick or whether it's around the barbecue on the weekend. And you know, man, I had the exact same thing and you should have seen what they did to me. I got some acupuncture in that work and then some car row, I took that horny goat weed stuff that I saw advertised in the paper, that was the best treatment ever, try this, try that, try Lyrica or hang on, I'll just see what Google says 'cause that'll tell me how to fix your problem. All of these different messages coming in at the poor injured worker can be confusing. It can be confronting, it causes fear. Perhaps one of the greatest things we need to consider is the term rest. It's normal human nature to say to people just rest I will do that for you because generally we are caring about the people who are around us, but that does lead to a negative effect. The more things that we take away from people that are their normal activities, leads to learned helplessness. People start to believe that they can't do that because if I could do that, why would everyone be wanting to take it away from me? And when we're not performing those normal activities that leads to deconditioning, our muscles actually shrink, our capacity shrinks, which means you're further back than where you were before the injury, which we have to regain before we can get people healed again. And the belief that you can't go back to work and you need to rest. If it is safe, as long as you can do something productive, work is good for you. Being back at work speeds up your recovery and speeds up your healing. And it's got to be done in a manner that's controlled and always primarily keeping people safe. And that requires a little bit of expertise to help with that. Now allied health providers, provide a wonderful, wonderful adjunct to the medical care that people are receiving, but there can also be some barriers that come about from that. Sometimes an allied health provider will discover something that has been missed so far and they'll provide an alternate diagnosis. And they'll say to the patient, this is what's actually going wrong. And while there's nothing wrong with doing that because we want to get the diagnosis right and we want to get the treatment right, it can cause confusion. And it can actually also undermine the level of knowledge and expertise in the other caregivers. So it's got to be done in a coordinated manner. Often advising further investigations, or in some cases I've actually seen where people have been refusing to treat a worker until a particular investigation's undertaken. And there are specific reasons to perform investigations such as MRIs, CT scans, etc. And if people don't meet a clinical need for that, it's really important that we don't do that investigation because sometimes things come up in that investigation that's not relevant to the injury, but can cause confusion and people to go down a pathway that's not necessarily the right one for this patient at that particular time. And sometimes there's some misinterpretation of signs. It sounds hard to believe, but some people are taught even amongst medical schools, the different medical schools will teach different signs and symptoms differently. So the interpretation of that can often lead to a misdiagnosis or going down a pathway that we don't necessarily want to go down because it's not going to get a good outcome for the worker. Now, treating doctors. After I said all that about everyone else, I'm now gonna turn the spotlight straight back onto us and show how we are often the problem and a barrier as well. Sometimes we get the diagnosis wrong. It's true, no one's perfect. Some people believe they are, but I can promise you we're not. And sometimes we have a problem that we give a diagnosis, which isn't a diagnosis. The classic example is back pain. Back pain is not a diagnosis, it's a symptom. And by just saying, we're gonna treat a pain doesn't necessarily give the injured worker that faith that we're treating a problem so that we can prevent it from happening again. The other thing and I sort of alluded to this a little bit before is that sometimes when an investigation is done, we then start to treat what's seen purely in that investigation. And there is many, many times when what we see in that investigation has nothing to do with what caused the injury and the ongoing problem. And we get distracted and we go down that rabbit warren, instead of focusing on what's wrong with the actual individual. We forget to talk to the person in front of us and consider their concerns and how to manage those. Now, there's also, if someone's come to you and said, I'm at work and I got saw the presumption that work caused that problem and that can lead to ongoing issues with blame victimization mentality that we need to avoid. If you're not sure, it's okay for us doctors to say, I don't know. I do say there are many people in my life, including my wife who say I don't, but I promise I do say, I don't know. And that allows me to then to have an open discussion with the patient and figure out a method of moving forward for us both together to figure out what is actually going on. We have to be very careful in the language that we use. Catastrophic language can be very detrimental to a person's outcome. Things like you will never go back to work. You will never be able to do the things that you used to enjoy. This builds a fear inside a patient and will lead them to then learn helplessness and not want to drive themselves to get better. And sometimes we even as doctors advocate for the patient by using the term rest. Rest means reduction in intensity and frequency. Rest doesn't mean stop, stopping actually leads to further problems. And we need to make sure that even if we are saying to people, just pull it back a little bit we say it means just pull it back a bit and don't use terms like rest or stop. All of this boils down to one thing, fear and fear, fear is normal. Fear is what kept us in our forebears alive and prevented an ugly death from the hands of marauding beast and dinosaurs coming in to eat us cause we got scared and we ran away. It is normal and it is a spectrum. It's a spectrum from a little bit of concern all the way through to total debilitating fear. And we're not talking about every single patient is totally debilitated with fear. We need to address all levels of that spectrum. So let's go back to those categories I was talking about and let's talk about worker things. We're gonna talk about fear of the unknown. If our communication isn't well presented, if we're not giving the information in a manner that people can understand, then there are areas of unknown. There are things that the injured worker cannot comprehend because we haven't given them the tools to do it. And that leads to that fear of unknown. Fear of never being able to do things because of that catastrophic diagnosis. Fear of pain and fear of pain is normal, but there is a difference between discomfort and pain and sometimes a little bit of discomfort as we lead through our progression, rehabilitation is normal and acceptable, but not when it becomes actual pain. There is normally a fear of getting worse. People avoid doing activities because they fear that doing that activity is going to make them worse. People are fearful of losing their job because of the injury that occurred. Whether that be because they might not be able to go back to doing that job because they've lost function or they fear that the workplace may actually not want them back just because they got injured. All of that adds up to fear of financial losses. And we've seen that recently with all the craziness that's going on in the world as our wage drops and we all live within our wage. The ongoing effect that that has not just on ourselves, but also on our family is a burden to have to live with and to try and work our way around. Fear in the workplace. Again, fear of the unknown, the workplace doesn't understand the injury. Sometimes they don't understand how the injury actually happened. Sometimes I don't believe there is an injury. Sometimes they believe they're gonna be prone to getting sued. There are multiple different fears within the workplace. And there's a barrier to trying to get people back to work because they don't want to make them worse. They don't wanna re-injure them. And quite openly, there are many organizations who fear that they are gonna have an increase in their premiums if they accept that there is a responsibility here and they continue to manage people by bringing them back to work and potentially getting injured again. Caregivers, whilst we're giving care, we're also fearful ourselves. You know, our family and our friends are fearful that the person that they care about is not going to get better. And what does that mean not just for the family unit, but for them within that family unit. Allied health professionals and doctors, sometimes we fear saying enough is enough. Sometimes we fear saying to someone, the modern medicine world has only got this much to give you and there's nothing else because we see that as giving up and we don't give up. We are in the world of healing people and saving people and protecting people. So to say that that's all we can do and unfortunately not going to get any better, we see that as failure. And there's a fear of us doing that. And we often see that people will go and look, just try this, try this procedure, try this avenue of treatment just because we want to give someone the hope that something else will improve them. And believe it or not, sometimes we actually fear not being liked. Usually it's a subconscious fear, but we're normal human beings, we all have ego and as doctors we have this tendency to put ourselves on pedestals and think that we have above everyone else. And so not being liked doesn't sit well with us. Remember again, though, all of these fears are normal and they're understandable. Every single example I gave you of a fear there is understandable. You can see why people get to that conclusion. But if we accept that there are fears, now the key is how do we manage those? How do we prevent those fears from impacting on return to work and returning to normal living? Because that's what we wanna do. We wanna get injured workers back to their normal life of which work is a considerable component of it. How do we control fear? Now, everyone in the audience who's had children or has been a child, so I'm gonna put that down to pretty much everyone, unless you're like me and you were born at 18, you've all had the story of the bogeyman under the bed. The thing that was scaring you when you were child and how did your parents manage that? Or how do you manage it for your children? You show the child that there is nothing under the bed. You turn the lights on, you get them down and you get them to look under the bed and by repeatedly showing them that they are safe, you control that fear. And returning people back to work and back to function after injury is about demonstrating to them that they are safe at each stage of their journey moving forward through their recovery. So how do we do that? The key, the key to every issue that's been raised here is communication. Communication solves all ills. And it's about the language that we use. The language still has to be firm, authoritative and yet compassionate. We have to understand that there are fears and not push them to the side or even belittle an individual because they're fearful because we're all slightly fearful. So we need to highlight that there is an avenue to better treatment and we can do this with communication. We show the treating doctor, the treating team, how to overcome those fears by stepping people through advancement in their treatment, advancement in their function and in their KPIs. By showing people that they are getting better, we can overcome the fear that they're not going to get better. We can overcome the fear that they're going backwards. And by showing the patient that they are safe, that will allow them to then be able to push to the next step. Not have to go long distances, but push to the next step. At the same time, we have to show the workplace that their fear can be managed. We communicate with them. We talk to them about the benefit of having someone back at work. We talk to them about the benefit to, not just the individual, but to the workplace of having someone back part of the team, part of that community and that culture within the workplace. That is done incrementally, it's done step-by-step and it's gotta start from the moment that someone is injured because by proving that people are safe and by proving that each little step continues to be safe and gains achievement, then we're showing that that fear is unfounded. So as I said, communication. You notice it's there twice and it's there twice for a reason. It is the key, okay? Everyone's gotta be on the same page. We as doctors have to start at the very start. We've got to make sure we get the diagnosis right. We match the mechanism of injury to the symptoms. It sounds simple, but it isn't necessarily. When we get that diagnosis correct, then we can apply evidence-based management. And that management is more than just, putting the plastic cast on the broken arm. That's managing the process, getting the key people involved, the injured worker, their family, their workplace, their caregivers, all on the same page moving forward. That way we can get people back to work as soon as possible and as soon as it is safe, I implore organizations to get a really good return to work coordinator and have good work available. People need to have good work, something that shows to them that they are still being productive, gives them a sense of purpose in the workplace. And we need to set guidelines and timelines for graduation and tick them off as we go. That way, we're showing people, they're making advances and they're doing so safely, which overcomes that fear. Lastly, sometimes these things are complex and it takes more than just someone who is a GP or a physio or an experienced allied health professional. Sometimes you need a medical advisor to look in from the outside and to give you that expertise. And that's where we come in and that's where we're always available to help, to guide and to hopefully get you all some good outcomes. So, Chris thank you very much and thank you everyone for listening. I see this lots of questions sort of rolling in, and I guess we'll head into those.

Absolutely, we'll set up for questions. And while we do, if anyone does have a question, we've got a number already. Join us on the chat box, give us your name, what the question is. We'll get to as many as we can with Sid and of course that's available right through until the end of our session here today. I've got one on notice for you Sid, or it might be more a comment. You mentioned early on in your presentation that age is a factor when we're talking about recovery, right? Now, it's gonna take me a long time to heal from you deliberately mispronouncing my last name, you did that absolutely deliberately.

That was a measure to check your resilience to be perfectly. I've got to say I'm very impressed.

Yes, I picked that up. And the other thing you mentioned before we get to our first question from John and thank you, John for joining us today, fear. You spoke about fear being normal and understandable, but is it reasonable? And when does it come to a point where that fear is not reasonable?

Yeah look, there's certain degrees of fear and not just reasonable but expected. If we weren't fearful, then we wouldn't have survived. We wouldn't have evolved where we are, but it's about keeping it in check to the point where it makes us cautious, but it doesn't prevent us from doing the activities that we need to do. So I myself, I have a little bit of fear of standing up here and talking to you and going out live into the great interweb that I can never pull back. So I'm fearful of saying something inappropriate or accidentally dropping a sway word, no. And so that's a normal fear because that makes me on check. It makes me mindful so that I don't go down a particular path.

But it shouldn't affect your performance.

I hope no, I'm hoping not. Anything's possible though.

Let's get to the questions that everybody's been patient with. John is first, we're trying to implement a recover at work process that encourages suitable duties. Do you have advice for communicating with treating doctors to promote health benefits of good work and idea of working recovery and what are the barriers for doctors against prescribing work in activity?

Yeah look, the majority of doctors who are taking care of injured new workers are general practitioners and they are working ridiculously hard, under very strict time constraints. And so the complexities of having to look at a suitable duties program, determine if that fits the injury and the capability of the injured worker and also what they actually do for a job and understanding all of that, that can be mindful. And it can also take excess time and understand they can have longer consults, etc, but if it's lumped on them without any warning, they can't plan for that. And often they'll feel out of their depth 'cause it's not their area of expertise. For instance, I can't tell you what the third line antihypertensive is to manage high blood pressure, but I know GP's can 'cause that's their bag. So if they're concerned and you give them all of the information, but you're still not getting the answers that you need, sometimes it's worth asking you for someone who is experienced in that area, such as an occupational environmental physician to give that advice. And we don't have to come in and take over the care, we can often just communicate with the doctor and, you know, talk doctor to doctor in our fancy language that we come up with that I spoke about earlier. And, you know, allay some of those fears of it's okay to put someone back to work and these suitable duty plans are usually put together by people who are very experienced so you can have that reassurance.

Next question doc is from Celia Rutherford and she says, do you have a view about the inclination of general practitioners in the community to investigate the nature of symptoms and causation beyond the worker's beliefs or medical investigations?

Thank you, Celia. The practice of medicine has changed. Once upon a time we didn't have MRIs, we didn't have CT scans and we relied solely on what was in front of us. And we had longer with patients. So we could get a more in-depth understanding of not just the patient, the injury, but the whole environment that they lived in. Now, there are many time constraints. So someone says I've got a sore shoulder, the first response is I need an ultrasound and an x-ray of that shoulder. And then we treat what we see in the shoulder. We see that the person's got a thickened bursa we say, well, that must be bursitis, that's what's causing their pain. That pain could be coming from their neck. That pain could be coming from their thoracic spine, but we focus on what we see. And that often will take us down a pathway that takes us away from managing that person. A thickened bursa in shoulder is actually a normal finding. It gets thicker over time because it's doing its job, much like we get calluses on our hands. So that lack of time that's available will often lead to people, having to take small shortcuts that take them down a pathway and by using investigations over and above a formal clinical assessment.

Andrew has joined us and thank you Andrew for your question. He says, hi, Dr. O'Toole. One of the challenges we have is upgrading established graduated return to work plans back to full hours. Can you provide some insights?

Yeah, look often we can get people this close and it's that final step. And if we're that close, we just see the light at the end of the tunnel and we want to get there, but there's always something. And it's about finding what that something is. And that involves that conversation, that in-depth conversation. Finding out what the individual's fear is, and also encouraging them. Saying, it's okay, we've got you to here and you've got here safely. That next step is still safe, because if it wasn't, we wouldn't recommend it. We wouldn't let you go and do it. And saying, try it, it's okay to say, try something and if you fail, we come back. But encouragement, communication, that is the key. And sometimes it needs someone external to come in and say, look, fresh set of eyes, I've never seen you before, let's look at the whole situation, actually Bluey it is safe, you're okay. And sometimes in those situations it's we'll actually Bluey, you know, you're right. You're not ready to go back or Bluey I don't think you can ever go back to that. But have you thought about doing this and that's 80% of what you do. Let's now talk to the workplace and say, can he just do 80% moving forward? Keep those communication options open.

And I would imagine another key word in that area is flexibility. Everyone has to be flexible.

Yeah, flexibility and compassion. I think they work hand in hand and actually showing Bluey that you care, that the workplace cares to get him back to normal living as much as possible and that back to full hours is a major component of that.

And I would imagine, again, it's a two way street 'cause the doctor's got to say, I wanna try this, but if it doesn't work, I'm prepared to, you know, do this, come back tell me, and let's try and work something else that might work.

Exactly and sometimes the hard decision has to be made. Bluey, you're all good. Go and do it and see that you safe and see that you can achieve it. And if I'm wrong, I have to say Bluey I'm wrong, let's pull you back. It's the communication, just try.

I'll give you a simple analogy. My son Mitchell, didn't like the look of watermelon wouldn't eat it. And then finally we said, it's safe, it's okay, you'll be right, everything and then he took a bite and he's never stopped eating watermelon since. So reassurance that it's gonna work, a bit of, you know, strengthen and I'll have a crack at this and then it just worked it.

But that worked for Mitchell because you were all there supporting him. He could see that there were a group of people there supporting him through that next step. And that's what we have to do when we come up to a barrier, we have to show that everyone involved in the process is there with the person to get them through that next step.

Excellent. Next question is from Cas and she says, Dr. O'Toole, I'm returning to work after two years leave from that position, one year sick leave due to a burn out, one year caring for a family member. I'm due to return in 2021. What questions should I be asking my manager or employer so I don't get burnout again and rejoin my work?

Look, 'cause that's a really great question. Obviously, there was something within your workplace that to you burning out. It may have been that the hours too long, it may have been that the tasks and demands of you were far greater than what you were able to deal with, because by sounds of things, you're very, very busy person. So before you go back, you need to speak to your employer about, has that changed? Am I going to be going back to the exact same situation that I was before? Because if there hasn't been a change, then it's almost inevitable that there will be burnout. Now, as part of your management of that original burnout, you may have learned new strategies to cope with it, and you might be able to go further than you did last time or you may not. And so you need to actually sit down and have that open discussion with your employer. Has anything changed? Are all those tasks and demands actually required? If they're not, then can we change it? Can I maybe start also on reduced hours and build back up again? Because it's been a while since I've been at work and I can't be expected to come in and smash out 38 hour week like that, I need to step back up. And these are the things that cause me concern in the first place, how are we together going to address that moving forward? Take dual ownership of it.

Doc and surely it's not a sign of weakness that if you say I can't cope with this or I struggled with this, or, you know, you just can't do it, that you admit to your employer, to the doctor that I struggled with this part of my job.

Yeah, everyone has a bucket of coping that we talk about and the bucket will fill and fill and fill and fill and fill, and then eventually it overflows. And with that overflowing, we get a little bit of a relief, but then it builds up again and overflows. And so, it's very difficult to build a bigger bucket. It takes time and sometimes you just have to say, well, this is my bucket. And I'm only going to be able to cope with this, I'm only going to do that. That's not saying that you're a weaker person. It's not saying you're a lesser person in any way, shape or form. It's like, I know exactly what my coping bucket is for my four children under the age of 13. And so I have a couple of hours a week that I just go, and then I come back cause I know what my coping bucket is.

Can I borrow that? Mel asks, how to combat fear of reinjury if the barrier is preventing getting a person to work.

Look, again, it's very, very complicated. We've got to try and find out why? Why that person is fearful of reinjury. And is it because they'd always been concerned about a particular task that they were doing in their workplace and they know when they go back there, they're going to have to do that task. Is it because they've had multiple injuries doing that task before? And so they just know, well, if I go back, it's just gonna happen again. So it's actually getting to the root of what fear of that reinjury is. And if it's a generalized fear, you know, I know that just going back to work is going to cause me injury, that's obviously a lot more difficult than if there's one specific task. Because we can talk about then, well, let's change that task. Because if you're fearful of getting injured, then other people will be fearful of getting injured of that task or showing that that task is actually safe 'cause we've made these alterations. So getting to the core of what the fear is, is the key.

All right, some great questions coming through. Here's one from Meagan who says, hello, are there some early warning signs or precursors that indicate an injured worker's fear, avoidance and potential catastrophizing is developing into a secondary psychological injury? Good question, yeah.

I'll just go get a psychiatrist to come in. Look, I think it's when the language is persisting and increasing in its intensity and frequency. We all catastrophize a little bit. And that's because when we are injured, we get more attention and that that's normal. You know, when people have a little bit of a sore back, you know, the hand goes into their back, etc, when they're walking around their family 'cause they hope then the kids will do stuff for them instead of them having to do it. Again, all normal. But it's when that just increases in its frequency and its intensity. And instead of the holding their back, they are holding up oooh as well, and then a oh, I can't do that. So you've gotta be mindful of how the language changes and increases over time. Everyone's gonna be different. Some people it will happen like that, some people will take weeks, some people will take months. And that's why controlling that fear at the start is really, really important to try and prevent it. And if you've known the person for a long period of time, you're going to have an indication when they're changing.

Or you'll know normal from abnormal. So relationship and trust with the GP, important?

It's vital and it's often difficult now because once upon a time you had the GP that literally delivered you and took care of you until either you or they were in the ground, hopefully them first, and that doesn't happen much anymore. It's very difficult to get a GP for life. We often go to a clinic and we'll see whichever GP is available first. So developing that trust can be difficult, but it is vital. And particularly if you do have a specific work-related injury, try and stick with one GP as much you can.

Yon is changing the focus for a bit. She says, hi, Sid as employers, how can we utilize some of the great resources on choosing wisely Australia and challenging GP's who want to refer for radiology within 24 hours of simple strains, etc, without any other indicators?

Yeah, it's very difficult. It's sorta like me rocking up to a lawyer and telling them how to defend their case. As they will, you know, you didn't go to med school for six years. And I think being mindful that they are coming from a pressured position, they often have the person who is injured demanding an x-ray. I have to get an x-ray of this, or I have to get the MRI and encouraging the GP to talk to the worker and say, well, there's no clinical indication for this and then explain why, but again, that takes time. And often some of the work that we do is actually educating GPs about that, reinforcing that there are guidelines for doing imaging because you often find things that are aren't related and that will distract you from managing the problem. And reassuring the GP, it's okay to say no to someone. And if they're upset about that, I'll talk to them and I'll say no as well and then they go, well, hang on, more and more people are saying no there must be a reason behind it. Again it's that showing people that reinforcement.

Explanation, communication. Sarah says, hey Sid, what is one of the most beneficial strategies an employer can implement to ensure they can facilitate early safe and durable return to work without exacerbating a worker's fear.

The most beneficial strategy is talk. Have a dedicated person within your workplace who manages return to work. If you're a small organization and it's just cost prohibitive to have that, utilize a service that does that. An open communication, never try to push something underneath the rug, admit something happened and work together. So what do you suggest we do to fix this problem? What do you suggest we do to help you get back into the workplace? Because that gives the individual who's injured control and a sense of control is what prevents people going down that secondary psychological avenue. So putting it back into the hands of the injured worker and working moving forward together and getting advice really, really early. I don't expect to see every single injured worker, but I'm always on the phone, if you want help you want that advice, just give me a call.

Be a good listener is part of being a good communicator, is it not?

Apparently so, I agree with that term. I'm a parent, sometimes I talk more than I listen, but believe it or not with patients, I don't. I generally ask an opening question and then just shut up for five minutes and let them talk.

And they'll provide the answer for you.

They do.

Or give you a way to find an answer.

Yeah, often and we sort of spoke about that earlier, when we're talking about time constraints on doctors. People just want to be heard. So if you give them the opportunity to be heard, often they've already started on that healing process because that weight is lifted off them and they believe that someone is caring and listening to them. And that's a huge step to moving forward.

Angela asks from your clinical experience, what is one of the most common mistakes you see in a return to work stakeholders making that intensifies a worker's fear and ultimately delays or prevents them getting back on the job?

I guess not talking or this is all too hard. I'm just gonna put this over here and it'll sort of take care of itself. We'll just get the certificates back from the doctor and we're not gonna actively engage with the injured worker to move forward. The workers now out here in the eighth and not knowing what's happening, they don't have any direction, they've lost contact with a significant component of their life which is work and their workmates. And that creates a chasm between the worker and the workplace, which exacerbates their condition and creates a further barrier to them coming back to work because they don't know if they ever going to belong.

Technical question coming up for you on notice. David, thanks for joining us. And David says, you talked about calling in occupational physicians to play a role where they can liaise with the treating GP. David says, I thought occupational physicians only did IME's and didn't have a trading role. How can we refer to an OC physician before we need an IME?

Thank you, David. Look, this is a common misconception and I'm actually the Queensland Chair of the faculty of Occupational Environmental Medicine. And it comes up repeatedly, why do people think that specialist physicians, trained specifically in the prevention and recovery from a workplace injury only get called on when it's too late, when we've got to decide what function a person has at the end. And as you said in your introduction earlier, the reason why we set up the organization that we did was because we would see across the course of a person's treatment where it went wrong and it was frustrating 'cause it's always the same thing. And anywhere between that, that four to six or eight week mark, you can see that something's not progressing as it normally should. And that's when you call in the OEP. The experts who can say, look, you're on the right track, it's okay, keep going with this, but it's taking a bit longer because Bluey is a smoker and he's a little bit overweight, that's all normal. Or look, you need to change tack a little bit because the evidence shows that this is the treatment. You know, things change over time, medicine advances over time. You know, once upon a time, we all thought that it was just stress that gave you ulcers but we now know it's a bacteria that causes it. And that's where we sit in the evidence base of return to work. What we once did, doesn't necessarily still work now. And we're able to give that advice to help the GP's moving forward.

Yep. Chris joins us. She gives you a wrap says, thanks awesome presentation, so there's

I'll take that,

But she's gonna give you a tricky question of course. How would you tackle a GP that catastrophizes an acute injury that will lead to a chronic injury?

Look, sometimes GP's are, as I said, under a lot of pressure and they've got pressure, not just from the patient sitting in front of them, but also the patient's family. And sometimes they are, as I said, treating a finding on an image, not necessarily treating a person and they also have their own fears. In those situations, what we tend to do is we talk to the GP and we work with the GP as a mentor or as an assistant to help them get that person through to the next stage. And you know, sometimes it's like, it's okay, what you're doing is okay. The person will be okay, we can all take a deep breath and that can reset their level of fear as well. And you know, it's not, we're not taking over the care of the patient, we're just adding that level of support in to the GP in an area of medicine that's poorly understood in a lot of areas. The first exposure a lot of people get in med school to work is getting injured is actually when they're out of med school as an intern and they're told to fill in a work cover certificate. So that foundation isn't there. So the fear is understandable. And again, that's what we're here for. We can actually be that mentor or so role.

Cause ultimately the plan is, everybody's working together to get that worker back on the job, to the best possible capacity that they can manage.

Yeah. And we always talk about getting the person back to normal living of which work just happens to be component.

A major component really.

Well for some of us it's 60% of the week, so.

Anna Georges, thank you Anna. She asks doc, how can stakeholders best facilitate return to work when managing the dynamics of both an employer and worker who are fearful? So it's fear on both sides.

That's always very, very difficult. It's hard enough to manage concerns of one part of the puzzle let alone two and then let's throw a doctor in there as well just to make it even harder. And again, it's communication, communication, getting expert advice when you need it. I've always found that case conferences are underutilized. I think getting everyone putting their cards on the table, talking about their fears and having an open communication shows that we're all actually headed in the same direction, we've got the same outcomes that we want, but then we can ask questions, we can come up with a conclusion at the end and set steps moving forward. And it's only by getting people down and it's gotta be frank and fearless conversation, which is difficult at times, but you need the right person to facilitate that. And there are brilliant facilitators out there for doing that sort of stuff.

Sid a couple of questions to go. Let's get on to Tips. And she says, hi, Sid, if a poor work culture and lack of support by management prior to an injury are a contributing factor to a worker's fear, how can this be adequately addressed?

Yeah, look, that is the most difficult component of any return to work is the underlying culture within a workplace. And culture unfortunately takes a generation to change because you can, if you've got 20 people in the workplace, you can't just change the minds of 20 people. I said, I've got four kids, I can't change the minds of two of them on any one thing at any one time. So trying to do 20, it's very, very difficult. And you have to use examples of where it's worked in the past and show organizations that by doing it this way, you get a better outcome. Here's why, here's when it doesn't work, let's use Acme incorporated over here. It just seemed to look extremely like your organization and how it's gone down a bad path and leading them through. But as I said, it takes leadership from the top down. The director of the company, the CEO has to take ownership of the problem and drive forward and then you've got to slowly chip away at that cultural change.

You mentioned Acme, it never worked for Wile E. Coyote for many, many years. He never actually caught the road runner.

No he didn't and I reckon if he ever did catch him, he probably wouldn't know what to do.

All right, which brings us to the last question, which is supplied by Andrea. And we thank everybody for your questions. Andrea asks, I often find that doctors don't engage very well if at all, with rehab offices, can you suggest ways to assist with getting them to engage with one another?

It's very difficult to get time with a doctor. And because of those time pressures we spoke about, they see a lot of the worker's compensation activities as just another administrative burden on top of them. So I guess when you communicate and communicate how this is going to save their time moving forward, if you have things that you need them to produce, giving them guidance or a suggested return to work plan that they can then amend or change so it's less time that they have to spend. Rehab is complex. There was a recent study, came out a couple of months ago and I'm gonna get the number wrong, but I think it was 53% of GPs wished they didn't have to see workers compensation claims. And a lot of that comes from how burdensome the admin is around it, because that takes time. To fill in a work cover certificate properly takes three minutes, when you've got, you know, less than 10 minutes for a consultation, that's a lot of time eaten up. So facilitating that communication by showing how you can make their job easier and get the outcome for their patient at the same time is more likely to get that engagement.

Well, thanks doc. Some wonderful advice and learnings here today. I just wanna see that I've done my homework properly and actions for workers and employers that I've picked up from what you've said today. Get a really good return to work coordinator, that another tip. Have a good work available for injured workers returning to work. So it's got to be meaningful so they feel productive.

Very much so, yes.

Set timelines for graduation and stick to them, but have a bit of flexibility.

Of course, yes.

'Cause things by arise. Roadblocks will occur and get a really good medical advisor who can work to assist you.

Very much so. And look, I guess from my point of view, the key messages are that fear is normal, it's understandable, but it's easy to achieve an outcome that brings the fear down just with communication. Just open communication is the key to everything.

That is your big take home message today, communication, communication, communication.

With the capital C.

Excellent. Well, thank you very much, Dr. Sid O'Toole for joining us today, that ends our session. Thank you for your company. The end of October is approaching, but we still have plenty of free, Safe Work Month virtual events on offer. These include sessions on reducing your stress temperature and managing the challenge of a multi-generational workforce. All you have to do is register and of course it's not too late. You can also access a full catalog of industry and topics specific video case studies, podcasts, speaker recordings and webinars and films to help you take action to improve your WHS and return to work outcomes. These resources are free to download and share from and Sid session will be online very, very shortly. In case you missed something or you wanna review a couple of those points that he did bring up. Thanks again, everyone for joining us and for supporting Safe Work Month and remember work safe, home safe.