Communicating with doctors - back to basics

Communicating with Doctors: Back to Basics

Dr Matt Brandth

Slide 1

Facilitator:

Hello and welcome to today's webinar on Communicating with Doctors: Back to Basics. My name is Natalie McSweenie and I will be your facilitator for today.

Slide 2

Our expert presenter today is Dr Matt Brandt, Occupational and Environmental Specialist, a member of our General Medical Assessment Tribunal and provides consulting service in south-east Queensland area. Before I hand over to Dr Brandt we have some tips on making the most of your webinar experience.

Slide 3

Firstly Dr Brandt will present for approximately 40 minutes. At the end of the presentation there will be an opportunity to answer your questions. You can ask your questions at any time by using the Q&A box on the right hand of your screen and we will collate and answer as many questions as we can at the end of today's presentation.

Slide 4

Also to encourage you to interact throughout the presentation we will ask a couple of poll questions. Again a simple prompt will pop up on the right hand of your screen and you will have a brief moment to respond.

Slide 5

I now invite Dr Brandt to share his expertise on treating doctors' role, benefits of early communication, potential barriers and solutions. Welcome Dr Brandt.

Dr Matt Brandt:

Well hey everybody and for those of you who don't know me or know of me, my name is Matt Brandt. I'm a consultant Occupational Physician. I've been working in the field of Occupational Medicine for about 14 years including several years if you like on the front line, where I've been treating workers who have an injury or illness and helping them to stay at work or safely return to work. I'm also currently a member of the Assessment Sub Committee of the Australasian Faculty of Occupational Environmental Medicine and we set the standards and examination assessments for doctors who are passing through the Occupational Physician Specialist Training Program. And as an examiner I assess the effectiveness of candidates' communication skills across a number of domains and a number of different types of assessments.

I perform varied roles including risk management advice, toxicology, forensic assessment of claim liability but in this context and in the rehab setting most of my work is in a consultation advisory role. So I'm advising employers and insurers on how they can attain the best possible safe return to work outcome for workers who have illness or an injury and that's whether it's work related or otherwise.

Slide 6

So here's an overview of the key topics in today's webinar and we're focusing attention specifically on the communication process primarily between the employer and the treating doctor involved in the rehabilitation and return to work of an injured worker.

Slide 7

Effective communication is a core requirement in medical practice. It does improve the health and wellbeing outcome for patients. It's also so important that APRA who regulates our ability to practice medicine considers that it's an essential component of good medical practice. For most treating doctors and in this context we'll focus on the GP but in most of the interactions the communication occurs with the patient and their family and to a lesser extent then with other health practitioners and to an even lesser extent with third parties.

Counselling and advice is a key aspect of the consultation and in fact it's been reported that two thirds of primary care consultations involve just that with no prescription of medication or pharmacology. When you introduce the workers' comp process, it's a different context and multiple stakeholders become involved.

Slide 8

The worker, the treating doctor, the employer, the workers' compensation organisation and I like to think of the various stakeholders as members of a rehabilitation team with the worker being the focal point. And all key stakeholders are going to be involved in the communication process at different points in time and not usually altogether at the same time. And to have an effectively functioning rehab team you need to have an effective communication process. And a little bit later on I'll have a stab at what I think is a definition of an effective communication process and what the objectives are.

Slide 9

But before that I'd just like to outline my understanding of what the role of the treating doctor is in this whole rehabilitation and return to work context. Well primarily, the treating doctor's role is to treat their patient. The treating doctor is considered to be a patient advocate and I think there's a community expectation that the treating doctor provides patient centred care and will act in the patient's best interests and respect their wishes and their dignity and autonomy. But the workers' comp process introduces a broader context and I believe and I'm happy to debate this, that there is an obligation on the treating doctor in this context to embrace evidence based practice in regard to rehab and return to work because we now really understand the evidence behind health benefits of work and I'll briefly touch on these principles.

The health benefits of work principles support an early return to work where possible. There's an understanding now that the longer the patient is off work the less likely they are to return. There's an understanding now that recovery occurs quicker when people are back at work, almost irrespective of the nature of the condition or injury and we know now that people who are off work for longer periods of time do have an increased risk of adverse health, social and economic outcomes.

Slide 10

So there are benefits in an early communication process and I just wanted to mention a few interesting and important principles around the benefits of early communication with the treating doctor in mind. There's strong evidence that committed and coordinated communication and early action from key stakeholders is crucial in maximising a successful outcome for the return to work process. We know that treating doctors and other health professionals do have a significant influence on return to work outcomes – so work absence and work disability particularly in relation to medical certification practices.

Slide 11

Doctors who recommend an early return to work are significantly more likely to support an early return to work and in fact it's significantly more likely that the individual will then return to work as well.

Slide 12

And for anyone who is interested in reading some research on the area of return to work interventions Franche et al have conducted a systematic review of the literature which is available online and I think one of the key messages that they provided was that there is strong evidence that contact between the health care provider and in this context the treating doctor and the employer is associated with a significant reduction in disability duration and associated costs.

Slide 13

So before mentioning some of the things that can be done to prepare for an effective communication process I thought it would be worthwhile presenting my idea as to what the objective of communication is in this context.

Now the next slide is going to be a poll question.

Slide 14

And the question is "What difficulties do you encounter when communicating with a treating medical practitioner in order to facilitate rehabilitation and return to work?" We'll have a pause for the next minute or two to give everyone a chance to answer the question before we move on.

Slide 15

Well thank you for all your poll responses. I thought it might be worthwhile mentioning some of the things that can be done to enhance the communication process, so tips that can facilitate an effective communication process with the objective in mind. I'm mindful that a lot of the audience are likely to be very experienced professionals and maybe that you have other strategies and processes that you follow and it would be great to share those experiences so that we can enhance the educational experience for all of us today. But I'm also mindful that some of the audience have less experience and might be starting out in this type of work and as I move through some of these tips I don't want to convey the impression that there's necessarily one best way to do it.

The tips that I discuss are based on my experience and my discussion with my peers and with employers and also a review of the literature including published Workers' Compensation Guidelines. In general my feeling is that prior planning and preparation will maximise the outcome. Looking strategically if there's an organisational culture and a management system and processes that facilitate and support early reporting even of mild systems, there's a higher likelihood of being able to intervene early.

In the ideal situation it's of the best benefit to establish contact with the injured worker as early as possible after they report symptoms or an injury, preferably on the date of injury. One of my clients is proactive and engaging where possible before the worker even attends the treating doctor and this provides a framework for the conversation that the worker can then have with the treating doctor. And during that discussion there will be obviously important things to find out how the worker is and what can be done to help them but there's a discussion in regard to the available suitable duties and the return to work process. And I guess the worker may not be familiar with the return to work process and the availability of suitable duties because whilst they may have been provided with this sort of information at orientation they may have forgotten.

So much benefit from having that early contact with the worker before they go to the doctor preferably on the day of injury where possible.

Slide 16

But it's not always possible. If you're in a 24/7 operation the worker may suffer an injury after hours. So you may not be able to speak to the worker on the day of injury. But also say you receive a call from a worker who says they're phoning from home and they're unwell or they're injured and they haven't seen a doctor yet, it may not be known exactly at that time what you're dealing with, but there's a chance that this could turn out to be a work related injury.

My recommendation is to obviously enquire in an empathetic manner what the problem is. So importantly ask them how they are and how the problem is affecting them and what you can do to help them. If they suffered an injury or they think they may have suffered an injury, ask how it occurred and again this sets the train for early intervention and being proactive.

Slide 17

From my perspective I think it's imperative that the worker consults with the treating doctor as soon as possible following an injury event or the reporting of symptoms. I'll touch on this a little bit later but it's certainly my recommendation that you offer the worker that you could attend the clinic with the worker even if it's for a discussion with the doctor after the appointment. We'll touch on that a little bit later on.

If the employer has an alignment with a local medical clinic the employer can recommend that the worker attends that practice but it can't be enforced and ultimately the worker can choose which doctor they wish to see.

As an aside I just wanted to talk a little bit about the benefits of aligning with a medical provider or an occupational health clinic. It can certainly improve the level of service that your employees obtain if they're injured and anecdotally the treating doctors from such clinics are more likely to have experience in acute injury management and rehabilitation. They're more likely to take into account the health benefits of work principles and anecdotally they're more likely to use their CPD, their Continuing Professional Development to remain up to date with the changes in occupational health and in the workplace and again to facilitate a return to work. But the other benefit is that the treating doctor will establish a relationship with you and they can also obtain a good understanding of your duties and your workplace and again that can help to facilitate a safe and sustainable return to work as early as possible.

Slide 18

Another useful communication tool is the Injured Worker Pack. It can be a very useful resource. It has multiple benefits. I think primarily it demonstrates a level of commitment and support both to the wellbeing of your worker and their return to work but also to an effective communication process. But there can also be some very useful pragmatic information in there in regards modified suitable duties etc. and contact details.

As an aside I've worked with a client to help prepare a task analysis and develop a matrix of job demands – so physical, psychological and cognitive – for various roles and tasks and from that we were able to develop a suitable duties register for inclusion in the Injured Worker Pack. And it can actually also be useful in instructing the risk assessment process.

Slide 19

I'd recommend that you establish contact with the treating doctor as early as possible and don't wait for the doctor to call you. From my perspective and from the perspective of many of my clients face to face is the preferred mode of contact with the treating doctor. My recommendation is if you can't attend the initial appointment or very soon after, arrange to visit the clinic at a later time or arrange for a telephone discussion with the treating doctor and fax an Injured Worker Pack to the treating doctor.

Slide 20

As previously mentioned I think there's benefit in having a discussion with your worker before they see the doctor if possible where you can offer to attend the appointment with the worker to facilitate a conversation with the doctor and this has a number of benefits. First of all finding out how your patient is and what you can do to help them in their recovery but also having a discussion with the doctor as to what can be done to facilitate a return to work. Having said that I don't think you can expect to be present during the treatment consultation but it's quite reasonable to ask to have a few minutes with the doctor after the treatment consultation has completed.

Slide 21

So what can be done to maximise the outcome? I think being prepared. So having prior planning and preparation. In fact you may have had more time to prepare for the conversation that you have with the doctor than the doctor will be able to spend with you after they've seen the patient. I've had a think about this and I think there's some key messages to convey to the treating doctor that may well maximise the likelihood of being able to help their patient – your worker return to work safely and early.

First of all conveying to the doctor that their patient – your worker is a vital important part of your workplace and you want to assist in any way to help with their recovery. And obviously then providing some pragmatic information about suitable modified duties that are available as soon as their patient is considered to be medically fit to be able to return to work. And informing the treating doctor of your role to support the worker in their return to work and to ensure that duties that are allocated are within the restrictions provided. And finally to reassure the doctor that the worker will be regularly supported and reviewed during their return to work.

It's all very well but you have to do what you say you will and obviously it has to be a safe environment for the patient to be able to return to work.

Slide 22

And there's just a few other tips here as to some of the other aspects of communication. So attending review appointments and following up with telephone calls and video conferencing. This is very beneficial because it's a two way communication process. First of all it gives an opportunity for the doctor to let you know how the patient's going. Are they recovering as expected? Are there any changes to treatment? But it also gives you an opportunity to share with the doctor how the worker is coping with their return to work and whether we're now ready to start upgrading duties and perhaps giving some idea of any difficulties and barriers that have been identified along the way.

Slide 23

So there's another poll question. So "What do you find useful when communicating with the treating medical practitioner?" and again we'll have a pause for a minute or so to give everyone a chance to answer the question.

Okay. Thanks everyone for your response to the question. So I've talked around a few ideas about things that can be done to plan for an effective communication process with the treating doctor. I thought it would be worthwhile now talking a little bit about some of the barriers and obstacles that can arise in this process and some ideas for potential solutions.

Slide 24

There's lots of potential barriers and obstacles to an effective communication process. I'm going to touch on just a few examples that I've been able to think of and these aren't necessarily in any order of importance but I'd be more than happy to hear from the audience of any other obstacles or barriers that they've encountered and how they've tried to solve them.

Geographical factors are more likely not going to be an issue for some of the audience. We live in a very big state and in fact some of you may also provide rehabilitation services for workers around the country and the distance between your office, between the remote worker's work site and the treatment centre could be vast. So it's understandable that you may not be able to get there in person to see the doctor. But we've got so many technological solutions available now and telemedicine is huge in Australia now.

I wanted to now raise the issue of the 'Gatekeeper' and that's the barrier that may occur between attempts to contact the clinic and actually getting to speak with the doctor. And often it's the clinic reception staff that may be the gatekeeper. To be fair they're ensuring that the clinic is running smoothly and they've got a very important role in protecting the doctor's workload and time.

If you feel that there is a gatekeeper effect creating a barrier in being able to speak with the treating doctor by phone there are a number of things that could work. For example calling the clinic and asking to speak to the doctor. Now if the doctor is unavailable ask the receptionist for the most convenient time to call back or whether you can leave your contact details so the doctor can return your call.

Slide 25

If the worker hasn't already been provided with an injured worker pack then let the receptionist know that you'll send it through but also let the treating doctor or the receptionist know that the doctor can charge for any phone calls for the time spent on the phone discussing the injured worker's return to work. In terms of strategic management it's my view that if you're aligning with a medical clinic or an occupational health practice with interest, expertise and an organisational focus in occupational health then hopefully the gatekeeper effect is less likely to be an issue. But also I'd recommend that you take steps to build a relationship with the clinic manager as well.

Slide 26

Well in the poll response we've actually found that not returning the phone call is perhaps the biggest barrier that members of the audience have encountered. Why does this happen? Well doctors are obviously very busy. They can be pressured with their workload. They may not be at work and there may be other reasons as well.

One of my clients has an ongoing problem with a particular treating doctor who fails to return their phone calls but will happily sign off on the suitable duties plan. The problem is they've got a worker who is going to be on long term restrictions during the recovery from their condition and the employer has been endeavouring to accommodate this worker and place them in suitable alternative work consistent with their transferrable skills. The problem is this doctor did not provide sufficient clarity when completing and signing the suitable duties form regarding the duties that could be performed and so forth and wouldn't return the call. And this has created some delays in the process for all concerned.

Now there may be a role in this instance for a workers' compensation insurer to facilitate the process and break down any communication barriers, but there's also a role for an occupational medicine consultant to become involved where they can actually help to open up the communication channel to provide that link between the workplace and the treating doctor and to provide some clarity around fitness for work and restrictions.

So what can be done? Well find out which method of communication suits the doctor best. As I said it's ideal – face to face is ideal but if you can do it in some other way so be it. Endeavour to build a relationship with the clinic reception staff and the doctor and again money talks. So let the doctor or receptionist know that the doctor can charge for phone calls for the time spent on the phone discussing their patient's return to work. I feel that there may be benefit in situations where you're not getting anywhere where you ask the workers' comp insurer to assist.

Slide 27

One of the other barriers that can be encountered and certainly one that some of my clients have told me about is that some treating doctors will have limited confidence or understanding, appreciation and knowledge of workers' compensation. They may not be up to date with the health benefits of work. They may not understand your workplace or your duties. So my advice is in that situation be prepared to educate the treating doctor to facilitate increased understanding.

Slide 28

Just touching again on the potential barrier that might be created by treating doctor advocacy. The doctor might feel that it's in the patient's or worker's best interest to have a certain return to work plan and perhaps that they're not ready to return to work yet. They may actually be fit to return to work in some capacity and I think the best thing you can do then is really the steps that I suggested before where you reassure the doctor that your role is to support the worker to safely return to work or remain at work and that you want to help in any way you can with their recovery and that certainly it's safe for the patient to return to work.

Slide 29

This slide is on the workers' compensation medical certificate which is a very important communication tool and I've written a few in my time and I've also read many certificates in my time when I'm reviewing case file notes. In my experience they're not always filled in very well. They can be a very non specific term used. There may actually not be a diagnosis, so for example low back pain or there can be a real lack of clarity in terms of the restrictions for the patient to return to work. The certificate is a very important communication document. It's an entry point to the workers' compensation process and it should be provided by the treating doctor at the first consultation and thereafter with any change in treatment plan, work capacity or rehabilitation plan. And it's a really important document to facilitate the employer to develop a suitable duties plan and if you're finding that the information in regards restrictions and work capacity is unclear my advice is to contact the treating doctor for clarification.

Slide 30

Facilitator:

Well thank you Dr Brandt for a very informative presentation. We have some time for your questions. Just to remind you to use the Q&A Panel on the right hand side of your screen to ask these.

Dr Brandt we've had a question from our audience. You've used the term "empathetic" throughout your presentation. Can you describe an empathetic approach and can you give an example where a coordinator may not have shown this kind of approach?

Dr Matt Brandt:

So what is meant by "empathy" in this context? Well, I think it's putting yourself in the worker's shoes. So really finding out how they are and how their injury is affecting them and importantly conveying to them a level of support and ask them what you can do to help them. And I think that demonstrating the empathy in the context of your interaction with the doctor is important.

I've had one experience in the past that I can recall where the return to work officer was in the room with the patient but did not, at one stage, ask how the patient was and how they were going and simply wanted to know how soon the worker would get back to work. And I guess, from my perspective as the treating doctor, it made me wonder how that worker was going to be treated when they were back at work.

So hopefully, that sums up my impression of what empathy is and how important it is in this process.

Facilitator:

Thank you doctor.

[End of Transcript]