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ON - Opportunities for capacity

Dr Graeme Edwards presents 'ON - Opportunities for capacity'. Find out how the new Work capacity certificate – workers' compensation, can be used as an effective communication tool for general practitioners. Learn useful strategies for when an injured worker is certified as totally incapacitated for work, and better understand the new work capacity certificate's functionality, including in the preparation of suitable duties programs.

Dr Graeme Edwards is a Fellow of the Educational Supervisor of Trainees. He is a former Chair of the Faculty Policy and Advocacy Committee, with the Australasian Faculty of Occupational and Environmental Medicine in The Royal Australasian College of Physicians. He balances the industrial and medicolegal side of his practice with his general practice.

Dr Edwards has a unique combination of medical, business and communication skills. Dr Edwards' commercial expertise is derived from extensive experience consulting and presenting to business in strategic planning, business planning and human resource management.

Watch the webinar to gain insight into an injured worker's capabilities when they receive a work capacity certificate.

Download a copy of this film (ZIP/MP4, 11MB)

Realising Potential Capacity

Opportunities when certified TI

Dr Graeme Edwards FAFOEM-RACP, Consulting Physician, Occupational and Environmental Medicine

Slide 1

Slide 2

Good afternoon everyone. Welcome to today's session on Realising Potential Capacity - Opportunities when certified TI. The topic and expert speaker is brought to you by the Office of Industrial Relations. We are committed to driving initiatives across the whole scheme that improve safety, wellbeing and return to work outcomes for both employers and workers. My name is Amanda Krebs and I am the Education and Engagement Coordinator. I'll be your Facilitator for today.

Our session today will discuss strategies to find capacity opportunities when a worker is certified as totally incapacitated on a medical certificate. The session will go for approximately an hour and we will send all participants a copy of the presentation slides following the session. The recording of the session will also be made on the WorkSafe Queensland website shortly.

Slide 3
So now on to our presenter Dr Graeme Edwards. Dr Edwards is a Consulting Physician in Occupational and Environmental Medicine as well as a General Medical Assessment Tribunal Member. He balances the industrial and medicolegal side of his practice with an ongoing commitment to general practice. He's happy to take questions throughout the presentation today, so please don't hesitate to ask them if you have them. We'll now hand over to our expert. He'll be able to share his wealth of knowledge on this topic. So thank you Dr Edwards.

Slide 4
Dr Graeme Edwards:
I'll begin with two key concepts – rehabilitation at work and effective return to work. I'd like to explore with you two critical aspects of realising the potential capacity associated with an injured worker – effective case management and engaging with the certifying doctor. I'm going to do so from a doctor's perspective. Why? Because I would like you to understand the game. I like the analogy with the game of chess. You are a piece of the playing board moved around during the game. If there is one thing I would like you to get out of today it's a willingness to be a player, not just a piece on the board. As a player you can start as a novice and you can progress to mastery but if you don't understand how to play each of the pieces on the board you are never going to succeed. So what I would like you to achieve from this session is a better understanding of the role of the doctor, the medical certificate as a communication device and the value of case conferencing.

Some of you will already have a degree of mastery. So I'd like to remind you of a lesson I learnt from one of my mentors, a fellow called Buckminster Fuller. He encouraged me to dare to be naive for I cannot learn this. If I've heard something before, when I hear it again when compared to the last time I'm actually hearing it from a new starting point. So I invite you not only to listen but to think and think about what you might learn this time that will enhance your mastery of the game, to realise the potential capacity in your injured workers.

So rehabilitation at work and effective return to work requires recognising gainful occupational activities have long been recognised as beneficial to people of all capacity. It is the fundamental basis of the discipline called occupational therapy. But what we see all too often is people not making the connection between gainful occupational activity and work. If you surveyed the popular press and general media you may easily develop the impression that mean, nasty employers set out to deliberately injure, kill or main their workers. But that's not my experience.

Slide 5
In Queensland alone there were just under 90,000 workers' compensation claims lodged in 2014-15 financial year. 25,000 of these were serious enough to require more than seven days off work and all these claims were estimated to cost the Queensland economy $12.3 billion. But the good news is most people get better. However for some injured workers not having the systems in place will cost you and your business a fortune in time, energy, effort, statutory claims costs and common law damages. For some businesses the cost to the business will be highly significant.

Slide 6
Fortunately if you look at these numbers from another way approximately 57% of claims are recorded as not requiring any time away from work.

Slide 7
Over 20 per cent of injured workers actually return to their same job and about another one per cent of injured workers return to work in a different job but with the same employer. Based upon the 2014-15 statistics there is a further six per cent who are fit but not with that particular employer. If you look at the average cost of the claims medical expenses only, we're talking about $1,700 on the average cost. However ten times that number, $17,000 is the average cost of claim for someone who is away from work. But when you're thinking about these numbers remember the nature of the injuries are not directly comparable. So it is simply not a matter of being at work dramatically reducing the cost of the claim.

Slide 8
If you drilled down onto the impact of psychological injuries and in brackets you'll see the combination of the psychological injury and the physical injury, the statistics are much more concerning. Only 64 per cent of workers with a psychological injury alone will return to the same job. About 2.5 per cent will be able to return to work with that same employer but with a different job and between 20 per cent and 30 per cent of injured workers will be fit but not with that employer. So between one in three and one in five people with an accepted psychological injury were fit to work but not with that same employer.

Slide 9
So it's important to remember that suitable duties critically depends upon the employer, not the doctor and that's not the message that I commonly hear. With a physical injury suitable duties requires consideration of the injured workers physical abilities matched to the physicality of the task requirements and the workplace environment. In contrast when there is a psychological condition but when there is both a psychological condition and physical factors the vocational rehabilitation plan needs to incorporate a cognitive dimension, what I call an agreed contingency plan. The return to work contingency plan then addresses not only the physical task requirements but also the perceptions of both the individual and the immediate supervisor. This establishes an agreed action plan to be followed in various circumstances designed to enhance, improve the worker's confidence, resilience and their capacity while at the same time reducing the risk of relapse. It's the strategy necessary to reduce the risk of reinjury.

Slide 10
We can make a difference for a significant proportion of those people who are certified as requiring time away from the workplace. By understanding the role of the doctor and the employer together we can make a difference. Empirically for the significant proportion of those people who have some capacity at work, they are clearly better off at work and the evidence base to support this statement is growing.

Slide 11
The longer someone is away from work the less likely they will ever return to work. The Faculty of Occupational and Environmental Medicine first promoted these numbers in 2011 and they were based upon research published in 2002 by Johnson and Fry from some research for the Victorian WorkCover Authority. These numbers were specific for males and for the nature of workers in their study. In 2011 they were highly appropriate to generate debate and conversations. Since then the published evidence and another look at the mathematics behind these numbers means the specific numbers are not absolutely accurate. They don't translate across different jurisdictions or injured worker populations. So technically these numbers do not directly apply to the Queensland situation. However the collective evidence has affirmed both the magnitude as reasonable and the trend is definitely repeated across different studies and for different populations. So the numbers are still reasonably indicative and applicable today even though they were based upon data collected over 15 years ago. An inescapable fact of life is that as we get older and with the passage of time more and more information becomes known.

Slide 12
So the Faculty reviewed the research on which our position statements around the health benefits of work were based in November last year and this was released only last month. So we are incorporating today information that is hot off the press, highly topical and very relevant to our topic.

Slide 13
Simply put the evidence is clear. Good work, a safe, healthy, engaged and productive workforce makes a positive contribution to the health and wellbeing of the worker and those affected by the worker.

Slide 14
If we drill down into the mental health issues then the work of Van der Noordt and colleagues is enlightening. This slide includes in the background a forest plot created by a systematic review of prospective studies. I want you to focus on the two circled diamonds. Neither diamond crosses the vertical line. This is important as it means there is a good correlation between the studies that were of sufficient quality to analyse and there is a high level of confidence in the conclusion. The research shows clearly that employment is a significant factor for both improving the general mental health of the workforce and reducing the risk of depression. Consequently we need to look more constructively about how we assist workers with psychological injuries to reengage with the workplace as soon as reasonably practical.

Slide 15
Fortunately for most people it's easy. There is no real planning necessary to enable them to return to work. But for those who can't return to work immediately we obviously would like them to do so as soon as reasonably practical. The key concept here is planning, not the plan. It is the processes involved in having the conversations, in talking to people, thinking about the issues relevant to the business and the injured worker and then working out the contingencies concerning the 'What if?' scenarios should things don't progress quite the way you hope. Building the confidence and engaging with the injured worker that enables you to create success.

Slide 16
So as I've said previously most injured workers get better without too much drama. So from my perspective what you deserve is one thing – the ability to detect the case that might go bad, a system that enables you to detect, prioritise your efforts and allocate the limited resources available to you to make the biggest difference for both you and the individual that you're aiming to assist.

Slide 17
So the key message for effective return to work is your system for planning the rehabilitation at work for your injured workers. The evidence indicates if you do this for the potential psychological scenario and applying the principles across your workplace you'll get better results. So let's move on.

Slide 18
Firstly let's look at these terms 'capacity' and 'functional capacity'. These are concepts you will hear more and more about. Presently there is limited common understanding about what they actually mean. Capacity is a concept of theoretical maximal ability derived from population statistics that describe a group of people. It's an estimate of normal. The functional capacity of an individual is a comparison of the individual's current assessed ability, what they can actually do against their conceptualised maximal ability of their capacity. For any one individual there are various determinants of ability that may be suboptimal at that point in time and potentially modifiable by education, training and conditioning. From a medical perspective all forms of treatment and medication come under the conditioning banner and may affect the individual's ability to be educated. So these concepts apply equally to the physical injury as well as the psychological injury.

Slide 19
So when we talk about capacity what we're also interested in is the individual's ability, their ability is significantly influenced by an individual's tolerance and tolerance is this phenomena that cannot be reliably measured or consistently tested. It's heavily influenced by personal choice and can change to reflect the prevailing attitudes and beliefs of the individual. It's associated with a perceived level of comfort. So while an individual's ability may reflect an individual's general physical conditioning, more commonly it reflects their psychological resilience or endurance from the duration or intensity of effort required to do the job task rather than their technical and physical ability to complete the task itself.

Slide 20
Another challenge you have is that you have a legal obligation to understand and as far as reasonably practical accommodate the worker with a disability and their rehabilitation requirements. This is where the Workers' Compensation legislation significantly overlaps with anti-discrimination legislation. But the information received reflects the questions asked and in this situation the initial questions asked are in the form of the approved medical certificate, what soon will become known as the certificate of capacity. This is a structured communication device to facilitate communication between the certifying practitioner and all other stakeholders involved in the game. A lot of work is currently being invested in redesigning the certificate to enhance the quality and the consistency of the information you receive. So regardless of the form of the certificate I again ask you to dare to be naive. If a response does not make sense for any reason then I implore you to trust your intuition and seek clarification. The bottom line is you are allowed to question the doctor but if you are not receiving an answer that makes sense ask yourself 'Am I asking the right person the wrong question or the right question but the wrong person?'

Slide 21
So from my experience there are basically five flags of potentially challenging cases and they are intuitive. I'd like you to trust your intuition. It is a very powerful human attribute which I greatly respect and value. It is a tool readily available for you to use. If the diagnosis doesn't make sense to you, if you are not getting information in the detail necessary to construct a suitable duties plan or you receive the unexpected totally incapacity certificate that does not seem to fit the circumstances as known to you, or if your worker is not getting better the way you expect given your previous experiences or the information that has been provided and particularly if you are frustrated with the communications on the certifying doctor – these are the flags of the potential problem worker. Awareness of these factors will tune your antennae. Trust that gut feel concerning the cases and use these flags to trigger an escalation of your efforts. Simply put, you have the right and the responsibility to respectfully question the doctor and the injured worker. The sooner you tune into and then act on that sense of something not being quite right the quicker and more effective will be your management of the case and achieve the optimal outcomes for this worker's rehabilitation.

Slide 22
The problem that we have as medical practitioners is that we are working in busy general practices and even for experienced practitioners the importance of various rehabilitation or psychosocial issues may be hidden and not fully appreciated during the short timeframes of contact with the injured worker. It takes time for new knowledge to manifest in clinical practice. So you will experience varying degrees of competency among the medical profession. There may be times when the practitioner involved is working from old knowledge. While generally advising you and their patient with good intent they may create confusion and frustration to you and your worker. So remember it takes time for best practice to reach a level of awareness, acceptance and adoption before mastery is attained and that applies to any profession, not just medicine. This leads me to outlining the important role of the employer representative in effective case management.

Slide 23
The National BEACH Study of General Practice has revealed that for the average general practitioner less than two per cent of their case load may be associated with a work-related injury. That's less than one in 50 patients. Given that most of these will be straightforward, it's quite reasonable then to understand that the majority of medical practitioners will not have a caseload experience of dealing with the difficult case to pick them up early. The subtleties that are important to your worker. It is only when a service provider perceives a discordance between the expected recovery and the findings or behaviour of the injured worker that the importance of an unrecognised problem may be appreciated. This need to perceive is paramount.
So it's not surprising to me that you may perceive a problem before the doctor is aware of an issue. Consequently it is critical for effective case management for there to be effective partnership between the certifying doctor and the employer to support the comprehensive rehabilitation needs of your injured  worker. So that you can communicate information in a timely, efficient and respective manner then we will achieve a faster and more accurate insight to the advantage of all involved.

Slide 24
So having expanded your understanding of the doctor's perspective I want to return to the system issues of effective case management by illustrating what might be contributing to a protracted claim. There may be an incomplete or a misdiagnosis. The understanding of the mechanism of injury is critical to assessing what might and might not be the work-related injury. I'll spend more time on this issue later when I talk about the medical certificate shortly. There may be treatment related issues. Is it a realistic goal that given the circumstances of the injury and the nature of the underlying condition that this worker return to the same job that contributed to the injury? If the worker is not going to return to their pre-injury role then we need to activate strategies as soon as practical so as not to frustrate all parties by setting up false expectations.

Next I will touch upon this thing called the biopsychosocial issues. When we were young and invincible sleep was thought to be discretionary. However the more we know the more important sleep is to our resilience, ability to cope and our reparative functions and recovery. Dysfunctional sleep is a major factor influencing the speed of recovery of your injured workers, often under-appreciated by the patient and the doctor. Yellow flags are specific biopsychosocial factors that are associated with and likely to be predictors of chronicity. So not all biopsychosocial factors are actually yellow flags. In 2005 I conducted a research project looking at the prevalence of yellow flags at the time of first presentation to a specialised workplace injury clinic.

Slide 25
These are the top five findings. Notice the beliefs of the injured workers. Sixty-five percent indicated a need for active guidance and nearly 60 per cent expressed a fear of further harm. Almost half believed that they needed to stop their activity in order to get better. Notice also that 55 per cent of patients on the day they first presented to the doctor were reporting less than ideal sleep. That does not mean they had a diagnosable sleep disorder, but it does mean that they were most certainly vulnerable to adverse outcomes. Now not all these people demonstrated delayed recovery, in part because I was actively addressing the issues. However it highlights how difficult it can be to distinguish the signal of a case that needs more resources from the background noise of normally injured workers during the early phase of their recovery.

Slide 26
Returning to the other areas that may give rise to protracted recovery. There can be employer related issues where there is a breakdown in the injured worker's relationship with fellow workers, their supervisor or their manager. There may be genuine difficulties in defining reasonable accommodations for the nature of the injury. When I first went into occupational medicine I was the medical advisor to a large bottling plant in Brisbane. With the HR Manager we implemented a program focused on absence management. What I found was that the level of productive activity of our injured workers when they were about 80 per cent better was the equivalent to a full time equivalent. When we had these injured workers in a controlled workspace environment engaged in productive activity their productivity was actually better than the general workforce. Not only was their timely return to work good for their recovery, it was also good for the business. It was not just about getting someone to read a manual or lick stamps or do that filing there never seems enough time to do. This outcome was dependent upon specialist medical advice concerning the nature of the duties that they were performing appropriately and safely to the advantage of everyone.

So most of you will not have the resource of a specialist to advise you. However if you do need assistance then the important message is your insurer can assist. Finally if we look at this thing called case management issues, are all the stakeholders working with a common understanding and are the rehabilitation needs of your worker being adequately coordinated? Only this week I assessed a worker whose physical therapist was being overly cautious treating the worker's back pain and not recognising the psychosocial vulnerability that this escalated in the mind of the worker, creating a barrier to their effective return to work.

Slide 27
But before I do I want you to better understand what is going on in the mind of the doctor. How do we formulate the working or provisional diagnosis, the medical methodology of how we come up with the diagnosis and decide how we might treat or investigate the individual? As I said the better you understand how this piece on the chess board moves the greater your competency as a player of the game. When an injured worker comes through the door we are already starting to conceptualise what might be wrong. The patient opens their mouth and talks to us. They demonstrate and they interact with us and we develop what we term a 'differential diagnosis' from which we choose the most likely working diagnosis, narrowing or expanding the possibilities as we attain their history. We then test and refine our thinking by specific probing questions correlating and cross-correlating the accumulating information provided with the biologically plausible concepts given the situation that we're being informed. Then we test our diagnosis by the laying on of the hands, the targeted examination that affirms or otherwise the diagnosis.

So we don't usually need to do a comprehensive examination in order to make a diagnosis or treatment recommendation. When necessary we also test the thinking by appropriate investigations, observing the response to treatment or we may obtain expert opinion. The response to treatment in itself can be a valuable clue. So if you think the cause of pain is an inflammatory process but the pain does not respond to anti-inflammatory drugs then it may not be an inflammatory process causing the pain.

Slide 28
So let's now return to the certificate. This is a structured communication device. From some doctor's point of view it's an obligatory nuisance. Too often it is completed poorly usually because its purpose is not understood or the doctor has not been trained in how to use it as an effective communication tool and historically it asks for information that even I may not know. So remember what I said earlier. The information you receive reflects the nature of the questions you ask. So I'm very encouraged that with the delivery of the new certificate of capacity we're going to have a more effective tool that is more reliable and consistent in providing you with information that enables you to do your job.

Slide 29
Having formed the diagnosis what we put onto that certificate sometimes all we can do is summarise a collection of symptoms. At that initial consultation we may not have a diagnosis. A common example is low back pain where we do not have a specific site, a specific structure or a clear mechanism that may be generating the pain. So even if the 'provisional diagnosis' box is not ticked it does not mean that the words in the diagnostic box is an actual diagnosis.

So let's look at the cognitive processes underpinning the completion of actual certificate. For example ticking the 'provisional diagnosis' box is an important communication between the doctor, you and the insurer. It is signifying something is missing to make a diagnosis and this may include a discordance or an inability to readily reconcile the reported mechanism of injury and the clinical findings. So one of the challenges about the certificate as a form and any form for that matter is that it requires the doctor to stop, think and descend from operating at a level of unconsciousness to record consciously what they are thinking. We all go about our day-to-day activities working at an unconscious level of functioning. To stop and tell someone else what you're actually thinking is actually hard to do well unless you know what to do, practice conceptualising the suitable constraints and work within a supported system. It takes time to gain mastery. So given that we're talking about something that most GPs do infrequently, it is not surprisingly that their efforts are less than ideal.

Slide 30
So effective case management relies on effective communication. As an important piece of the game and working as a player I encourage you to advise the certifying practitioner of any circumstances at work or elsewhere that you feel might be relevant to the doctor's considerations. They should be respectfully related to the doctor. Ideally this should be done with the insurer's knowledge but the consent is not necessary. Things like your workplace's capacity to accommodate a disabled, injured or ill worker. The resources available to you at the workplace or via the insurer. These are things that you may know that the doctor may not.

Consequently I implore you to communicate with your practitioners and if you have any concerns about the workplace capacity to accommodate an injured worker communicate that concern as soon as practical to both the doctor and the insurer. The sooner you do that the quicker the issue can be addressed. So if you think something might be relevant please communicate it. We expect and it is the doctor's role and the responsibility to use their professional judgement to weigh and discern the relevance of the information you provide when assessing the needs of their patient. So any circumstances that you think might be relevant please communicate them. Simply put, if you don't tell them they may not know. That way we can approach best practice.

Slide 31
So best practice promotes rehabilitation at work whenever possible but remember it is not always practical and sometimes planning is necessary before it can happen. Consistent with a biopsychosocial model of multidisciplinary care, integrated patient-centred care respects the diversity of healthcare providers and stakeholders involved in any one injured worker. During my medical training at the undergraduate level, that is when I was at medical school, it involves studying one subject after another after another. But there was always a focus on multisystem analysis and hence multidisciplinary considerations. Once we got into the hospitals our training and focus was rightfully on addressing the immediate disease, injury or condition affecting that patient. Highly appropriate for specialist needs and training of our hospital-centred specialist medical practitioners, it's not surprising then that considering the traditional model of medical education our doctors leave the hospitals with a narrow injury or disease focus.

It's not until we venture back into the general practice or undertake the multidisciplinary specialist practices of paediatrics or occupational and environmental medicine that the multidisciplinary perspective again becomes preeminent. The intrinsic value of general practitioners is that they are multidisciplinarians. They can look at all aspects of the health needs of the worker. Sometimes however it is difficult to separate the work-related injury from their other issues. So what we want and what we respect is the GP's role in minimising the risk of treating just one condition without addressing the impost of other non-compensable conditions. This is a significant determinant of prolonged or ineffective rehabilitation. We have to be mindful that the insurer is primarily interested in the index injury.

Rightfully they have a responsibility to manage potential costs shifting and therefore focus on the work-related bit of the injured worker. This creates tension between the public and private purse. The problem with disputed liability is it creates conflict and delay. There is significant body of evidence that this can significantly increase the risk of poorer outcomes, but it's a fact of life, it is necessary, it is appropriate. We simply need to recognise and manage its consequence. So one of the roles of all players is to recognise and manage these issues appropriately as part of the best practice integrated patient-centred care.

Slide 32
So best practice integrates your input into the care of the injured worker and in essence efficient case management relies on respectful communication, respectful of the injured worker, respectful of others who may be influenced by any information communicated and respectful of the doctor, remembering to respect that there is a variability in the skills and competence of the doctors involved with your workers.

So let's look more closely now at the strategies to engage with the doctor.

Slide 33
GPs are generally very willing to help you help their patients but only if they trust you. The key issue is you can't expect their trust. Because of miscommunications in their past or from their interpretation of the general media message 'mean, nasty employers out to abuse and misuse employees' you actually have to earn their trust. With trust you can achieve amazing things but trust is fragile. If you breach the trust of anyone you have to work very hard to get it back and that goes for your employees in general, not just your injured workers and the doctors you have to deal with.

The quality of your communication is important and the most common instrument that you will use is the suitable duties plan. Make it easy for the doctor. It is easier to edit something other than to create a new. So even if the patient is certified as total incapacity craft a suitable duties plan relevant to what you hope the doctor will certify. If they already have it available prior to the appointment then it is more likely to happen. Do what we have been talking about today. The evidence shows it will have a positive impact on the profitability of a business and be reflected in your financial performance, not just the best outcomes for your injured workers. But if you still are having problems then use the appropriate specialist. That is where my specialist discipline comes to the fore and my colleagues are very willing to help and understand your patient's needs and negotiate the way forward.

Slide 34
Let's finish with a discussion now of case conferencing. It is a very powerful but underutilised tool at your disposal. All parties do not need to participate in all forms of a case conference. In essence a case conference is any conversation involving the treating practitioner concerning the injured worker and involving more than two parties. The injured worker does not need to be present, however the most common is the treating medical practitioner, the injured worker and the employer. The other common case conferences where a third party rehabilitation service provider and injury management advisor be they an occupational therapist or other healthcare provider, meets with the doctor and the patient. But it's important that there should be clear separation from the medical consultation that respects the employee's right to confidentiality.

It may occur, the case conference, before or after the consultation but you should always give the doctor and the worker an opportunity to interact without you being present. This applies even if you have the consent of the injured worker to be present during the consultation. The employee's consent to a conference may be formal or in writing. It might be implied by their participation. Ideally there should be also written information for the doctor, employees and employers to explain the role of case conferencing in your system of managing the rehabilitation work requirements of your workforce, what it may cover and how it differs from a medical consultation. As a participant you may have more experience of case conferences than the doctor. So I invite you to assert your role but in a respective manner. If there is a clear understanding of the purpose of the case conference then there is less likely to be seen an impost on the doctor or the injured worker.

I tell my registrars that there is no such thing as a stupid question. If something is unclear but you are uncertain then I would encourage you to speak up. The only stupid question is the one you did not ask. To maximise the productive outcomes, clarify at some stage during the interaction the intent of that particular conference. Bring it back to consciousness what it is that you want to get out of the case conference. The intent must be about optimising the recovery of the injured worker. What the evidence shows is if you do that not only will it save you money and importantly it will save you time and unnecessary effort, it will reengage with your worker.

Slide 35
So to recap most doctors do appreciate support of their patients that come from an active engagement with the employer. Most are willing to help you help your patient but only if they trust and you must earn their trust. If you are still having problems then use appropriate specialists.

Slide 36
Finally the evidence is compelling – good work improves the general health and wellbeing and reduces psychological distress. This includes during the rehabilitation of your injured workers.
Thank you.

Slide 37
Thank you so much Dr Edwards for your informative presentation today. If you have any specific questions on the topics below for Dr Edwards please type them into your Q&A box now. Remember, the North Queensland Return to Work Conference is on in Townsville next Friday. If you are attending this year please come over and say 'Hello.' We'll have many resources to share with you and can assist with any questions you may have. Also, remember to keep an eye out in your email for other online opportunities coming up and get in quick to register.

So thanks to everyone who has participated today. We've received a number of questions and Dr Edwards will be able to answer those for you now. So we're just quickly finishing collating them at the moment but Dr Edwards, can you please help us by answering what's the best way to access a surgeon from public hospitals if the employer is not getting the information they needed?

Dr Graeme Edwards:
Two things. First of all the surgeon may be either a staff appointee working full time in the hospital setting or they may be a visiting practitioner supported in the day-to-day management of their patients by a medical team. So the easiest way for information to be sourced from the hospital setting is actually through medical communications and it's not always available to you. But by having a relationship with either a medical practitioner that you have a good relationship with as your medical advisor or by consulting an occupational physician we can negotiate the communication challenges to identify which doctors on the ground in the hospital are responsible for the worker that you're concerned about. We can then open up that communication channel and start getting that information that you need.

It is a very real problem when the initial treatment or the continuing treatment for a work-related injury occurs in the public hospital setting. One of the strategies is to assist your injured worker to actually engage with a private practitioner where the communication channels are much more readily accessible to you. That's not always possible and there is no simple answer. I hope that helps.

Thank you so much Dr Edwards. We've also had another question come through about whether you have some advice to provide to rehabilitation consultants who are negotiating elements of the worker's capacity certificate. Can you shed some light on that at all?

Dr Graeme Edwards:
It's always difficult without having specifics of the situation. In principle there is a belief structure that is influencing both the injured worker and their behaviours, the doctor and their behaviours as well as identifying what it is that you want to achieve in the rehabilitation goal. Consequently the best thing you can do is to identify where is that person at? What is it that they are believing is the underlying justification for their stance? How familiar are they with the evidence base?

One of the opportunities that the creation of a new certificate of capacity is that it gives us an opportunity to reengage with the medical fraternity and assist them to better understand their role and not overstate a level of incapacity or capacity because they're incorporating into their consciousness external factors applicable to that particular claim. But that doesn't mean that those external factors don't exist and we need to be sensitive to how do we incorporate those factors in the structure and format of our rehabilitation plan, the suitable duties plan. But as I said, there's no easy answer. It depends upon the circumstances of the case and sometimes you need specialist assistance.

Wonderful. Thank you so much Dr Edwards for answering that one. We've also had another one come through. Thank you everybody for sending them all through. Can you please clarify permission required to talk to treating medical practitioners? Does the employer have to have written consent from the injured worker prior to contacting the medical practitioner?

Dr Graeme Edwards:
You don't need any consent to provide information to the medical practitioner, none at all. Your job is to provide the information. You only need consent if you wish that individual or that practitioner to respond to and discuss the information that you have at your disposal. You have actually an obligation to communicate to the medical practitioner any information that you think might be relevant to that doctor and their consideration concerning your worker. You do not have to rely on the worker themselves to be the conduit of information. You have a direct channel but it's one way. If you wish to get into a discussion and to appreciate whether or not the information you are providing is of significance or is relevant, that's when you need the consent of the worker for that doctor to answer. It's a subtle but important point. A lot of people think that just because there is this thing called consent and you want the worker to consent to your interaction, actually you don't need consent to communicate in a one way direction.

Now there are other legal parameters around what you can do with confidential personal information and privacy policies and the like, but when it comes to the informing of the treating practitioner of information known that might be relevant to their assessment of their patient, the onus is actually on you to communicate not to communicate. I hope that makes sense to you because what I hear too often is 'I didn't say anything because I didn't have consent of the patient.' Well from my perspective that's not valid. I hope that answers your question.

Thank you again Dr Edwards. We really appreciate you taking the time out to answer these questions. We've got a couple more but there's also one that I'm able to answer. The question was 'What training is being provided and available to GPs with how to understand the capacity, the worker's capacity certificate and use?' That's a great question. We'll actually have a dedicated doctor website which will have specifically designed content relevant to doctors and their role in supporting patients to get back to work. There will also be personalised education modules that will be CPD accredited for access by all doctors. So this education will be delivered by doctors for doctors. So it really promotes peer to peer learning. This will provide instruction on how to complete the new work capacity certificate as well as providing practical strategies to support doctors in the transition to certify their patients based on their functional capacity.

We'll be engaging with the doctors and their peak associations throughout the year as well. We'll be at conferences as well. So it's to help inform them of the change and basically better educate them on this new worker's capacity certificate.

So thank you everybody for attending today. We've actually reached the end of the session. If your question wasn't answered we'll be providing a follow-up resource from both of Dr Edwards' educational sessions answering these. There's also going to be a recording put up online within two weeks and we'll be sending a follow-up email with the presentation slides.

So again, thank you Dr Edwards for your time today and sharing your expert advice. We have a survey at the end of this session today and would really appreciate if you could take the time out to give us your feedback and tell us what you think as well as any other topics you want to hear about.

So thank you everybody again for attending and see you online next time.

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