This presentation provides advice to general practitioners and practice managers about applying the relevant principles and considerations in assessing a patient with a workplace related psychological injury.
These are illustrated with a case study.
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Doctor Education Series
Office of Industrial Relations
Patients presenting with a workplace related psychological injury – the initial consultation
Recorded on: 19 December 2016
Presented by: Mr Dalton Langenhoven, Education Engagement Officer, Moderator
Presenter: Dr Genevieve Yates, Medical Educator, a GP and a writer
About the presenter
Dr Genevieve Yates, MBBS (Hons) FRACGP, is a medical educator, a GP and a writer. Currently she is the RACGP Queensland Censor, RACGP Expert Committee member (Pre-Fellowship Education) and senior examiner, a performance assessor for AHPRA and a member of MDA National's Education Services Advisory Group (ESAG).
Welcome to today's presentation specifically designed for general practitioners that will assist them in making an initial occupational health assessment of a patient presenting with a workplace related psychological injury.
The topic and speaker is brought to you by the Office of Industrial Relations. As a Department we are committed to driving initiatives across the whole scheme that improves safety, wellbeing and return to work outcomes for both businesses and workers. We recognise the valued contribution that medical practitioners make towards supporting workers return to the workplace as safe and early as possible.
My name is Dalton Langenhoven. I am the Education Engagement Officer within the Office of Industrial Relations.
We are pleased to introduce our presenter today, Dr Genevieve Yates. Dr Yates is a medical educator, a GP and a writer. Currently she is the RACGP Queensland Censor, RACGP Expert Committee member and senior examiner, a performance assessor for AHPRA and a member of the MDA National Education Services Advisory Group. She worked as a GP medical educator for over a decade and currently works as an educator facilitator for MDA National and the Black Dog Institute. She was an associate director of training of North Coast GP Training until the organisation ceased to operate in December 2015.
In 2010 Genevieve received the Arts and Health Australia awards for excellence in medical humanities and education, and in 2014 she was awarded the GPET medical educator of the year. In 2016 she received the RACGP Queensland Chair award for outstanding dedication and commitment to the RACGP Queensland and service to the discipline of general practice.
I will now hand you over to Genevieve to present today's topic.
Dr Genevieve Yates:
The initial presentation of a patient presenting with a workplace related psychological injury can feel pretty overwhelming and complicated. The good news is that you don't have to do it all at once. The initial priorities are to formulate an immediate management plan and to assess risk, and we'll be talking about this in detail during the webinar.
The other key message is to acknowledge the patient's distress in an empathic way, but not to ascribe blame or to over-medicalise. Only diagnose a specific psychological disorder such as depression, anxiety or post-traumatic stress disorder if you are confident that the DSM-5 criteria have been met. At this early stage, talking in broad terms such as referring to stress, distress, feeling unwell, those kind of terms, is probably more appropriate.
Be careful not to definitively blame the workplace for their distress or give the patient reason to believe that you think that they are entitled to compensation.
So how common are these claims and how often are they accepted? In 2015-16 4.6 percent of the claims received were for psychological injury in Queensland, and out of these there was 37.2 were accepted and 62.8 were rejected. And the reason the rejection rate for psychological and psychiatric claims is so high, is that workers can't receive compensation for certain psychological injuries that arise out of or in the course of reasonable management action, as they are excluded from the definition of an injury under the Act. And in the last financial year 93.3 percent of these rejected claims were rejected on this basis.
The average decision making timeframes for claims for psychiatric injuries was considerably longer than for the general length of time it takes to process a claim. So it was 31.2 days for psychological injuries compared with 7.6 days for all claims. The reason being is these claims can be quite complex, so it takes longer for them to be processed.
So just imagine you're on a Monday morning, it's busy and you're running an hour behind. You've got a new patient, 28 year old Molly, and she enters your room and she bursts into tears. She says her boss is horrible and she just can't face going into work. She wants a medical certificate.
Now how can we manage a consultation such as this effectively without falling another hour behind?
It's all about prioritising. Here is a list of suggested priorities for that initial visit for someone coming in with a possible workplace related psychological injury. We will talk through each of these priorities in turn.
The first priority is to engage. Engaging is something that is crucial for all of our consultations with patients, but for many people with psychological distress, workplace related or otherwise, the decision to see a health professional has come after considerable deliberation and hesitation, and it can be quite confronting for them to do so. And their experience of this first visit can influence their attitude towards healthcare professionals and towards the system for some time. A negative experience may dishearten them or it may enrage them, while a positive experience may be the turning point in their road to recovery.
So the engagement could be maximised by things like displaying empathy, which is of course demonstrating the ability to take the patient's viewpoint without necessarily agreeing with it. You need to try and build trust, and then the other kind of normal good communication skills like letting the patient lead the interview, responding to non-verbal cues, listen attentively, occasionally summarising and checking you're understanding, so reflective listening, avoiding asking a stream of closed ended questions, the yes/no type of questions, avoiding interrupting the patient, and as mentioned earlier, acknowledging their distress but not over-medicalising it at this early stage.
It's also important to foster hope. This is in the sense of assuring patients there's help available, and that you will be able to help them facilitate getting this help. But it's not about attributing causation or by inferring that compensation is warranted.
So other than the engagement side of things, one of the first questions we have to ask ourselves is is this likely to be a work related psychological injury? It's often not easy to establish this in the initial consultation, and it's not important that we do, but we have to be thinking about this as we're going through the history taking process as it will help guide our initial management.
So there are two key considerations when we're thinking about this question. The first question is does it meet the definition of a psychological injury? So a psychological injury includes a range of cognitive, emotional and behavioural symptoms that interfere with the worker's life and can significantly affect how they think, feel or behave and interact with others. They tend to be diagnoses that are DSM-5 type diagnoses, so things like depression, anxiety and post traumatic stress disorder.
What's really important is that it's not job stress. So in itself job stress is not a disorder or psychological injury. The second key consideration is to ask yourself is this clearly work related? Now this can be a little bit hard to work out, because often there are a combination of factors, and although we are not responsible for making a definitive declaration on this, it's something we have to get a bit of a feel for when we're working out how best to process or manage this claim. So employment must be a significant, material, substantial or the major contributing factor for the injury for it to meet this definition.
So let's go back to Molly. So Molly says that her boss has been bullying her, and as a result she's been teary, anxious, sleeping poorly and is dreading going to work. She says the symptoms have been worsening for the last four weeks, and she's now at the point that she feels she's just about to break. So she's sort of at that 'hit the edge' so to speak.
So what is workplace bullying? So workplace bullying is a very strict definition. So it's characterised by persistent and repeated negative behaviour directed at an employee that creates a risk to health and safety. But what's even more important is what isn't workplace bullying. So I've got a list of things there, and basically the reasonable actions taken by the employer in relation to dismissal, retrenchment, transfer, performance appraisal, disciplinary action, deployment, those kind of things, are not workplace bullying.
So we're going to be thinking about this as the history goes, but one of the other key things to do in this initial consultation is to assess the immediate risk. So there are two components to this risk assessment in a patient in this category, and the first one is about a suicide risk assessment, and this is the kind of assessment we should do with any patient presenting with significant psychological distress.
And there's a second type of assessment to consider in these patients, and that is a work risk assessment. And the question we need to ask ourselves is can this person safely continue or go back to work in the short term? Now they may need a few days off, but they should be encouraged to continue to work if they are willing and if it is appropriate.
Another one of the priorities we need to think about is what is the patient hoping to happen in the long run? Do they want to continue in the same job? Are they wanting to change jobs? Are they after financial compensation? Do they want retribution? Do they want someone to be punished or held responsible for their actions? Again getting a feel for what the patient is wanting to get out of the process can help manage expectations and help guide how we best manage this in the longer term.
So back to Molly. Molly describes behaviours which are consistent with workplace bullying. So you feel it is perhaps a workplace related injury and it has significantly impacted on her mental wellbeing. And her symptoms are moderately severe and consistent with a depressive disorder. She just really doesn't feel she's up to going back to work at this stage, and she says she wants a few days off just to 'sort out her head'. She is not suicidal, again, but she doesn't feel that she can return to work at the moment.
You ask about what she wants out of this process and she's really ambivalent and uncertain about pursuing a workers' compensation claim. She doesn't have a particularly desired outcome in mind, but she just wants the behaviour to stop and she wants to feel better in herself.
So we've done the initial assessment. We have taken a history, we've engaged, we've talked about what the patient wants to get out of the process, and then we have to decide how we're going to proceed as far as the future goes, which direction we're going to head. Is this going to be covered or is this going to be a workers' compensation claim? Is this not? Or are we still undecided?
So there's a new work capacity certificate for worker's compensation in Queensland, and the top part of that form you'll see on your screen at the moment. And this gives a new option saying 'Claim is report only'. You'll see that box on the right hand side of the form. Now this is for if the patient is unsure about whether to pursue the claim. So it's not actually lodging a claim, but what it means is if you submit this as a report only, if later on they decide that this is a workers' compensation claim that is wished to be pursued, the information and the date of the first lodging the report will be used as a determination for the beginning of the claim and the injury period.
So if it is quite clear cut to you that this is a psychological injury claim that is significantly work related and the patient is wanting to pursue that, then putting in as a new workers' compensation claim is the way to go. If you're not sure and/or the patient isn't sure, the report only might be a good option. And the third thing is if during the course of this consultation you determine that this does not meet the criteria of a work related psychological injury, in that case you would go down the usual Medicare billing route as you think that this doesn't meet the criteria that is required, or is not likely to meet that criteria.
A little bit of a word about billing if you are in the report only category. So if this is a claim that may end up being lodged for workers' compensation, you do need to privately bill those consultations. So Medicare is not able to be used. However rebates can be achieved later if the workers' compensation claim is not pursued or if it's dismissed.
So just to update you or to remind you about the Medicare benefits related to work related injuries, so I'll just read from the MBS document. So Medicare benefits are not payable when the medical expenses for the service are for compensable injury or illness for which the patient's insurer or compensation agency has accepted liability. So please note that if the medical expenses relate to a compensable injury for which the insurer is disputing liability, medical benefits are payable until the liability is accepted.
So it gets a little bit complicated, but the best thing to do if in doubt, just privately bill until it is decided whether or not a claim is going to be pursued or not.
So back to Molly. So in discussion with Molly we decide on the report only option and we privately bill her and give her a regular type of medical certificate for three days.
The other important priority is giving information and resources to the patient to take with them. So on the screen now you'll see some links to some workplace specific as well as some more general psychoeducation resources that you may want to use. So if someone is thinking that they are being bullied, there are some great resources online to go through in patient friendly language what this actually means, what kind of resources, what kind of help that they can get for this, and what avenues they have for pursuing this. So not only for workers' compensation, but for other government agencies.
And remembering to not just focus on the work aspects. This is someone who's got psychological distress and needs to get appropriate psychoeducation. So using your preferred e-mental health resources and/or psychoeducation resources for these patients.
And finally it's really important to arrange early follow up. While we've done sort of a triaging type process in the initial consultation, a thorough assessment is needed, and this takes a lot longer to do, but it's a crucial part of trying to sort out what is going on for these patients and what best management strategies to use in the longer term. So if you can manage it within a few days, and also a longer appointment, half an hour or three quarters of an hour as a minimum, to try and sort out the finer details of their mental health issues currently and possible precipitating factors.
Remembering if someone is happy to continue to working – or maybe not happy, but if they're willing to continue to keep working, that is the better strategy. But if they are not safe, not psychologically safe to return to work, then a short term medical certificate is appropriate.
So that's my key messages. We don't have to do a full assessment on the first visit. Hopefully this webinar has given you a list of priorities to work through on that first time they come in. And assessing the risk and formulating an immediate management plan are part of those key priorities to the visit.
So that concludes today's webinar. Thank you very much for attending, and I hope you found it useful. I'll hand now back to Dalton.
Thank you Genevieve for sharing your experience on today's topic. The Office of Industrial Relations is committed to sharing knowledge with its stakeholders on the latest topics related to effective rehabilitation and early return to work for injured workers. We hope the information provided has been of value.
We also encourage any doctors who have any feedback or follow up questions about the topic to mailto:firstname.lastname@example.org.
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