by RD Michaels, MA, CCRC, ARP, CVE, RCC, Dipl.ABVE, CDE III and Stephen H. Jenkinson, CSW
Until recently, it has been the family physician who has determined return-to-work options in personal injury matters. The doctor receives a form, and he/she fills in a return-to-work date. Often, this date is determined on the subjective report of the patient. It may be an indeterminate date sometime in the future.
It has been in this way that disability was determined and benefits paid. There was little, if any, relationship between this determination and the patient's ability or capability to either return to the pre-accident job, or to any other job. Doctors typically did not perform job analyses nor relate capabilities to the world of work, let alone consider the ramifications of alternate vocational options such as change of career or job, job modification or job accommodation. These options are often not a consideration prior to a classification of "totally disabled".
Before going any further, it is necessary to properly define our terms of reference. The World Health Organization defines disability, as "any restriction or lack (resulting from an impairment) of ability, to perform an activity in the manner or within the range considered normal for a human being." This is distinguished from impairment, which refers to the medical condition that may lead to a disability: "any loss or abnormality of psychological, psychological, or anatomical structure or function."
Canada Pension Plan - Disability Legislation states: "...disabling condition can be physical or mental. Under CPP Legislation, the disability must be severe and prolonged. Severe meant [the] condition prevents [an individual] from any meaningful or gainful employment or working regularly at any job. Prolonged means condition is long-term or may result in death."
Now medical and other professional associations, and the Courts, are telling doctors that, while they determine impairment, they are not the determiners of return-to-work. The Ontario Medical Association's Position in Support of Timely Return to Work Programs and The Role of the Primary Care Physicians, March 1994, states: "Physicians are thus encouraged to help patients focus on their capabilities, rather than disabilities, and to keep active. The family physician should provide an accurate and objective assessment of impairment, and diagnosis of specific capabilities."
"...family physicians would not comment on whether or not the patient can return to work."
"...the concepts outlined can be applied to include physicians in all specialties."
The Alberta Medical Association Position Statement Early return-to-work after illness or injury: The role of the Physician states: "Prolonged absence from work may be detrimental to a patient, and returning to work as soon as possible without endangering the patient's health or safety should be encouraged. An early return-to-work after an illness or injury (work-related or otherwise) benefits a patient socially and financially. It also preserves a skilled and stable work force for the employer. This statement describes, in general terms, the role of the attending physician in the return-to-work process. Planning for return-to-work should begin early in the disability period. The physician should become familiar with the essential physical demands and health and safety hazards of the patient's work..."
As cited in CARP News (Volume 1, Number 2, 1996), "Depending on the nature of the medical condition and the work available, a trial return-to-work may extend over weeks or months. When dealing with more complex cases, the physician should utilize the special skills of other health care professionals ...Formal analysis of job demands and hazards, work capacity assessment and structured rehabilitation programs may be necessary."
The American Medical Association, in its Guides to the Evaluation of Permanent Impairment (1994)
draws a clear and firm distinction between disability and impairment. The AMA has taken the position that, while disability ratings are based upon impairment, physicians must:"...refrain from speculating about nonmedical consequences of an impairment." In addition, "it is not possible for a physician, using medical information alone, to make reliable predictions about the ability of an individual to perform tasks or to meet functional demands." A court decision, Carl B. Adams v. Margaret M. Heckler in U.S. District Court, Northern Division of Indiana, an upheld by the 7th Circuit (580 F Supp 315 1984) has recognized that medical doctors cannot speak as vocational experts.
With all these commentaries on the role of the doctor no longer determining disability and the non-medical aspects of an impairment, it is the vocational expert (vocational evaluator, consultant, counsellor) who determines the vocational implications of medical impairments, and disability. The National Association of Disability Examining Professionals is clear in delineating Standards of Practice. "Disability evaluation requires a collaborative approach to data collection and decision making. The primary evaluating clinician is obligated to utilize and accept the expertise from other clinical practitioners whose training is in other related but applied fields. For example, a [physician] should solicit the expertise of a Certified Disability Examiner III [includes vocational evaluators, case managers, rehabilitation counsellors] regarding worker trait, labor market analysis, or psychological issues. Similarly a Certified Disability Examiner III clinician should require the consultation of a [physician] regarding physical limitations and diagnosis prior to having the evaluee participate in physical testing activities, to include work samples and materials handling assessment."
Each specialist involved in the disability evaluation process has his/her own area of expertise. It is incumbent on each of us to know the limits of the areas of expertise, and to make the process a team approach. In Court, if one goes beyond their particular area of expertise or specialty, there is a risk that the entire testimony will either not be accepted or carry less weight. Determining the vocational implications of a medical impairment requires specialized training and expertise. Aspects of the individuals' life included in these implications are the medical, psychological, social, vocational, educational, cultural, behavioral and economic factors that comprise the uniqueness of each individual.
RD Michaels is a Clinical Rehabilitation Evaluator with RD Michaels™, a Nanaimo based company providing coast-to-coast Vocational Testing
and Evaluation and Vocational Implications File Review™ in Canada and the United
States. He has conducted over 2,000 vocational evaluations since 1978.
Stephen H.Jenkinson was Services Manager with RD Michaels™.