For those of you who have been injured in the course of their working careers: have you ever noticed how hard it is to get a referral to see a workers compensation doctor? Virtually impossible, right? There is a reason why most physician’s look at Worker’s Compensation patients as though they have the bubonic plague. And that is on a good day.
The reality is that many physicians view industrial medicine as too complex, too time consuming, filled with paperwork, unrewarding, and loaded with patients who have lawyers that are gaming the system. This is despite the fact that the vast majority of injuries that occur at work are exceptionally well-documented and that the injuries, oftentimes, are severe. There are several other factors that prevent the patient having access to real clinicians and surgeons who could be of great value to the industrially injured patient. The best way to understand how this process works is to actually present a scenario where the patient has been injured.
Let’s take, for example, Mr. Johnson who works for Terminator Industries. Mr. Johnson just so happens to be a 55-year-old male who for the last 15 years of his life has dedicated himself to his company working as a maintenance engineer. Mr. Johnson has always been eagerly ready and available to help his company because he has that special pride that he believes is fundamental to the success of his company. He believes that his employers have developed a trust and reliance in him and respect the job that he has done for them over the last decade and a half. Mr. Johnson is a firm believer that his company will stand by him through the proverbial thick and thin. That was until one fateful day 3 months ago – Mr. Johnson was asked to loosen a stuck valve with a large wrench.
Mr. Johnson and 3 others happily obliged their employers request and while using a 12 pound wrench to loosen the rusty and tight valve with all his might, Mr. Johnson felt something pull or tear within his right dominant shoulder. This was accompanied by the most excruciating pain he had ever felt. The pain subsided a little bit but not enough so that Mr. Johnson could continue working. The incident was witnessed by his coworkers who were helping Mr. Johnson. Shortly thereafter he reported the incident to his supervisor who promptly sent him to the plants infirmary where he was given Motrin, told to apply ice and put on light duty for 3 days.
Unfortunately the pain worsened and Mr. Johnson returned to the plant’s infirmary where he was subsequently sent to an occupational medical center. There he was assured, after a drug test, that he sustained nothing more than a simple sprain or strain of the shoulder and that he would be fine within the next 30 days. Of course, this was provided he would do his physical therapy. After the 30 days he was discharged and pronounced fit for full duty despite ongoing complaints of pain.
Mr. Johnson knew that something was wrong and he had difficulty doing his job. He wanted to go see somebody besides the occupational Medical Center physicians who told him that everything was fine and that he had nothing more than a strain or sprain of the shoulder. Mr. Johnson complained that he could not use his arm. He could barely lift it without severe pain. For his large size he was weak, he had trouble sleeping at night and there was a catching sensation deep within the shoulder. He was told that he had no choice but to go back to the occupational Medical Center. Mr. Johnson did not want to upset his employer so he complied and return to the Occupational Medical Center where ultimately a magnetic resonance imaging study was obtained. This study demonstrated damage to his rotator cuff. Mr. Johnsons suspicions were confirmed that something really was wrong with his shoulder. However this newly recognized finding was never added to his claim. He was told that he simply had a sprain or strain and that any additional findings were pre-existing and related to his advanced age of 55. Mr. Johnson began to hurt so bad that he sought outside care after being seen in the emergency room on a couple of different occasions after his original injury.
Three months have now gone by and he is not any better. If anything he has gotten worse. His job performance has fallen off. His activities of daily living have curtailed for fear of injuring his shoulder even worse. He has tried to see his family practitioner but unfortunately like many physicians his family doctor does not accept Worker’s Compensation patients. Finally a friend tells him that he should seek legal counsel. Shortly thereafter Mr. Johnson is fired from Termnator Industries because he cannot meet the rigorous demands of his employment contract.
Mr. Johnson wanders the desolate and frightening landscape of industrial medicine for several months, wondering what to do. He continues to have severe pain in his shoulder. He tries menial tasks such as bagging at a supermarket but this does not help pay the bills. There is a significant stress in his life that translates to marital problems. All Mr. Johnson wants is to get better. He has tried to see an orthopedic surgeon but was told that his claim is only allowed for a sprain or strain of the shoulder and that he should seek legal counsel. Finally he does. He is ultimately referred to a practice that specializes in helping the injured worker navigate the labyrinth of industrial medicine.
Mr. Johnson experiences an amazing and dazzleling array of paperwork including bewildering forms all of which are confusing and horrible to look at. But it is explained to him that without these forms nothing ever gets done. A first report of injury form (FRO1) is completed acknowledging the injury has occurred. Medco 14 forms are completed to ensure that the patient receives his disability wages. A C 23 form is completed changing his new doctors practice to the physician of record and not surprisingly nobody ever knows who the original treating physician of record was to begin with. Mr. Johnson is informed that he can only have one physician at a time treating his condition. A C9 form is completed requesting additional treatment including physical therapy, a cortisone injection, and so forth. All important treatment options that all patients outside of the industrial arena oddly are entitled. Mr. Johnson begins to gain confidence in his new treating physicians and believes that he will be all right until he goes to his first independent medical examination. This is known as the dreaded IME.
The” Examination “takes all of 15 minutes followed by a dictated report that states that all of these findings – including his injured rotator cuff – are nothing more than degenerative in nature and related to his age. These injuries have nothing to do with his work-related injury and that because he played football when he was in high school 30 years ago think it then most likely his present day problems are a result of this. Finally after 3 appeals, Mr. Johnson, with the help of his attorney and his physician, has been successful in getting his claim allowed for the proper and realistic conditions that reflect the nature of his true injury which obviously is – wait for it, a rotator cuff tear.
The appropriate paperwork is submitted for an arthroscopy with rotator cuff repair which is immediately denied by his company but subsequently appealed and now approved for surgery. It is now almost 2 years after the incident has occurred. Mr. Johnson has not worked since that time. As expected he has become frustrated and embittered with the system and his employer who he believed in. Ultimately Mr. Johnson returned to work but in a different capacity and with a different company.
This is a factual story. Sadly this story plays out 100s of times each day many times with a less than satisfactory ending. It arises from an ignorance of the system especially as to what advantages the employer has over the injured worker. It is true that a small percentage of industrially injured patients will have a good result and a good experience, especially when treated in a timely manner. The argument is that the industrially injured patient in most instances is treated differently than somebody outside of the industrial arena. The above story is not without lessons. And there are things that can be done to mitigate or lessen the frustration that patients such as Mr. Johnson undergo.
First and foremost, know your rights. As an injured worker you are entitled to see the physician of your choosing provided he or she is in approved BWC physician. There are fewer of us now.
Many physicians and their practices are now employees of hospitals which do limited Worker’s Compensation. They feel the same frustrations with denials as private practitioners do. Nonetheless you are entitled to a physician of your choosing provided the above criteria is met. This is relatively simple and can be ascertained by making a call to the practice. Once you have met this physician and he tells you your condition or claim is only approved for a sprain or strain you must ask this physician whether or not they are willing to be supportive of your care and to obtain those conditions necessary that fairly represent the nature of your injury. This means writing letters and doing battle against independent medical examiners hired by the employer to squelch your case.
If they are not willing to do this and they tell you that this is not their responsibility then find another doctor.
You are allowed 1 treating physician of record at any given time. This is known as the POR. Your physician of record is responsible for completing all of your forms in a timely manner. This includes C–84’s, C9’s, legal reports to your attorney responding to denials, the need for additional conditions, and to refute allegations made by independent medical examiners. Obviously, there is a lot that goes on behind the scenes that patients do not always know about. Nonetheless, a skilled physician who understands the industrial process can guide you through the labyrinth of industrial medicine. A skilled physician of record is like a guide through the wilderness when you are lost. There is a lot that can and will go wrong without a good guide. If you drink the wrong water you get diarrhea. Stray off the path too far and you get eaten. I think you get the picture.
Seek legal help.
You are entitled to this and you will need it. A skilled industrial lawyer is as good as a skilled industrial physician. Together their success rate in getting the conditions necessary to treat you for your work-related injury is extremely high. Typically a Workmen’s Compensation attorney who is worth his salt will give you expert guidance but at a cost. You typically are responsible for any letters and will need to negotiate his fees which typically are very reasonable given the circumstances. My recommendation is not to sign up with the first attorney that you meet nor pony up with the largest firm but instead interview at least 2 and possibly 3 different attorneys before you settle on your choice. You should also ask the advice of your physician of record since he will have to communicate with these attorneys directly. Your doctor of record typically knows the best lawyers out there and ones who truly have their clients interest at heart. A poor choice in legal representation is just as bad as picking an unqualified physician.
If you find a physician who you believe will work for you to get you proper medical care do not be dismayed that he or she may not be the ones to do the actual treatment or surgery. Physician’s who are skilled with industrial medicine also know other physicians who will be willing to treat you once the paperwork and the conditions are approved. These other doctors simply just do not want to do the paper work necessary but once approved will be delighted to treat you. But again, first and foremost, you must have a qualified and skilled physician of record to help you navigate.
There are many other facets to industrial medicine. Some good some bad. But the reality is that this is the system we have and our expectations should be reasonable. Some people argue that it should be called EMPLOYER’S COMPENSATION because it always seems to favor employer with which I agree. However, this is the natural evolution of a system that in many ways has evolved from overutilization and abuse by its participants. In essence, those who came before us in many ways mucked it up for the rest of us. The system still works only with a new set of rules. Clearly these rules favor the employer just like playing blackjack in Las Vegas favors the casino. Nonetheless with bona fide work-related injuries the injured employee can get the help they need. The deck is not stacked against the injured worker as badly as it seems. Proper advice from experienced physicians and attorneys almost always wins the day. The only difficulty is finding such good advice. It is out there in the proverbial minefield of industrial medicine and with the expectation of reasonable treatment in a timely manner well-trained physicians and attorneys who understand these nuances typically get the job done