Understanding why a condition may not be covered under workers’ compensation may be difficult for some patients.
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Published 8/1/2015
J. Mark Melhorn, MD

Breaking the News: It’s Not the Job

How do you tell a patient that it’s not workers’ comp?

What do you tell a patient who says, “My work caused my condition. What should I do?”

Sometimes, the answer is easy. But other times, despite the patient’s conviction that his or her condition is work-related, science suggests a different etiology. Do you elect not to address the issue and leave the decision to the employer, the insurance carrier, or the courts? Or do you, as the orthopaedic surgeon, attempt to address the issue based on current science?

Orthopaedists are often asked whether “the job is the cause” of a patient’s musculoskeletal condition. Finding the “cause” of a musculoskeletal condition has become an important aspect of workers’ compensation because the answer may dictate who is financially responsible for any treatment.

Many patients will say that their symptoms worsen when they are performing work-related activities, giving rise to their belief that the job is the cause for their condition. Some patients who initially sought care from their primary care physician under their commercial insurance were told that the condition is work-related. This approach may be the easiest and least stressful determination for physicians who simply rely on the patient’s statement that “the job is the cause,” without exploring other considerations.

Unfortunately, this approach may be inappropriate and can result in cost shifting from commercial insurance to workers’ compensation insurance. As orthopaedists are well aware, compared to patients covered by commercial insurance, workers’ compensation patients often have less satisfactory outcomes for the same diagnosis.

Causation analysis
Determining the “cause” of a musculoskeletal condition is a multifactorial process that involves both a medical determination and a legal determination. Unfortunately, physicians often receive little specific training in causation analysis.

Medical causation can be approached using the following six-step process outlined by the National Institute for Occupational Safety and Health (NIOSH) and the American College of Occupational and Environmental Medicine (ACOEM):

  1. Identify evidence of the disease.
  2. Review and assess the available epidemiologic evidence for a causal relationship.
  3. Obtain and assess the evidence of exposure.
  4. Consider other relevant factors.
  5. Judge the validity of testimony.
  6. Form conclusions about the work-relatedness of the disease in the person undergoing evaluation.

Legal causation has two parts: cause-in-fact and proximate cause. Both are often defined in terms of a “legal threshold,” which varies by jurisdiction. The physician who provides an opinion regarding “causation” must know the appropriate threshold for the appropriate jurisdiction.

Before forming a conclusion, the physician must reassess the data obtained in the previous steps. The physician must also take into account the legal jurisdiction in which the patient with the condition is working. The practitioner should know the definitions that would legally determine whether the disorder is work-related.

Patient education
Translating these medical and legal concepts into language a patient understands is difficult. Like other skills that physicians develop, the ability to educate the patient requires a broad approach. For example, education about causation will help with treatment, outcomes, and return to work options. Discussions that cover individual and workplace risk factors can be helpful and may lead into explanations of the concepts of impairment, disability, and apportionment.

Explaining why a condition may not be considered work-related (covered under workers’ compensation) may be difficult, especially if the patient believes that the condition is caused by work. Causation analysis, risk factor assessment, legal threshold requirements, and negation/communication skills are but a few of the topics that will be presented during the “AAOS Workers’ Compensation and Musculoskeletal Injuries: Improving Outcomes with Back-to-Work, Legal, and Administrative Strategies,” course which will be held Nov. 6–8, 2015, in Boston. To register and obtain more information, visit www.aaos.org/courses

J. Mark Melhorn, MD, is the director for the “AAOS Workers’ Compensation and Musculoskeletal Injuries: Improving Outcomes with Back-to-Work, Legal, and Administrative Strategies” course.