Absence in the Workplace Seminar

4th December 2012

Dr Charlie Vivian

Consultant Occupational Physician / Medical Director

Biography

• Qualified at St Thomas’s Hospital, London

• Short Service Commission with RAF

• Qualified as GP

• GP in Swindon (2 years)

• Occ Med Training with Adastral Health

• Consultant, then Director of Clinical Governance, AHL

• NHS (Glos) from 2007-12, inc Director of Quality for

NHS Plus

• Corporate Health Medical Director 2012-

Topics

1. The YMCA

2. The Equality Act (previously DDA)

3. Reasonable Adjustments

4. Plateau Management

5. Motivation and denial

6. Low Back Pain

7. Stress

8. Conflict

9. Golden goose and Golden rule

Case 1: YMCA

• 33 year old Delivery Driver

• Goes off sick with severe depression

• Assessed by OH. Unwell, and unlikely to be better in

next 3-6 months.

• OH letter to manager confirms this

• Manager says he cannot wait, and opts for dismissal

• Patient then challenges the OH opinion

• What would you do?

The YMCA

• (Y)

• M. What is the true MEDICAL condition?

• C. Manager CONSULTS with employee

• A. Manager decides ADJUSTMENTS

The Equality Act (prev DDA)

• Purpose: to stop unfair discrimination

• Patient qualifies if condition has:

– Substantial

– Long-term impact on

– ADLs

• NB: consider off medication

Case 2: the EA

• 40 year old receptionist

• Has migraines every 6 weeks

• Severe, and result in 2 days of S/A every time

• Tried various treatments, but none have improved

• What would you do?

Reasonable Adjustments

• OH outline what adjustments you need to consider

• Management decide if these adjustments are reasonable

Case 3: Plateau Management

• 45 year old mechanic

• Heavy physical role

• Develops upper limb disorder

• Various treatment is provided

• Sees some improvement over time, but then reaches

plateau, and can’t do full job

• What would you do?

Plateau Management

Common Sense

• The funny thing about common sense is, there’s not

much of it about.

– Mark Twain

• The benefits of ‘experts’

Motivation

• With motivation, almost anything’s possible. Without it,

almost nothing is.

• Whether you think you can, or whether you think you

can’t, you’re probably right.

– Henry Ford

Case 3: low motivation

• 27 year old with chronic pain

• Blames company for causing the pain

• Off sick for 3 months

• OH assessment using MI:

– Confidence: 2/10

– Importance: 8/10

• Obstacles: heavy work, and conflict

• What would you do?

Case 4: Motivation & Denial

• 54 year old senior manager

• Has stroke, affecting speech part of brain

• Can’t speak (aphasia)

• Desperate to stay at work

• What would you do?

Case 5: Low Back Pain

• 39 year old warehouse operator, with lots of physical

activity

• Develops low back pain, and goes off sick

• Diagnosis is ‘degenerative discs’

• Various treatment (medication, physio) but symptoms

persist

• ADLs are restricted

• Are they fit to work? Is this work-related?

The value of investigations

Eg X-Rays and MRI scans for back pain

• There is no firm evidence for a causal relationship between radiographic findings and LBP. Weak association only for degeneration and LBP, and cannot be applied to individuals. (Van Tulder et al 1997)

• High prevalence of abnormal findings on MRI in normal asymptomatic subjects. Little relationship with past or present clinical symptoms. (Vingard & Nachemson 2000)

Aylward, [2]

Musculo-skeletal disorders

10 tenets of MSDs that are yet to be disproved:

• Abnormal to go without significant (ie ADLs) pain for:

– >2 yrs LBP

– >3 yrs Neck or Arm

– >5 years knee

• The majority of those with symptoms do not medicalise

• Patients with LBP have a surrogate complaint (ie they can’t cope)

• Mild degeneration of MSD is normal

• PIVD hypothesis is wrong for axial pain, and marginal for radicular

Hadler, [3]

Musculo-skeletal disorders

• 10 tenets, cont – Most knee joints with pathology don’t hurt. Most joints that

hurt don’t have pathology – All treatment for LBP is ineffective, including surgery and

medication. – We don’t know what causes regional MSDs. To label as

injury is no better than labelling a spontaneous headache as injury

– Discectomy 2/12 quicker recovery than no treatment – (Sarno) Acute PIVD settles in 1-2/52. No validation for

surgery

• People become patients when they have exhausted their wherewithal to cope. Months/years of investigations and Rx could be avoided by directly addressing the coping challenge

Hadler, [3]

The failure of health and safety

From Burton K

Case 6: stress

• 34-year old administrator

• 3rd child is not very well

• Elderly relatives

• Financial worries

• Colleague at work off sick long-term

• Has argument with manager, and goes off sick. GP note

says ‘work-related stress.’

• What would you do?

Defining Stress

Tasks Capability

The Pint Pot Theory

The Myth of Positive Stress

Bored

V-max

Broken

Stressed Optimal

Conflict

• Win

• Avoid

• Give in

• Persuade

• Resolve (win-win)

From Killman

Bully

Victim

Victim

Bully

Outcomes from Conflict

Mgr Employee

WIN - LOSE

LOSE - WIN

LOSE - LOSE

WIN - WIN

NO DEAL

Golden Goose

• Once upon a time there was a goose that laid a golden

egg…

– From 7 Habits of Highly Effective People (Stephen

Covey)

The Golden Rule

• Do to others as you would have them do to you…

Discussion & Cases