The Injured Worker and the Internist

How're the kids? How's your wife? How's Joe? How's school? Are you still bowling? Idle talk? Hardly. To establish rapport? Not just. As internal medicine sheds 40 years of scientific reductionism, these questions are emerging as requisite in the clinical interview. We watch our patient's eyes and body language. We pursue any inkling of difficulty. After all, we are probing for the symptoms of some of the most life-threatening, and potentially remedial, diseases in our society: abusive relationships, self-destructive behavior, and affective disorders. Physicians are finally confronting this plague. How's work? This question needs to carry the same importance as those above. Gainful employment is one path to self-respect and some degree of autonomy in our society. But the path is never smooth, seldom easy, and occasionally dangerous. It is time for internists to deal with the pathogenetic potential of the contemporary workplace. Traumatic Injury Sprains, lacerations, burns, amputations, fractures, fatal falls The incidence of physical and thermal injuries varies from industry to industry and from place to place, but nowhere is it insignificant. Every injury is a reproach to our national ethic. No safety device should ever be breached. No lesson in carefulness squelched. That holds for the financially strapped small shop or farm as well as for the large employer. The clinical interview can include inquiries into safety practices. We can urge our patients to call for an investigation by the Occupational Safety and Health Administration of perceived abuses; their confidentiality is assured. Physical hazards should become a horror of the past. An insightful, proactive physician can help every worker at risk to understand the available recourse [1]. The Illness of Work Incapacity No longer do most of us stand or fall on the basis of the sweat on the brow, or product or assiduousness, or thought or thoughtfulness. Rather, we are integral to a grander, orchestrated effort. The workplace has become abstract: someone else has vision, someone else manages, someone else evaluates, and someone else decides. The worker, regardless of station, is subsumed by the corporate effort; individual differences, vagaries of life, unfulfilled hopes, frailties, and even illness are all subsumed by this greater effort. All that is humanity is served by organizations that may not recognize humanity in their midst. What can the worker do if he or she will not, or does not, or cannot adapt? Particularly in times of limited employment options, or limited options for real change, most people choose between unemployment and making do. This is a tenuous condition, a life of limited options colored by resentment. It is a workplace hazard that can engulf any one of us who is gainfully employed and is held accountable to some other person. The prevalence of this status has not been quantified. But every physician who cares to can know if a patient is in such pain. What happens when such an unfortunate person has backache? Who offers empathy if not options that might facilitate their coping with the illness? How many managers were promoted because of some intuitive grasp of the human predicament? There are some. More typically, our hurting worker sees no option but to enter the health care system. If the backache is perceived to have arisen out of and in the course of employment and it occurred by accident, then the consequences are likely to be indemnified by Workers' Compensation insurance: Whatever medical intervention money can buy is provided. Wage replacement during the healing is forthcoming. Residual compromise in earnings is compensated after the worker has arrived at maximum medical improvement. Such regional backache was not a candidate for indemnification as an accidental injury when the Workers' Compensation paradigm was formulated a century ago; it became compensable in this country 50 years later [2]. The inferential leap from illness to injury was acceptable once the label of ruptured disc became sensible; the ruptured disc is so dramatic an outcome, it overshadows consideration of the cause. A precedent existed; the inguinal hernia was a compensable rupture. So without much fuss, Workers' Compensation underwrote diagnostic and therapeutic interventions and wage loss for backache. The result is anything but salutary. During the past 30 years, the number of claimants, the extent of diagnostic zeal, and the aggressiveness of empirical intervention have skyrocketed [3]. An increase has also occurred in the number of tormented persons who plead for redress for their disabling backache and who mull about pain clinics [4]. Instead of learning from these lessons of compensable backache, arm pain in the workplace is now considered a compensable injury, and empirical remedies, including endemics of carpal tunnel surgery [5], are underwritten by Workers' Compensation. Many protest the colossal cost that has resulted [6]; too few decry the brutal outcome that awaits so many of these workers, and even fewer decry the pathogenic sophisms of ergonomics [5, 7] that fuel these claims. No student of the human predicament, no physician, should be surprised by this course of eventsthey should be horrified but not surprised. After all, seeking redress for regional back or arm pain under Workers' Compensation is a gauntlet of iatrogenicity [8]. The algorithm reeks of contentiousness: Is this really an injury? What interventions are appropriate? What is the magnitude of residual disability? Any personal angst that rendered the pain intolerable in the first place will be exacerbated by these contests. Any ability to make judgments about therapy will be compromised. We need to realize that if claimants refuse an intervention, the veracity of their symptoms will be questioned long before the value of the prescription. No wonder that avalanches of empirical interventions dot the landscape. To add insult to injury, when symptoms persist or progress despite these interventions, the honesty of the worker is impugned. The worker has a failed back; no one seems ready to assert that the worker was failed by the medical interventions, let alone the algorithm for redress. When empiricisms are exhausted, disability determination awaits. The worker must prove the persistence of symptoms to agencies that are imbued with impairment rating, the myth of a correlation between a medically demonstrable pathologic condition and work capacity [9]. Every internist knows that you cannot get well if you have to prove that you are sick. To the contrary, the patient will recall, dwell on, and record every morbid event with an intensity that takes on a life of it own. Impairment-based disability determination is Kafkaesque. If I have made you uncomfortable, then you understand me. They, the workers, are we. Only, we are in a better position to understand the plight of our injured patient, if we choose to do so. We can stop ignoring the perpetration of unfounded remedies [3, 8]. We can stop ignoring the fallacies and iatrogenicity of contracted and independent medical examinations [10]. We can decry the manner in which Workers' Compensation has gone awry. And we can call for change. No country has evolved a perfect solution. However, many precedents exist for alternative approaches, from abandoning accident-based schemes to providing national accident coverage without stipulating work-relatedness [11]. We need to urge more awareness on the part of our legislators for the sake of our patients. If social activism is difficult for you, there is a more familiar role. Internists are trained to listen to symptoms, to place them in context, and to comprehend their meaning. We are aware of the manner in which abusive relationships, for example, can manifest as the inability to cope with bowel complaints [12]. We should be as aware of the manner in which psychosocial turmoil in the workplace can render backache [13] or arm pain [14] less tolerable. To start, we just have to ask, How's work? Epilogue Although the issues in this diatribe might be familiar to readers, the relevant science is dispersed in a less familiar literature. My recent monograph is a source of additional references [8]. This monograph allows me to argue my perspective and to present counter-arguments with as much evenhandedness as I can muster. However, I believe that the advocacy of physicians for their patients who are attempting gainful employment against odds should elicit passion. For that I will not apologize.