Disability evaluation in workmen's compensation

Disability ALEXANDER

Evaluation in Workmen’s Compensation P. AITKEN, M.D., Brookline.

K this cfiscussion I sflalf confine In>- remarks to tfisaf~ifity evaluation as currentfg- practiced in workmen’s compensation cases. In industrial medicine physicians have been searching for many ?-cars for some means of Some answer is npparevaluating disability. ently required, not as an aid in treatment but to meet the tlemancfs of la>-men that are involved in the legalistic aspects of injury. Commissioners of industrial accident boards, insurance carriers and attorneys for pfaintifr and cfefencfant insist, for the purposes of adjudication, that thr physician resolve the patient’s disnf,ilit>- into mathematical terms. It is obvious that identical injuries ma>- produce severe cfisahility in some persons while protfucing none in others and ma>- result in serious handicaps in performing some occupations antf be of little significance in others. The physician, an-are of the nutnerous tangible and intangible factors involved in disahifit) and desirous of f,eing fair to all parties, often finds resolution on this f>asis difficult if not impossible. Even with the improbable adoption of a uniform compensation act for each of the forty-eight states, it seems highly unlikely that any formula couId ever f,e developed which could fle applied equitably to all persons and stiff include such factors as age, physical concfition, Mork potentia1, occupation and work availability, to name a few. M’h?; tfo 1l.e find ourselves in such a dilemma? Fort,>- years ago Inan>. t>-pes of injury did indeed result in permanent disability. lZIedical science had not developed to the point where it could offer much in the way of physical restoration. Social concfitions were such that the cfisabIed lvorker and his family became a liability to society. Even when able to do some work the disabled man had great diffrcufty in securing emplo>-ment. The compensation acts existing at that time provided for some indemnification for the worker for his anatomic Ioss but the awards lvere too niggardly to be of practicn1 value. Today, \vith the progress of medicine and

I

:\fassachusett.s

the dcvelopmcnt of antibiotics, w-e no longer see the disabilities of fort)- >-ears ago. W’ith the cfevefopment of phvsicaf rehabilitation antf vocational training, it -is questionable whether and totall! any injur>- is truly permanentlydisaflling, provided the injured person is given everv opportunity and has the fortitude to rehahifitate himself‘. We can be proud of our accomplishments in recfucing cfisabifity, although w stiff have much to learn regarding adequate medical care after injur?- ancf the use of physical rehnbiIitation and vocatronal training. Although the compensation acts have Ixcome far more fibera the>- have not kept pace rvith sociologic changes or with the progress of medicine. IVeekIy compensation rates in some states still fai1 to provide for adequate family security. The disabIed worker still has as much cfiffrcult~- securing employment as he did fortl~ years ago. The provisions in man! states fail to allow for adequate nncf continuous medical care and no provision is mncfe for physical rehabilitation or vocational training. \Ye are stif1 being confronted with indemnit? based on focal anatomic or functional loss ancf the presence of disfiguring scars. Little or no attention is paid to the injured workers genuine need, name]>-, that of restoration to gainful empIo,vment. Questions of disabifit>- are stiff settled by laymen and the merits of a case arc tfefended by laymen in the courts or through legal procedures of our industrial accident commissions. In these legal entanglements the physician is but a pawn. He must not consider the ph>-sical, ps>-choIogic, domestic ancf financial complications of the injur>-; he must resolve the disability into percentages much as one would appraise the damage of an automobife. In the end an adjudication is reached. The commissioner, frequently untrained for his joI> ant1 confused IIS; the weIter of contlicting medical testimony, clears the case from his docket. The insurance carrier is reIieved of further liability. The attorney receives his commission and the doctor his fee. The patient gets his awarcf, a sum of money which he spends

Aitken and a disability which he keeps. Such a system invites legal controversy and invites the prolongation of disability for financia1 gain long after the disability has ceased. However, it is no wonder that a truIy disabIed worker, realizing that his work potentia1 and market vaIue have been jeopardized, wiI1 proIong the disabiIity unti1 he has received his award. In this he is often aided and abetted by his lega counse1 whose interest in the award is not aItogether altruistic. How is it possibIe for any physician with a cIear conscience to render a disabiIity evaIuation in those states in which the Iaw specificaIIy Iimits the maximum medica expenditure to $200 or limits the duration of medical care to ninety days? DisabiIity evaIuation under these circumstances is a fraud. The injured worker must be given an opportunity, through adequate and continuous medica care, to restore himseIf to gainful employment. He must not be deprived of these rights through unrealistic and antiquated compensation laws. It is high time the medica profession took stock of the entire situation. It is time we evaIuated our responsibiIities to the injured worker and fuIfiIIed our obIigations toward restoration. And we must assume a dominant roIe in demanding that the responsibiIities of others, nameIy, Iabor, management, insurance company and government, be fuElled. A cooperative effort has aIready made considerable progress under the aegis of the Subcommittee of IndustriaI ReIations of the Committee of Trauma of the American CoIIege of Surgeons. This committee, in cooperation with the C.I.O., A.F. of L., U.M.W., the United States Department of Labor, the United States PubIic HeaIth Service, OffIce of Vocational Rehabilitation and two insurance companies, has been studying for the past five years the problems of the injured worker. An articIe on the basic principIes for rehabilitation of the injured worker and another on the operating principIes for a modern workmen’s compensation system have been deveIoped and approved by the Regents of the College. I shouId like to quote these as I fee1 they are pertinent to today’s discussion. PRINCIPLES

FOR INJURED

REHABILITATION

wants to be rehabiIitated and restored to gainful empIoyment. Settlement of cases on a basis of cash awards aIone does not meet the continuing needs of the injured worker and his family. 2. The need for higher standards and broadened benefits in workmen’s compensation is recognized. Such standards and benefits should be developed against the background of presently known advances in physical restoration and vocational rehabilitation and adequate standards of individua1 and family need. 3. FuII utiIization of ali our potential manpower is essentia1 to the welfare and strength of the country at a11 times. The discarding of disabled workers is an economic extravagance detrimental to the weIfare of our country, whoIIy aside from the personal effect on the worker and his family. Solution of the problems of trauma requires co-operation, and not competition, between a11 interested groups and agencies. We must therefore improve and expand a11 activities, public and private, that aid in rehabilitation of the disabIed worker. 4. The medica profession should adopt the concept that the responsibilities of the treating physician extend over the entire period of disabiIity to the end that the patient is restored to gainful empIoyment at his highest attainable skill. 5. RehabiIitation and restoration to gainfu1 employment of the injured worker must begin with first aid and continue through the period of disability. In order for a physician to carry out this responsibility, it is essentia1 for him to recognize the tota medica probIem of the patient in addition to his injury, as we11 as his persona1 problems. The physician must bring to bear on these probIems a11 the skiIIs and disciplines that science and society can offer, and utilize al1 community resources which can assist him in the accompIishment of these objectives. OPERATING MEN’S THE

ESTABLISHED

712

OF OF

BY

A

MODERN

THE

THE

THE

WORK-

REQUISITE PRINCIPLES

INJURED

AMERICAN

FOR FOR

WORKER

AS

COLLEGE

OF

SURGEONS I.

II.

Rehabilitation of the injured worker and his return to gainful employment should be the basic concept in an improved workmen’s compensation system. We recognize that the disabIed worker I.

FOR SYSTEM

ATTAINMENT

REHABILITATION

OF

WORKER

PRINCIPLES

COMPENSATION

Before the principles for rehabilitation of the injured worker as established by the Subcommittee on Industrial Relations of the American CoIIege of Surgeons can be attained a critica review of the current practices in workmen’s compensation, medica care, and medica and vocationa rehabiIitation is required. Since rehabilitation of the injured worker and his return to gainfu1 empIoyment is one of the basic concepts of workmen’s compensation, changes in the attitude, laws and administration of this system are essentia1.

DisabiIity Evahation

in Workmen’s Compensation

A. It must become the duty of the compensation agencies to supervise the medica care of workmen’s compensation cases with the view: I. To determine the accuracy of the medica1 diagnosis. 2. To see that competent and continuous medica care is provided as Iong as medicaIly indicated. 3. To see that adequate medical and vocationaI rehabiIitation is provided when indicated. 4. To make sure that an injured worker has obtained the maximum recovery possibIe before making any fina financial determination of permanent disability. R. To assist the compensation agencies in the performance of these duties, panels of impartia1 medicaIIy quaIified experts should be estabIished within the compensation systems. These panels should be utiIized in the performance of the foIlowing functions of the agencies: I. Supervision of a11 medical care to insure the adequacy and continuity of medica care from the date of injury or disability, whether due to accident or occupationa disease, to maxima1 restoration. a. To review and examine when necessary al1 seriousIy injured cases at an early date to determine: (I) The need of consuItant services by medica specialists. (2) The need of medical rehabilitation. (3) The disabled person’s work potential and the need for vocational rehabilitation. 2. To establish standards for the provision of medical rehabilitation services to workmen’s compensation cases. 3. To determine the causa1 relationship of injury or disease in contested cases and the need of additiona panels of impartial medicaIIy quaIified experts for such determination if necessary, C. Attainment of the basic principtes can be accompIished onIy by changes in the administrative ruIes of procedure and/or in the compensation Iaws themseIves. Provisions must be made for: I. CompIete and continuous medical care from the date of injury or disability, whether due to accident or occupationat disease, to maxima1 restoration without statutory limitation of cost or duration. 2. Complete medical rehabilitation, referrat to vocationa rehabiIitation services, and adequate financia1 support for such

III.

services unti1 maxima1 restoration is achieved. Appropriate and medically prescribed return to work before maxima1 restoration is an accepted rehabilitation procedure and may aIso be carried out as on the job training or retraining. to insure family 3. Adequate compensation security during the entire period of disabiIity and rehabilitation. of compensation statutes to 4. Expansion broaden second injury fund provisions to further encourage industry to employ physically handicapped workers. Coverage of a11 empIoyees including those of smaI1 establishments and those engaged in occupations now considered as non-hazardous. To insure the maximum efficiency in administration the law should require the appointment only of experienced individuaIs as commissioners. These positions shouId be career appointments at adequate saIaries and not subject to changes in administration. The costs of the vocationa rehabilitation of the disabIed worker should be borne either by industry or the State vocational rehabilitation program or jointIy. A compensation system so constituted would restore more effIcientIy and compietely far more individuaIs to gainful employment and would at the same time eIiminate the present highIy controversia1 and expensive procedures and in the end wouId be far Iess expensive to industry, Iabor, the insurance carriers and the community as a whole.

Under such a system, the present litigious miasma wouId be ebminated. Vast numbers of injured workmen wouId be restored to useful empIoyment at their highest attainable skill. Many workers and their famiIies would be free of the stigma of dependency on public welfare. A need for evaIuation exists, of course, but disabiIity would be determined by medica men, in the Iight of the way in which it affects the person and his overa abiIity to return to usefu1 employment. If this Society has pent-up energy which seeks an avenue of productivity, I hope it wiIl foIIow the Iead of the American CoIIege of Surgeons in striving for more realistic compensation laws. We should not entrench the present archaic system by attempting to develop methods of disabiIity evaluation which aIIow others to slough off their responsibilities or to make financia1 gain at the expense of the injured workmen.

713