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Communications with Your Treating Doctor: What Your Insurance Company is Telling Your Treating Physician: What You Need to Know

This article will discuss the communication between you, the Injured Worker, and your treating doctor.

One of the Largest Insurers in the State of California, the State Compensation Insurance Fund, issued a publication intended for their physicians who treat injured workers.   This publication includes a discussion concerning communications with injured workers. It is called “A TREATING PHYSICIAN’S GUIDE to Patient Care in the Workers’ Compensation System.”

The publication states that “[o]ne of the unique features of occupational medicine is the need for the treating physician to function as part of a team. The players on this team include the injured employee, the employer, the physician, and the claims administrator. Depending on the specifics of the case, other parties may be involved, including an occupational health nurse, a physical therapist, a vocational rehabilitation counselor, or the patient’s family physician.”

Conflicting Interests

Of interest, for Injured Workers, is to note that during the course of industrial medicine treatment, there are many more people that have a need or an interest in the communications concerning their treatment.  In a non-industrial format, the only people that may be involved in the matter could be simply the patient, the doctor, and the insurance company.”

Doctor-Patient Relationship

The publication goes further to indicate that in “[c]ommunicating with the Injured Employee[,] experienced clinicians are aware of the importance of trust in the doctor-patient relationship. For the occupational injury patient, the establishment of this trust may be particularly challenging and can require special attention. This need is especially true if the employer has referred the patient. In this situation, the patient may view the treating physician as the stereotypical “company doctor” whose allegiance is primarily to the employer. This view should never be the case, either ethically or as a matter of law. It is important to remember that professional ethical codes and civil court rulings require that the physician’s primary allegiance be to the patient. Ethical and legal obligations notwithstanding, the injured employee often may assume that the employer-designated physician is unable to make objective, unbiased decisions relating to such issues as a return to work, and that cost containment considerations are compromising the quality of medical care. “ [emphasis added]

The State Compensation Insurance Fund does an excellent job explaining the dilemma which physicians face in treating industrial patients.   The unspoken rule, unfortunately, is the “Golden Rule.”   In sum, whoever has the “gold” makes the rules.   In order for a physician to continue to obtain business from the insurance company and the employer, they must make efforts to not “rock the boat” with respect to treatment.  They know if they provide too much care, place an injured worker on temporary disability for too long, or write a permanent disability report with a lot of value, that their future employment by the insurance company and/or employer will be in doubt.  Further, in industrial medicine, the Injured Worker is not obligated to pay for the treatment. As a result, the physician has no direct monetary relationship with their patient.

Effective Communication

The publication goes on further to state that “[f]or the physician, effective communication and an appropriate “bedside manner” require an awareness of this potential mistrust. Open and frank discussions concerning the patient’s attitude and feelings about work are essential. It is often appropriate to discuss return-to-work goals before establishing the diagnosis and treatment plan.” [emphasis added]

One can find it quite unsettling that physicians are warned about mistrust between the injured workers/patient and their treating doctors.   What about the Insurance Company or the Employer?  Are there issues of mistrust that the doctor should consider with respect to their communications with all parties?  Should the doctor harness a little mistrust as to the intentions of the Insurance Company and the Employer?  Aren’t there times in which an Employer is not being honest about “return to work” issues or “industrial causation issues?”  In sum, the physician should consider mistrusting all parties and not just the Injured Worker.

Return to Work as an Issue

The publication goes on and states that “[i]t should be noted that making the decision regarding return to work status can be fraught with pitfalls, especially for the “soft tissue” injuries that are so common in the industrial setting. These conditions often involve pain syndromes with minimal or no objective findings. It is important to listen carefully to the patient and correlate the subjective complaints with clinical findings and diagnostic studies.”

This statement is very interesting.  There is some import concerning “soft tissue” injuries.  This statement seems to clue in physicians with respect to cases involving minimal findings.   To some degree, this is ironic.  Many “soft tissue” or “minimal or no objective findings” cases can be explained by the lack of medical attention and the lack of medical testing.  First, many times, physicians are not seeing the patients. The facilities have non-physicians handle medical appointments/evaluations.  On these occasions, the Injured Worker is seen by a Physician’s Assistant (“PA.”)  The lack of the physician constantly monitoring treatment creates a lack of understanding of the Injured Worker’s condition. This can create an incorrect perception of the medical conditions.   Further, due to the Utilization Review process, diagnostic studies requested by the treating physician to provide objective findings are denied.  This denial prevents the Injured Worker from being able to prove that there are in fact objective findings.   In sum, the physician’s analysis and communications are compromised when addressing “soft tissue” or “minimal or no objective finding” cases by the Insurance Company and how medical treatment is delivered.  I will concede, however, that, at times, there are some Injured Workers who greatly exaggerate their pain.   Small injuries registering on the self reporting pain scales as a 10 out of 10 every time they are seeing the doctor is a perfect example of this exaggeration.

The publication then states that “[d]ecisions regarding functional status and work restrictions, however, must be the physicians. The physician must make the decision on sound medical judgment and should not be inappropriately swayed by the employer, the claims administrator, the attorney, or the patient’s wishes.”

Again, this publication needs to state and advocate the lack of bias in the system.   Again, the “Golden Rule” is always in play in the back of any physician’s mind.   This is not meant as an insult to physicians.  It is simply the reality of industrial medicine. The simple concern is that the Injured Worker’s treatment, disability status, and entitlement to future medical care is not compromised by this leaning.

Common Goals for Industrial Medicine Treatment

The publication goes on to note that “[t]he challenge for the clinician managing work injuries is to maintain a focus on the patient’s problems and to involve him or her as an active participant in the rehabilitation process. It is important to emphasize that the physician, the patient, the employer, and the claims administrator all share a common goal: effective rehabilitation and prevention of further injury.”

I disagree with the publication’s conclusions of the common goals.   The commons goals should be the prompt diagnosis of the medical condition, the prompt provision of diagnostic studies to assess the correct diagnosis, the prompt provision of the treatment indicated by the diagnosis, the proper time off or correct work limitation during the recovery, and the return to full duties if possible.

Injured Worker’s Complaints

Finally, the Publication indicates that the Physician “[w]hen communicating with the injured employee:

  • Listen.
  • Sit down.
  • Explain.
  • Perform a hands-on exam.”

This is the one section that I completely agree with the State Fund.   It is so important that Physicians listen and document all of the injured worker’s complaints.   Failure to listen and a document can bring rise to the question of whether complaints were reported and timely reported.  Sitting down with the Injured Worker is also important.  A patient/doctor relationship is also a business relationship.   Both sides need to take treatment issues seriously.  Injured Workers need to comply with the physician’s instructions to assist with their recovery. This can include taking the proper medications, participating in physical therapy, and following any other instructions indicated.

A Physician’s explanation of what is going on is also very important. For some injured workers, their only contact person on their case may be their doctor.  At times, the Physician is the only person who may be available to assist the claim and provide the injured worker with important information.  Finally, it is always important for the Physician to actually perform a hands-on evaluation.  Hands-on evaluations provide valuable information to assist the physician with respect to the accurate diagnosis of the injured worker.   Also, it can provide valuable information concerning the Injured Worker’s developing medical condition.

As an Injured Worker, Where Could I Get Advice?

If you would like a free consultation regarding workers’ compensation, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. They have been helping people in Central and Southern California deal with their worker’s compensation cases for 26 years. Contact us today for more information.


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