Introduction
The role of the personal physician is to diagnose, treat, and prevent illnesses and injuries, prevent additional injury, offer advice and support to the patient, and provide appropriate factual medical information to the patient, the employer, and the benefits payer. Fulfilling these responsibilities requires that the personal physician understand the important role that work plays in allowing a patient to experience a fully satisfying life.

This consensus document addresses the role of the personal physician in assisting the patient to minimize life and work disruption. This assistance entails keeping the patient’s daily routine as normal as possible, and for the employed patient, includes helping him or her stay at or return to work as soon as it is medically feasible and safe to do so. Remaining active and being productively engaged in life benefits both the patient and his or her family. It not only enhances recovery, but reduces personal, household, social, and economic problems, and also prevents needless work disability and job loss.

The personal physician should also be aware of the important contributions that can be made by other parties, especially those familiar with the patient’s work life, in the stay-at-work and return-to-work process, and should work cooperatively with these other parties to help the patient minimize the impact of health conditions and maintain the fullest possible participation in life. Whenever possible, all parties should endeavor to prevent needless work disability by helping the working patient stay employed.

Position Statement
The American College of Occupational and Environmental Medicine (ACOEM) recognizes that:

• a fundamental purpose of medical care is to restore health, optimize functional capability, and minimize the destructive impact of injury or illness on the patient’s life;
• medically related withdrawal from normal social roles, including work, is destabilizing and may be detrimental to a patient’s mental, physical, and social well-being;
• maintaining or returning a patient to all possible relevant life activities as soon as is safely possible has many beneficial psychosocial and physical effects;
• the physician can positively affect the likelihood and rapidity of healing by setting clear expectations for recovery with the patient and by providing useful and appropriate guidance to the patient and his or her employer; and,
• with patient consent or when legal requirements are met regarding disclosure of personal health information, the physician can collaborate effectively with other involved parties in the stay-at-work and return-to-work process.

Guidance for Physicians
The physician should encourage the patient to safely minimize life disruption due to illness or injury and to keep to an as normal as possible daily routine. For the employed patient, this includes finding a way to stay at work. If work is interrupted, elapsed time away from employment should be minimized. The physician must promptly facilitate the patient’s return to function and encourage some type of productive work activity, whether via the normal job or through a temporary assignment. The exception to this general recommendation is any situation that would involve unavoidable serious medical or safety hazard to the patient, his or her coworkers, and/or society, or in cases where existing laws or regulations prohibit a patient with a particular medical conditions from working in certain occupations.

Programs to return the patients to work should include:

• Medical treatment or care plans that consist of current best medical practices and are evidence-based if possible. Treatment plans should identify the optimal sequence and timing of interventions. Unnecessary delays in health care services should be identified and minimized.
• Activity prescriptions for function at home and at work as part of the treatment plan. This will require making detailed recommendations for graded or stepwise increases in activity over time. If medical and functional recovery do not proceed as expected, it is important to investigate and address the reasons for delay. This will often require exploring the contribution of psychosocial issues and/or co-morbid psychiatric diagnoses and reaching out for input or assistance from other health care professionals, the employer, or others with knowledge of the situation.
• Gradual resumption of activity and normal daily routine to aid recuperation, which entails most employees returning to work before they have made a full recovery. However, return to any type of work assignment requires that the employee’s current capabilities match or exceed the physical, psychological, cognitive, and social demands of the specific tasks being contemplated. This may require careful planning and discussion with both the employee and the employer. Many patients will need to be educated and reassured if they are to overcome the common misconceptions that rest and avoidance of activity are beneficial. Deconditioning makes return to function slower and more difficult.

In complex cases, especially those with long-term implications, on-going workplace hazards, unusual working environments, slower than expected recovery of function, or questions of potential risk to the public, the treating physician is advised to consult the best available local or regional physician(s) who have expertise in occupational health and safety. These professionals can assess the situation and make recommendations or actively intervene in the situation to facilitate an optimal outcome. Often, useful information and expertise is also available from employers, insurance companies, or appropriate governmental agencies.

Developing Return-to-Work Plans
Return-to-work plans should include the following components:

• Early in the course of treatment, the physician should discuss with the patient the expected healing and recovery times, as well as the positive role an early, graduated increase in activity has on physical and psychological healing.
• The physician should ask about the impact of the medical condition on the patient’s ability to perform responsibilities at home and at work, and the availability of family and community support systems.
• When a patient has recovered sufficiently to return safely to some form of productive work, the physician should point out this milestone and explain to the patient that resuming normal activities while symptoms continue to resolve is an important part of the rehabilitation process.
• The physician should look for potential obstacles to the recovery of function and return to work as soon as possible. These can include physical, mental, and non-medical issues such as undiagnosed or under-treated conditions, psychosocial, legal, or workplace issues. When obstacles are identified, they should be appropriately documented. The care plan may also need to be re-evaluated and adjusted.
• Identified obstacles should be referred to parties who are appropriately involved in the patient’s health-related employment situation, such as other clinicians, benefits or claims payers, case managers, occupational health and safety professionals, human resources professionals, or workplace supervisors.
• The physician should support direct communication between patient and employer early in treatment or rehabilitation in order to reduce social isolation and maintain the bond with the world of work. A physician’s offer to participate in a three-way conversation with a patient and his or her employer can help identify and facilitate the removal of obstacles.
• At each visit, the physician should provide guidance to the patient (and employer with patient authorization or as permitted by law) about what job functions are safe to do and realistic to expect. These “activity prescriptions” will naturally change over time. Protective and preventive measures may also be prescribed as appropriate.
• If the patient is able to do something productive, but there is no work available because of statutory prohibitions or employer policies, business practices, unwillingness or inability to make accommodations, or mitigate workplace risks, the physician should offer to contact the employer on the patient’s behalf. The physician should also make it clear to the patient that the work restriction is due to non-medical issues (i.e., employer policy, etc.), recommend that the patient remain as active as possible, and counsel him or her that they are still in charge of their own future.

Prescribing Activity: Estimating Current Work Ability, Medical Risk (Restriction), Capacity (Limitation), and Comfort (Tolerance)
When formulating activity prescriptions, the personal physician should consider and provide guidance regarding patient function both at home and at work. Employers will rely on activity prescriptions as estimates of current work ability. The patient’s medical vulnerabilities and altered functional capabilities should be considered and matched against the demands of the job and working conditions. It may be necessary for the physician to explain the activity prescription and coordinate with the employer.

• Capability or Capacity: Despite the traditional request for “restrictions” or “limitations,” both the patient and employer often find it more useful and positive if the physician also describes which activities the patient can do at the present time. Due to the enormous range of possibilities, this is only practical when the employer submits a list of usual and/or proposed alternative tasks so that the physician can check off those tasks that are currently medically appropriate. When in doubt, a referral for physical or occupational therapy assessment of ability to perform the tasks in question may provide helpful information.
• Restriction Based on Personal Risk: Protective measures required to prevent recurrence, additional injury, or foster recovery are restrictions. These restrictions describe what patients should not do even if they think they can. Restrictions are the result of the physician’s assessment of medical and personal safety risk. Restrictions should be relevant to the job demands. They should also be based on objective information such as physical examination findings, test results, and incidental observations, or the documented presence of recognized occupational hazards. To make it feasible for the patient and employer to honor restrictions, restrictions must also be specific, e.g., an exact weight and height for lifting, a length of time per hour, and number of times per shift that an activity can safely be performed, postures to be avoided, etc. Restriction(s) duration should coincide with the expected time required for wound healing and recovery of tissue integrity, for medication to take effect or side effects to abate, for workplace modifications to be made or hazards rectified, etc.
• Restriction Based on Risk to Others: If the patient’s medical condition and the nature of the work performed will significantly endanger the safety of others, the physician must put public interest before that of the patient. The physician must specifically consider regulatory requirements regarding fitness for duty for workers who are exposed to hazardous working environments or whose duties affect public safety, such as pilots, commercial drivers, police, firefighters, and nuclear power plant workers.
• Limitation (Inability): Limitation describes what the patient is simply unable to do. These are existing constraints in his or her physical or mental capability to perform the required tasks. The physician is advised to rely on objective findings to the maximum extent possible. Some losses are obvious and permanent – a fused joint makes full flexion impossible; the loss of an eye eliminates binocular vision. If after a heart attack a patient can only exert to 4 METs during treadmill testing, then he or she cannot do a job that requires an average energy expenditure of 5.5 METs. Limitations secondary to deconditioning are transient and may be rapidly reduced as strength, endurance, and flexibility return with the increased activity of a graduated return to work. Limitations due to pain-related involuntary guarding and weakness can often be elicited during the physical examination or through incidental observations. Patient self-reporting is not a reliable method of making this determination as the patient often self-imposes limitations based on either excessive or insufficient caution, or on clinically-insignificant symptoms, inaccurate beliefs, or secondary gain.
• Comfort (Tolerance): Although temporary restrictions for new symptoms such as pain, numbness, and fatigue may be appropriate for a few days or weeks after the onset of an injury or illness, they are often not appropriate for chronic symptoms of this type. After an adequate work-up, and particularly in the setting of degenerative or soft tissue conditions, predictable or familiar symptoms of pain and fatigue without corresponding objective findings need no longer be interpreted as potential warning signs of medical risk. In stable conditions and in the absence of demonstrable risk of further physiological derangement or tissue damage due to activity, the physician can appropriately advise the patient whose longstanding or diffuse symptoms increase with activity to manage those symptoms as a tolerance or comfort issue.
• Social or Workplace Limitations or Restrictions: Some patients will demonstrate difficulty working under specific social conditions. For example, a brain injury, mental illness, or personality disorder may temporarily or permanently reduce a patient’s ability to cope with social or workplace conditions perceived as stressful, threatening, or overstimulating. The patient may be able to cope if modifications are provided such as working alone, doing self-paced tasks, or working in a quiet place. Progressive reintegration towards a more normal working environment should be part of the treatment plan.
• Environmental Limitations or Restrictions: Some patients will be at medical risk under certain environmental circumstances. For example, allergic symptoms usually require complete avoidance of exposure, but irritant symptoms may abate with reduced exposure to specific chemicals. Some medical conditions require avoidance of cold, heat, or constant vibration.
• Schedule Modifications: A legitimate medical basis for work schedule modification is mandatory. Accommodations of this type cannot always be arranged due to employer policies, work rules, union contracts, or other constraints. The physician should avoid “medicalizing” issues such as family disruption or job dissatisfaction. Temporary provision for shorter work weeks or periods of rest alternating with exertion may allow a patient with overuse symptoms or reduced stamina due to illness or surgery to work during recovery. Some examples of an appropriate medical basis for shift changes include documented medical sequelae of chronic sleep disturbance or demonstrated worsening of blood sugar control due to circadian rhythm disruptions in a diabetic.
• Medical Aids, Adaptive Equipment, Personal Protective Equipment, or Workstation Accommodations: The physician should inform the employer when assistive and protective devices are available to help the patient augment or restore his or her ability to conduct particular tasks or perform key functions despite temporary or permanent impairment, and give specific examples when appropriate. Conflict will be avoided if the physician consults the employer’s safety or human resources department before prescribing these items.
• Duration: Each activity prescription should specify whether restrictions and limitations are permanent or temporary, estimate their future duration, and set the date for the next reassessment. Disability duration guidelines derived from large databases of actual episodes are available and help the physician set realistic expectations, although normed population data is less useful in psychiatric conditions. Job loss, with its attendant economic, social, and mental health repercussions, can result when indefinite or long-term restrictions and limitations preclude a worker from performing the essential functions of his or her job. When a reduction in work capacity is likely to be prolonged, both the patient and employer should be informed promptly. Appropriate early planning may be crucial for preserving employment or allowing the best possible transition.

Understanding the Roles and Responsibilities of Others
The optimal resolution of health-related employment situations will often require the exchange of information and a problem-solving collaboration with other legitimate stakeholders. These stakeholders include occupational health specialists, medical and rehabilitation professionals, case managers, family members, benefits payers and insurance adjusters, and employer-based resource personnel such as workplace supervisors, return-to-work coordinators, human resources managers, and union representatives.

The role and responsibilities of the employer include the following:

• The employer and patient have a responsibility to provide the physician with the necessary employment-related information to enable appropriate medical advice and support. Since some patients are often unable to accurately describe their jobs and unaware of their employers’ ability to accommodate special needs, the physician should request that the employer provide a written or video job description that identifies the job risks, essential tasks, and available work modifications. Direct communication between an employee and his or her employer after an illness or injury is beneficial and often improves the employee’s perception of his or her ability to work.
• The employer determines whether, when, and how an employee is put to work within the medical restrictions and functional limitations prescribed by the physician. The employer is also responsible for ensuring that the workplace culture supports a timely return to meaningful work. Examples of a supportive culture include ensuring that any restrictions and limitations prescribed by the treating physician are respected, that temporary or permanent worksite adjustments are promptly made when called for, that advice from appropriately qualified experts is obtained before deviating from treating the physician’s recommendations, and that the patient feels safe in the workplace.
• The employer is responsible for maintaining a safe workplace. When a patient reports that he or she is concerned about the safety of the workplace, it is appropriate to request additional information from other parties, typically employers or insurers, with the patient’s permission. A three-way conversation can be very effective. Processes such as binding arbitration, for example, are frequently already in place as part of the employer’s human resources policies and contracts. Another alternative is to refer the patient to an occupational medicine physician or other local professional resource who is more prepared to handle situations of this type.
• Most employers are required by law to provide workers’ compensation insurance that covers all costs for medical care and provides partial wage replacement during a patient’s time away from work. A patient who says his or her injury or illness is work-related is entitled to file a claim, whether or not the employer agrees, although the claim may later be denied. In some states, the physician is obligated to report work-related conditions. Thus, the physician should be familiar with the basic facts of workers’ compensation in his or her jurisdiction and refer patients to the state agency responsible for workers’ compensation for information. In addition, when impairment or disability is expected to be protracted, all but the smallest employers are under legal obligation to hold the jobs of ill or injured employees for up to 12 weeks (the U.S. Family Medical Leave Act [FMLA]) or to make reasonable accommodations for otherwise qualified employees with covered disabilities (the U.S. Americans with Disabilities Act [ADA]).
• Benefits claim administrators and insurance adjustors often act as communication intermediaries on behalf of employers. Nurse case managers are often engaged to expedite the process of care and facilitate communication among all parties. In disputed cases, lawyers may assume the role of a communication conduit. Physical or occupational therapists, ergonomists, and employer-based health and safety professionals may be able to assist when functional demands of jobs need to be specified, options for work accommodations need to be developed, or hazardous conditions need to be rectified.

Respecting Patient Confidentiality and Managing Medical Information:

• In general, the physician should not give information to anyone concerning the condition of a patient or any service rendered to a patient without the patient’s consent. However, there are some exceptions to this rule. For example, laws in most jurisdictions provide for at least a partial waiver of the right to medical confidentiality for workers’ compensation claimants, usually limited to information specific to a particular workers’ compensation claim. Despite that, some states prohibit direct communication between the physician and employer or other parties about a benefits claim or the medical record unless the claimant consents or is present. The physician should be aware of the legal requirements in his or her jurisdiction and compliance with national laws such as the U.S. Health Insurance Portability and Accountability Act (HIPAA), the ADA, the FMLA, and medical codes of ethics for other areas that are not covered by the workers’ compensation waiver.
• Information about a patient’s ability to work and perform specific tasks that does not include any diagnostic, treatment, or billing information can be freely shared with the employer because this information is considered administrative. However, for the sake of consistency, the best practice is to ask the patient to authorize the release of this and other types of information to the employer or benefits/claims payer in order to be consistent with the general legal and ethical obligations concerning a physician’s duty to keep patient information confidential. For instance, if an employer requests information about the patient’s medical condition or treatment that is job-related and consistent with business necessity within the limitations of the ADA, prior patient consent should be obtained. Consent should be specific rather than general, and a written HIPAA compliant authorization is required.
• The physician should make an effort to support the reasonable business processes of the employer and insurers by obtaining authorizations from the patient to release pertinent information on a need-to-know basis. The information provided in the resulting medical reports and forms should be tailored to the intended audience and purpose. For example, a report directed to a patient’s work supervisor should only contain what the employer needs to know in order to manage attendance, schedule work shifts, provide medically appropriate work, and manage a workplace safety program. Most of the time, an estimate of work capacity, medical restrictions, and functional limitations will suffice. Initial reports of work-related conditions should also contain an explicit description of the reported circumstances or mechanism of the injury. In contrast, reports directed to benefits or claims administrators should also contain all diagnostic and treatment information reasonably necessary to evaluate and adjudicate claims, assuming that appropriate authorization has been obtained from the patient.
• The patient has the right to examine and obtain copies of his or her medical records. The treating physician should routinely provide the patient with a copy of all activity prescriptions and employment-related forms prepared for the employer or benefits/claims administrator.

Billing for Care Coordination Services:

• It is appropriate for the medical office to charge separate fees (unless prohibited by law or contract) for communication, care coordination, and completion of reports designed to facilitate stay-at-work and return-to-work for the patient. These services take time as well as professional knowledge and judgment by the physician and support staff. These activities provide value to the patient, other members of the health care team, the employer, and insurers.
• Larger fees are justified in situations that require the physician to go beyond the provision of routine medical care to review materials and formulate answers to questions posed by an employer, a workers’ compensation payer, or a disability benefits claims payer.
• Billing policies should be explained in advance of providing service and all activity performed should be documented.

Conclusion
ACOEM believes that by following the principles outlined in this document, the physician will enhance the patient’s medical and functional outcomes, prevent needless work disability, and help the patient stay employed. Keeping the patient employed not only benefits the individual, but has a positive impact on the patient’s family, community, employer, and society in general. This document complements ACOEM’s 2006 guidance Preventing Needless Work Disability by Helping People Stay Employed adopted in May 2006.

Acknowledgements
The original and revised versions of this statement were proposed by members of the ACOEM Work Fitness and Disability Section. This document was initially based on a prior policy adopted by the Canadian Medical Association in March 1997, and adopted by the ACOEM Board of Directors in 2002.

This revised version was approved by the ACOEM Board of Directors on November 8, 2008. Revision committee members were: Jennifer Christian, MD, MPH, chair; Melissa Bean, DO, MPH, MBA; Ron Blum, MD; Jennifer Branch-Rooke, MD, MPH; Daniel Bruns, PsyD; Kevin Byrne, MD, MPH; Brian Caveney, MD, JD, MPH; Shari Glynn, DO, MPH, MBA; Harold Hoffman, MD; Marcos Iglesias, MD, MMM; Rodger Kessler, PhD; Aryeh Klahr, MD; Mark Melhorn, MD; Arlen Rollins, DO, MSc; Ann Marie Stokes, MD; James Talmage, MD; and Don Williams, MD.