Scrutinizing Claims of Work Relatedness in Workers' Comp

Friday, September 3, 2010 | 0

By Robert J. Barth, Ph.D. and J. Mark Melhorn, MD

Workers’ compensation was created to address health problems specifically of a work-related nature. Unfortunately, discrepancies have emerged between that purpose and the reality of modern workers' compensation. As has been explained in the American Medical Association’s text, Guides to the Evaluation of Disease and Injury Causation (referred to as AMA Causation for the remainder of this article), there are many clinical issues that find their way into workers’ compensation despite little to no scientific support for claiming that those issues are work-related. Examples specified in AMA Causation  include carpal tunnel syndrome, complex regional pain syndrome type 1, post-traumatic stress disorder, and chronic back pain. Conversely, AMA Causation  also explains that the potential work-relatedness of some conditions may go unrecognized because of the less than obvious nature of the relevant occupational risks.

One factor in the development of such discrepancies is the dominant tendency for workers’ compensation systems to allow doctors to offer opinions, rather than facts, regarding work-relatedness. Reviews of workers’ compensation files (such as a review of files that was undertaken specifically in conjunction with the creation of AMA Causation), reveal that doctors develop opinions regarding work-relatedness in an idiosyncratic, haphazard, and even cavalier fashion. Similarly, a Florida workers’ compensation insurer surveyed its panel of doctors about how they determine work-relatedness, and the prevailing response was that they do not — they simply assume work-relatedness based on the fact that the patient came to see them in the context of a workers’ compensation claim. Based on such reviews and reports, one might develop the impression that there are no health-care standards for evaluating work-relatedness.

<b>AMA Guide Can Help</b>

AMA Causation was published in 2008 with the goal of eliminating such impressions. It specified scientific and clinical standards for determination of work-relatedness. Given the information in this text, workers’ compensation professionals can scrutinize conclusions regarding work-relatedness from any individual case and determine whether the doctors who offered the conclusions did so in a manner that is factually based, scientifically credible, and consistent with professional standards.

Two points from the preceding paragraph warrant emphasis: Factual basis and scientific credibility. The first, factual basis, is dependent on the second, scientific credibility. AMA Causation explains that scientific causation analysis involves a search for facts. The text highlights the discrepancy between this and legal causation, which, instead of being based on facts, is rooted in subjectivity — the subjective claims of the claimant, the subjective opinions of experts, and the subjective judgment of decision-makers. Because the workers’ compensation system is so thoroughly plagued by subjectivity, workers’ compensation professionals might never have realized that determinations of work-relatedness could potentially be based on facts, rather than on opinions.

Health science is the source of the facts that are needed for making credible determinations regarding work-relatedness. Unfortunately, this critical portion of the process is usually ignored.  Doctors’ opinions frequently develop absent any consideration of the relevant health science. AMA Causation repeatedly emphasizes that the determination of work-relatedness, even for a single case, should involve a review of the scientific studies that have analyzed the possibility of a causative link between the presumed occupational cause and the claimed occupational health condition.

In other words, it would be appropriate for a doctor’s evaluation of work-relatedness in an individual case to start with a review of the relevant scientific literature, rather than with an examination of the plaintiff or an interview of the plaintiff regarding his or her history.  AMA Causation actually provides such reviews of the relevant science for many issues that enter into workers’ compensation. For example, for claims of post-traumatic stress disorder (PTSD), a review was provided of studies that examined the possibility of a causative relationship between traumatic civilian experiences in adult life and the development of PTSD symptoms.  Such studies have repeatedly revealed a lack of causative relationship — the syndrome of PTSD occurred at the same rate in groups of people who had experienced trauma and in groups of people who had not experienced trauma. The repeated replication of such scientific findings creates a significant obstacle to credibly concluding that PTSD is caused by civilian trauma in adult life (such as anything that might happen to a worker in the workplace). Such scientific findings allow a doctor in any individual case to address work-relatedness based on facts (e.g., the fact that scientific findings have failed to support claims of work-relatedness), rather than based on opinion.

In addition to such reviews of the scientific literature, AMA Causation provides examples of how doctors can conduct an analysis of work-relatedness for any individual case and how the results of that analysis can be documented. The text additionally addresses many of the benefits of a credible approach to evaluating work-relatedness, such as  sparing claimants from unjustifiable exposure to the reliably harmful health effects of involvement in workers compensation, identifying work-relatedness that might be overlooked if a scientifically credible approach is not used, combating the tendency for claims of work-relatedness to cause more important non-occupational causes to be overlooked, minimizing the unnecessary adversarialness of the workers’ compensation system by providing a factual basis for claim resolution, and controlling the explosively increasing costs of workers’ compensation.

<i>J. Mark Melhorn, M.D. is the editor of AMA Causation and an orthopaedic surgeon specializing in the hands and upper extremities in Wichita Kan. Melhorn is president of CtdMAP, an organization that reduces work-related health problems by evaluating occupational risks.

Robert J. Barth, Ph.D. is owner of Barth Neuroscience in Chattanooga, Tenn.</i>