What can you do if your treating doctor tells you that you can never return to employment, or tells you that at this time employment is not a safe or suitable option for you?

First it is important to understand that vocational rehabilitation is an emerging science and not all general practitioners or medical specialists will be up to date with the latest research into its most effective practices. After all, vocational rehabilitation may not be high on their list of ongoing professional development priorities. This is not because they are not interested, but it could be because of the high volume of new medical and pharmaceutical developments that demand their attention. This means that it is possible that they may be wrong if they discourage you from seeking access to vocational rehabilitation. However, they could also be correct because this may not be a suitable time, or the way you plan to go about returning to work is not practical, safe, or suitable, in your current circumstances. A third possibility is that a proposed treatment plan (which may not have been fully discussed with you yet) is not compatible with a return to employment at this time.

So for these reasons, whether correct or not, any medical advice that discourages your interest in returning to employment at this time may need to be more fully explored in order to be understood. If a vocational rehabilitation service provider has already expressed interest in assisting you, they would normally help you to explore the reasons for any discouraging medical advice directly with the medical practitioner. So if you do receive any discouraging medical advice it is important that you try to understand the reasons given in support of that advice.

Trying to understand any reasons given for discouraging medical advice is an important step because following bad advice could delay your overall recovery. In the worst case scenario, a general practitioner or medical specialist could be incorrectly and permanently writing off your future employment potential. From the latest developments in vocational rehabilitation research we know that suitable employment is beneficial to most people and supports or enhances their recovery. Also, many jobs can be customised to accommodate a wide range of injuries, disabilities and health conditions. Sometimes general practitioners assume that pre-injury duties will be required to return to work when in fact this is not correct. In addition, ongoing support from an expert vocational practitioner can sometimes be available to help you retain employment, in a pre-injury or altered form, even after you become established in a suitable job.

For most people then the key issue is not whether or not they can work, it is in what kind of job, over what hours, and how the job can be modified. Job redesign, workplace accommodations, or ongoing assistance at work, or behind the scenes, may also be available. Treating doctors and medical specialists can encourage you to find the most suitable forms of rehabilitation assistance to match your needs. Often this can be coordinated with your current treatment plan. Discussing this with your treating doctors and medical specialists keeps them informed about how you plan to return to employment. This means having regular conversations with them about any vocational assistance that you receive, so that they also understand your recovery at work goals, the services you are seeking, and how and when you plan to return to employment. Having a rehabilitation consultant involved can make this even easier. They can provide the information to your general practitioner or specialist to reassure them that you are not at risk and will be appropriately supported throughout your recovery.

By ensuring your treating doctor and other medical specialists understand your vocational plan, you will be able to get their support when this is needed. Later you may need them to approve your recovery at work goals and the methods proposed to help you achieve those goals. Not doing so runs a risk that you will receive uninformed or discouraging medical advice which can delay your vocational rehabilitation. Usually the support of your treating doctors and specialists for a recovery at work plan is quickly obtained once they are fully informed about what is being proposed and how the plan can advance your recovery goals.

In practice the best way to get your medical team on the same page as early as possible, is to organise a face to face meeting with you, your advocate, the rehabilitation provider, and your treating doctor or medical specialist. This usually requires you to book a long consultation with the treating doctor for this topic alone, so that there is sufficient time to introduce your rehabilitation consultant, explain the key elements of the vocational plan, and discuss how it can be coordinated with the treatment plan.

After this meeting, and with your permission, your rehabilitation consultant can keep the treating doctor informed by sending brief written reports (one or two sentences work best on official letterhead or email) as each stage of the recovery at work plan is completed. Each treating doctor may have a different preference for how this communication is managed. It is usually important not to try and use telephone or text messages as these forms of communication are usually not effective in busy medical practices.

The reason this method works is because treating doctors are used to getting brief written reports about their patients from a wide range of other medical specialists. Treating doctors may like these reports to be in a pdf form attached to an email, so they can be copied or scanned into their patient records. Rehabilitation consultants can attend ongoing medical appointments with you to ensure that the recovery at work plan remains on track, and the communication remains strong between the vocational team and the medical team.

 

What can you do if you have tried the steps above and the treating doctor or medical specialist still do not support your returning to employment?

It is possible that treating doctors, medical specialists, and other allied health professionals, all have different views on the feasibility of employment after accidents, injuries, or the onset of severe general health or mental health conditions. Some of these positions will be well informed and based on good reasons or evidence, and others may not. Some views may be out of date or no longer supported by evidence. Since in many cases it is not possible to access vocational rehabilitation without the written support of a treating doctor or medical specialist, it will be important to try and understand the reasons behind that advice.

If a person has a definite goal of returning to employment, or of obtaining employment for the first time, medical advice that employment is not feasible for them can be damaging. Such advice can damage their sense of hope and personal confidence. If that happens, it is best to first consider that the treating doctor or medical specialist may be correct. Or at least consider that their point of view needs to be understood and respected. Having acknowledged that though, it is also important to explore and assess the reasons behind their advice. The depth of their current knowledge of vocational rehabilitation can be important. It is possible that your treating doctor or medical specialist has a limited knowledge of current vocational rehabilitation practices and of evidence for what works best. So it is possible that the reasons given for not attempting employment at this time may need further discussion. If that is the case your rehabilitation consultant can include that issue among the others to be addressed in your vocational rehabilitation plan. There are also other tools and assessments available to rehabilitation consultants to help you fully explore the range of employment options that may be possible, given your strengths, skills, and current medical and other work restrictions.

This is why it will be important to involve your rehabilitation consultant in discussions of this type with your treating doctor and medical specialists. Usually, any problem is quickly resolved once the medical team is aware of the details of the vocational plan, how any risks will be managed, and how any work restrictions caused by illness or injury will be accommodated in the workplace. Often, the best way to do this is as early as possible, in a face to face meeting. This is usually done by having your rehabilitation consultant also attend one of your medical appointments.

In the rare case that this approach does not work, you can always ask for a second medical opinion, or change your treating doctor and medical specialist. But this step should only be taken after everything else has been tried and you still disagree with the advice provided. Your rehabilitation consultant can help you to find second medical opinions, or find alternative treating doctors and medical specialists if that step is actually required.

 

How can you know if you have the ability to return to work successfully after injury or illness?

People who have ceased work following an illness or injury are often unsure if they can successfully return to any form of employment. Often what makes some people succeed and not others is how much they value employment as an important part of their life and of their recovery. It is natural to feel anxious about returning to work after a long illness or injury break. But this anxiety can quickly reduce once you are back at work discovering how many duties you can still perform successfully. The key point is that if you are interested in a return to paid work then there is every chance you will succeed with the right help.

If you are not interested at this time, it could be because of low availability, due to medical appointments and other commitments. Or it could be because of insufficient wellness, severe pain, or low energy levels. There are many medical conditions, even in severe forms, that do not exclude employment from the recovery journey. The key issue is often finding the right help to explore the best employment balance for you at this time, given the other constraints on your time, energy, and wellness. For many people, having the opportunity to work part time during their recovery, can be very helpful and can actually help with their recovery. Having a regular weekly time structure, a sense of purpose, more social interactions, plus the added income from employment, help to offset the burden from long periods of illness or injury. In summary, whether or not you feel capable of any form of part-time employment after injury or illness, is not always due to the severity of the illness or injury. It also depends on your personal circumstances such as your other commitments, your availability, as well as how much you value employment as part of your life, and how much you want it to be part of your recovery plan.

Another important point is that there are many different types of jobs with mixes of duties and hours that can vary considerably. Working from home options are also available more than ever before. Often employers are willing to accommodate the needs of particular workers by adjusting hours or duties even more to suit their needs. This is why a rehabilitation consultant can be so helpful. They are often experts at talking to employers about these kind of adjustments, and can also explain them to you and your medical team. Not only can they help you obtain the right mix of duties, they can also help employers to make further changes to your duties and responsibilities if that is needed.

 

Can we predict who is going to succeed in VR?

It is currently not possible to predict exactly who will succeed and who will not in vocational rehabilitation. This is because many things influence the outcomes, from personal, medical, and social factors through to employers' circumstances and the nature of workplaces. But it is possible to say when an individual has higher assistance needs that require more intensive forms of assistance. This may be what a treating doctor is concerned about. High needs for assistance or substantial restrictions on the hours that can be worked and the duties performed, do not mean employment is not possible. It just means it might take longer to find the right employer, job, and the optimal mix of hours and duties. An experienced rehabilitation consultant will see this as a challenge, not as a reason for not attempting employment.

Treating doctors may be worried that either the needs for assistance are too high, or cannot be addressed sufficiently in the vocational plan. If this is the case, the situation can often be resolved simply by identifying the barriers to employment that the treating doctor is most concerned about and by asking your rehabilitation consultant to suggest how those barriers will be overcome throughout the vocational plan. Such a discussion can help everyone involved to understand what is being provided through the vocational plan.

 

What barriers to employment can be addressed in vocational rehabilitation?

It is possible that your treating doctor is aware of more barriers to employment than have been discussed with you to date. No matter what the nature of the barrier may be, there are always ways to overcome many of those to make some forms of part-time employment feasible. The kind of barriers that can be addressed are extensive and include medical conditions, physical impairments, cognitive impairments, mental health, side effects of medications, and functional limitations. There are also intermittent and unpredictable health conditions which can become barriers to employment for short periods without warning.

There are also secondary barriers such as the negative attitudes of others (sometimes called stigma) and how jobs are organised at the workplace. Your rehabilitation consultant will have had extensive experience addressing a range of individual, social, and workplace barriers to employment. So this means that it will be helpful to discuss each potential barrier as soon as it concerns you and before it actually becomes a problem.

 

Should I take as much leave as possible from my job or should I try to continue working during my treatment and recovery?

We know that taking long periods of sick leave and becoming disconnected from the workplace are associated with higher work-related disability and risk of job loss. This in turn can lead to even longer periods of unemployment. Treating doctors and other health professionals are increasingly aware of the health benefits of remaining connected to a workplace as much as possible during recovery from serious illness or injury. For instance the Royal Australian College of Physicians (RACP) now support a focus on recovery at work as much as possible. This support is based on compelling evidence that good work is beneficial to people’s health and wellbeing; and that long term work absence, work disability and unemployment have a negative impact on health and wellbeing. There is a helpful RACP webpage outlining this approach from a treating doctor's perspective. See the following link:

https://www.racp.edu.au/advocacy/division-faculty-and-chapter-priorities/faculty-of-occupational-environmental-medicine/health-benefits-of-good-work

In line with this approach, your treating doctor should only authorise sick leave if it is medically necessary, and then only for defined periods for specific medical reasons. Long term sick leave for insufficient reasons can actually create additional work disability and be harmful to your recovery. Sometimes a change of hours of working from full time to part time is all that is needed to enable a worker to participate fully in a treatment plan, while maintaining good connection to their workplace. This step can be important to prevent the work related disability that can result from a loss of confidence and loss of skills that can follow from through losing touch with the job, co-workers and supervisors.

 

Summary

A good vocational plan involves working together with your treating doctor, medical specialists, your rehabilitation consultant, and your employer if they are still involved in your rehabilitation. The aim is to find ways to overcome the issues that make employment more challenging than it needs to be. Having several barriers to employment can mean that your employment options are more restricted. This in turn implies that more creative solutions are needed to overcome those barriers. Yet, having a lot of barriers to employment is not a good reason for giving up on your employment goals. While finding a solution may not be easy, it will be important to seek out the best vocational and medical help you can find. If you have any more questions about this topic I encourage you to raise them as discussion points with your rehabilitation consultant and with your treating doctor and medical specialists.

 


 

Dr Geoff Waghorn, Brisbane, ORS

Dr Waghorn has 24 years’ experience as a Registered Psychologist and 23 years in research. He is one of the leading experts on vocational rehabilitation including Individual Placement and Support (evidence-based supported employment) within Australia and internationally. To date Dr Waghorn has contributed to over 120 peer reviewed research publications. Most of his research has focussed on improving the recovery and social inclusion of individuals living with disabilities and health conditions.

In 2014 Dr Waghorn entered into the Disability Employment Australia Hall of Fame for his significant contribution to improving the lives and experiences of people with mental illness seeking employment. Dr Waghorn’s expertise includes an ability to simplify complex information and research to ensure that it can be practically applied in the real world. Geoff is a passionate advocate of open employment for people living with disabilities and severe mental illnesses who want to work. He has challenged low expectations in society with questions such as “show me the evidence that this person cannot work given the right support and a suitable job match