Max Lebow, MD, MPH, FACEP, FACPM
Urgent message: A thorough, occupational medicine-specific history is essential to identifying and resolving work-related injuries and illnesses quickly and safely—for the benefit of the patient and the employer.
Like any medical history, the occupational medicine history is meant to guide the clinician to the proper diagnosis and treatment for the patient. However, it is set apart from the “typical” history in that several other goals must be achieved in the process. Not only are the duties and responsibilities of the occupational primary treating physician often mandated by law, gathering the proper historical information at the beginning of the case will lead to a timely resolution and rapid return to work for the injured worker, help avoid an adversarial relationship between the employer and the employee, and identify any red flags to assure that the subjective complaints and description of the injury match the objective findings of the physical exam. Finally, healthy, respectful skepticism is helpful in determining if the claimed injury or illness occurred out of and in the course of employment vs the result of off-duty activities.
(Note: the specific words I used “arising out of and in the course of” is the term often used to make the determination of on-duty versus off-duty injury)
Here, we discuss some of the key requirements and nuances of obtaining an occupational medicine history in the urgent care setting.
Goals of Occupational History
- Establish the precise onset of symptoms
- Understand the patient’s job duties
- Obtain detailed mechanism of injury
- Determine if the illness/injury is Work Related
- Determine if case meets OSHA First Aid requirements
- Determine work status: full versus modified duty, or TTD
- Determine treatment options
- Estimate time to Maximum Medical Improvement
- identify any “red flags”
Understand Your Patient’s Job Duties
Injured employees often present with paperwork that identifies their job title. What does that actually mean, though? Job titles can be ambiguous, and often do not describe what the employee—your patient—actually does. Questions such as the amount of time spent standing vs sitting; lifting requirements of the job, including how much and how often; and description of any particularly awkward motions such as cleaning behind sinks help define the worker’s actual duties.
This information is obtained in three different ways.
First, ask specific questions during your history. For example, if someone is claiming a knee injury, it is important to know whether most of their time is spent sitting or standing, and if they are carrying heavy loads.
The second way is to talk to your client company. The examining physician should talk to the company contact to obtain job duty information, or better yet, obtain a copy of the defined job duties, which will generally describe the percentage of time spent sitting vs standing, the usual loads that the employee is expected to lift during the day, and other important information about the physical demands of the job.
Finally, I have found that scheduling a visit to the job site provides invaluable information about the work environment and insights into the daily activities of the workers. It’s also an opportunity to meet the supervisors, safety officers, and those I will communicate with in the future to facilitate better relations.
Of special importance is the determination of whether the job is “safety sensitive.” Does the employee drive, operate machinery, work around toxic materials? The answers to these questions not only help reveal the mechanisms of some injuries, but also help the occupational medicine provider create a modified duty program that can keep the injured employee at work and active during the recovery period.
All this information can illuminate how the injury or illness occurred, and help the occupational medicine provider formulate a treatment plan to optimize recovery and return to full duty at preinjury levels as quickly and safely as possible.
Length of Time with Current Employer and at Current Position
The length of time the patient has been on the job can be a predictive indicator for how quickly recovery will progress. For example, an employee claiming an overuse injury in the first few weeks of employment represents the need for strengthening, rather than treatment for repetitive strain injury. An injury shortly after hiring may also be a red flag for possible workers compensation fraud.
The length of time a worker has been performing a task may also offer more subtle clues that the root of the complaint may not be physical. For example, long-term employees who have had a recent change in their job function, or a shift change, may be dissatisfied with the change and more likely to claim a work-related injury. Only close attention to the details of the mechanism of injury and the subjective complaints and objective findings can make these important differentiations.
Full or part-time employment?
One factor that may be overlooked by the occupational medicine provider is that many people now may hold two or three part-time jobs simultaneously. This is a common reason for delay in recovery from musculoskeletal injuries. Patients who have jobs outside of the one related to their treatment may be unable to rest adequately between shifts, have frequent missed appointments or missed physical therapy treatments, or be nonadherent with self-treatment, such as stretching and home exercise.
History of the Current Illness or Injury
Understanding precisely when they injury began is an important part of the occupational medicine history. Gradual vs sudden onset can help differentiate repetitive stress injury from acute musculoskeletal strain, and help predict the timeline and outcome of the case.
Delay in reporting may represent a red flag for deception or secondary gain associated with the injury. Most serious injuries are reported immediately, and treatment can begin quickly. If there is no obvious reason for a delay in the injured worker presenting to the clinic, probe for a reasonable explanation. One method of probing for issues such as workplace dissatisfaction is to ask: “What is it like to work for company ABC?” An open-ended question is less likely to elicit a defensive response, and more likely to give an unvarnished answer.
Is this injury new, or a recurrence?
A good description of any previous injuries, especially in the previous 36 months, can help differentiate a new injury from a recurrence of an old injury (and, therefore, help direct treatment decisions). The differentiation can be difficult, but a reasonable decision can be made with patient questioning and a review of thorough records.
Obtain a Detailed Mechanism of Injury
For an urgent care patient, it is adequate to document that the patient experienced “back pain after lifting,” or “hurt ankle climbing steps.” In a typical urgent care setting, there is little riding on where or when an injury occurred. By contrast, the workplace injury should be described in greater detail, to assure that the mechanism can reasonably explain the patient’s injury claim. For example, understanding the approximate weight of an object can help determine whether this injury occurred during routine job activities, was an unusual event, or occurred in an activity unrelated to the job. This information can also help determine work modifications at discharge.
Document a Thorough List of Subjective Complaints
In urgent care or emergency medicine, the provider will perform a clinical triaging to distinguish serious injuries from minor injuries that may not need immediate attention. By contrast, in occupational medicine all subjective complaints and injured body parts and locations should be recorded. One way to accomplish this, and help organize your eventual treatment plan, is to ask the patient to list areas of pain, from worst to least troublesome. It is important to ask this question again at every subsequent visit to help monitor recovery, or identify more persistent areas of pain that may need special attention. Also, a great deal of inconsistency may be a red flag to identify exaggeration of the injury.
Finally, when this process is completed, the occupational medicine provider should document “No other injuries present.” This statement is intended to assure that no non─work-related illness or injuries are later injected into the case.
Past Occupational History
Similar to a past medical history, the goal of the past occupational history is to identify previous injuries, both work-related and non─work-related, that may interfere with the patient’s timely recovery.
Akin to this, consider whether the patient is being treated for any other work injury currently; has any disabilities caused by a previous work injury; or has any current restrictions or accommodations in the workplace. It should be remembered that an injured worker could have multiple workers compensation cases running at the same time. Multiple previous or concurrent workplace claims may be a clue that the patient is trying to manipulate the work comp system.
While this may seem like a lot of information to gather, once the provider becomes familiar with the process and understands the rationale of the occupational medicine history, it takes only a few minutes to get the relevant facts. Because the occupational medicine physician has many administrative (as well as medical) decisions to make, having all the information together at the beginning of the case will facilitate correct diagnosis and proper treatment of work-related injuries, while also assuring that the injured worker and the employer are both treated fairly.
Max Lebow, MD, MPH, FACEP, FACPM Is Board Certified in Emergency Medicine and Preventive/Occupational Medicine, and is President and Medical Director of Reliant Immediate Care Medical Group.