Sports Medicine in the Workplace: Adapting--and Expanding--Your Practice
Jacqueline WhiteTHE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 11 - NOVEMBER 96
Physicians versed in sports medicine may want to look to industry, where primary care skills are increasingly in demand. Aggressive rehab methods honed on athletes can also return workers to the job more quickly. The result? Physicians can expand their practices while helping employers save on worker's compensation costs.
To hover on the sidelines at the local high school football game, black bag in hand, has traditionally placed the sports medicine physician in a classic win-win situation. Though a volunteer, the physician is immersed in the pure practice of sports medicine. And by providing a visible and committed presence at the games, he or she can attract not only the players but also their family members as new patients.
But with the growth of managed care and restrictions on patient choice, many physicians are finding that being the first to treat an athlete doesn't always progress to providing follow-up care. "First aid on the field isn't necessarily the way to grow business," concludes Len Wilkerson, DO, a family practice and sports medicine physician in private practice with the Center for Sports Medicine, Orthopaedics, and Family Practice in Kissimmee, Florida.
Instead, Wilkerson and a handful of other sports medicine physicians are turning to industry as a way to expand their practices. Unlike other areas of medicine that are glutted with specialists, occupational medicine has a growing need for clinical services--a void that primary care physicians can address (1-2). Under managed care, primary care physicians are assuming a greater role in managing occupational illness and injury (3). In addition, a 1990 study (4) predicted that addressing the shortfall in the next decade would require a threefold to fivefold increase in graduate specialty training.
In themselves, industry contracts are not always lucrative--Wilkerson notes that worker's compensation rates are "the lowest of the low." But Wilkerson, who is also an editorial board member of The Physician and Sportsmedicine, has found that treating employees is an effective way to increase his patient base; he often ends up treating employees' families as well. His practice currently has contracts with about 30 local organizations, ranging from Walt Disney World and Godwin's Gatorland to the police and fire departments.
And unlike a physician volunteering on the sidelines, a physician contracting with a business can determine in advance what type of healthcare reimbursement to expect.
Of course, the key to long-term success with local industry is to develop a relationship that is mutually beneficial--and that means improving the corporate bottom line. As Wilkerson notes, "The big insurance carriers talk to each other. They find out who has good outcomes, and then they come to us."
"Companies are struggling to find a way that they can realize medical cost containment," agrees Dwight Gaal, MA, an exercise physiologist and CEO of The Industrial Athlete, a Rochester Hills, Michigan, company that specializes in developing and staffing on-site therapy and fitness centers for industry.
By applying sports medicine principles, Gaal says companies not only can contain their medical expenditures, but can actually decrease them. As an example he points to the routine practice by college and professional athletic teams of offering on-site medical and rehabilitation services. Such a setup, he says, is efficient in cost and in returning players to competition expediently. By treating workers like "industrial athletes" and offering them similar services, Gaal says business can save money because workers also will return to work faster.
But even without an on-site therapy center, applying sports medicine principles, such as cross-training and protected rest, can get workers back on the job more quickly. "What occupational medicine can learn from sports medicine is rapid rehab. That's an area where sports medicine has traditionally been a leader," says William B. Bunn, MD, JD, medical director for Navistar International in Chicago, a heavy equipment manufacturer, and an associate professor of environmental health at the University of Cincinnati.
In the past, Wilkerson says, a physician would often say to an injured worker, "You can't do your job. You're off duty for 6 days. Come back then and we'll check you again." But in his current practice, in addition to developing an aggressive rehabilitation program, Wilkerson has advocated that industries develop light-duty assignments. "To put someone off work is a rare event," he says, "because most people can do office work. They can think and talk." Light-duty assignments keep workers connected with and invested in the workplace at the same time employers reduce worker's compensation costs.
To ensure savings, the contracting physicians need to provide consistent coverage so that all injured workers funnel through their office. "We had five industrial accidents the other day," Wilkerson says. "We need to be able to accommodate them. Otherwise, if that patient ends up going to the emergency room, they go into a non-cost-effective system."
Phillip Zinni III, DO, MS, ATC, concurs: "Employee care always comes first. You never compromise that." Zinni is a family practitioner at the Center for Sports and Occupational Medicine, which has contracts with 27 local companies in Dickson, Illinois. Making sure he or his partner treats every injured employee, he says, has been a key to controlling costs and realizing significant savings for their clients.
Preventing Industrial Injuries
For Wilkerson, actively helping companies save money has proved to be an excellent way to build loyalty. He advises physicians to be on the lookout for repeated injuries that may point to the need for worksite modification. For example, after seeing a number of shin injuries from a company where workers were unloading pallets, Wilkerson suggested that employees don soccer shin guards. A similar suggestion--that workers at a utility company wear safety glasses--put a stop to eye injuries at the company.
The reputation of occupational medicine as a preventive discipline can also embrace a broader definition of injury prevention. For example, beginning with the preemployment physical, a physician could recommend strengthening exercises to help a worker arrive on the job in shape to safely perform it, says Zinni. Once within the industrial setting, the physician can address such wellness issues as weight management, smoking cessation, and exercise, he says. Especially for companies that are self-insured, Zinni says, "If we can document savings in wellness, then they can lower their direct out-of-pocket costs."
Such suggestions serve not only the physician and the company, but the employee as well. As Gaal points out, "Medical cost containment has always resulted in something being taken away from the employee, whether it's a cutback on physician choice or more of a co-pay." But programs that offer fitness or wellness components will often be perceived by employees as perks.
Additional Training Needed?
It seems unquestionable that occupational medicine is beneficial on many fronts. But do primary care physicians with an interest in sports medicine have adequate training to treat America's work force? "Knowledge about the mechanism of injury, the pathology, the treatment, and the prognosis would generally be the same as in sports, and that knowledge would cross over," says J. Steven Moore, MD, MPH, associate professor of occupational health sciences at the University of Texas Health Center at Tyler.
A physician who has a strong background in musculoskeletal medicine will be able to do "a decent job" with employee injuries, Zinni says, although the pattern of injury location and type will differ from sports. The vast majority of work-related injuries that Zinni sees are musculoskeletal.
"The big issue in sports medicine is usually acute trauma. There's also some overuse, typically of the lower extremity," says Zinni, who points to a lower-extremity stress fracture as the classic overuse injury in sports. In occupational medicine, however, he says overuse and cumulative trauma are more common: "We see upper-extremity injuries such as carpal tunnel syndrome and rotator cuff strains."
But occupational medicine now encompasses much more than the strains, sprains, and other minor injuries typically seen in an industrial "lump and bump" clinic, according to Kenneth W. Kizer, MD, MPH, under secretary for health in the US Department of Veterans Affairs and an editorial board member of The Physician and Sportsmedicine. Changes in the work environment and greater understanding of the long-term effects of toxicologic and lifestyle hazards have expanded the purview of the field to include such topics as chemical exposures, infectious disease, and travel medicine concerns.
Kizer stresses the value of formal technical training for physicians who want to get involved in occupational medicine. In addition to his occupational medicine specialty, Moore, for example, is also an industrial hygienist, certified to measure contaminants in the workplace. Likewise, Zinni has found that to handle such problems as environmental exposures, taking continuing medical education classes has been helpful. Occupational medicine is a specialty certified by the American Board of Preventive Medicine. (See "Training Opportunities," below.)
An important area that physicians interested in occupational medicine will need to be familiar with is worker's compensation law. Moore outlines three administrative decisions that physicians will face. The first is determining to what degree an injury is related to work, which involves assessing the worker's activities both on and off the job.
"This requires a great deal of effort by physicians to be objective," says Moore. "Their job is not to echo the patient's opinion of the cause, but to talk to the patient and develop their own opinion." Because an injury deemed work related entitles an employee to worker's compensation benefits, the physician often faces pressure to reach such a finding, he says.
The second decision involves determining an employee's work capability. If the employee is capable of some work, the treating physician should define the limitation, Moore says. He notes, "The trend has been for companies to reduce the physical stress required in jobs and to build in the flexibility to assign workers to less demanding jobs during recuperation."
Third, at the end of medical treatment for a work-related disorder, most compensation systems require a final report that documents the presence and magnitude of any permanent disability, Moore reports. This becomes an employee's impairment rating.
Try on a Hard Hat
In addition to brushing up on pertinent medical and legal topics, physicians interested in treating workers can take other steps to become familiar with the field. "Touch base with occupational physicians in your area," Moore advises.
"Tour a plant," he adds, "and just think to yourself, 'As I look at these jobs, do I see any activities being performed that would cause injury or strain?'" Just as familiarity with a sport aids a physician in bringing an athlete back into the game, so, Bunn says, will familiarity with an industry help the physician return an employee safely to the workplace.
Getting to know local industry is also a smart way to generate new business leads. "Follow the business section in your paper," advises Gaal. "Get a feel for who's having problems controlling worker's comp costs. Look at recent promotions to get names to use for cold calling." Wilkerson says a mailing in which he promised local businesses savings on medical costs resulted in several contracts.
The Motivation Factor
Physicians who enjoy working with highly motivated athletes may need to shift gears in their interactions with employees. An athlete, for example, may be willing to share detailed information about a training program and will tend to be tuned in to physical symptoms. "Descriptions of what occurs on a job may not be quite as clear," Moore says.
"Workers are not quite as invested in maximizing their work capacity to achieve maximum on-the-job performance," he says. Whereas the athlete aims to push the envelope of performance, Moore says, "Work has to be designed to be within the physical capabilities of a large percentage of people." And while the injured athlete views each day of inactivity as a loss, for many injured workers it's a bonus--a day off work. The result for the treating physician, Moore says, is that "you're often in the position of restraining the athlete but pushing the worker."
"You can't be a wimpy doctor. You have to trust your own abilities," Wilkerson says. When a patient is claiming not to be able to do an activity that the physician is confident can be safely performed, Wilkerson's approach is to say, "That's between you and your company. It's not right to put me in the middle." His recommendation? "You shift the responsibility back to them."
The New Team Physician
Physicians with a background in sports medicine will find the team approach serves them well in the workplace. "Occupational health is not driven by the medical community," Moore says. "You're not all that autonomous. It's not like the operating room, where you say X, and they bring you X." Instead, occupational medicine requires a multidisciplinary team, including such members as safety engineers, loss-control managers, ergonomists, ventilation engineers, and human resources specialists.
As managed care moves onto the playing field and nudges many physicians from their berth on the sidelines, the team that more and more primary care physicians may want to try out for is the team that keeps America competitive.
Jacqueline White is a contributing editor for The Physician and Sportsmedicine.
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