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SCIENTIFIC ARTICLE

A Survey Regarding Physician Recommendations

Regarding Return toWork

JeffreyWatson, BS, Robert Shin, MD, David Zurakowski, PhD, David Ring, MD, PhD

Purpose Returning patients to work may be influenced by subjective factors and physician bias.The purpose of this study was to determine whether factors such as complaints of pain and patientmotivation influence physicians’ recommendations regarding return to work or activity.

Methods One hundred twenty-five members of the American Society for Surgery of the Handcompleted an online survey describing a 25-year-old patient with surgically treated diaph-yseal fractures of the radius and ulna. Physicians were asked whether the patient could bereturned to work in 4 distinct scenarios varying with occupation, time since injury, radio-graphic union, patient motivation, and pain.

Results Logistic regression analysis demonstrated that all 5 predictor variables were highlysignificant predictors of return to work. Pain and diminished motivation were associated witha significantly lower probability of return to work.

Conclusions Although in the scenario depicted, objective factors such as radiographic unionand job demands are the major determinants of physician clearance to return to work,physicians are also influenced by patient motivation and complaints of pain. (J Hand Surg2009;34A:1111–1118. © 2009 Published by Elsevier Inc. on behalf of the American Societyfor Surgery of the Hand.)

Key words Motivation, pain, return to work.

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USCULOSKELETAL CONDITIONS are responsiblefor the majority of work disability and asso-ciated costs in industrialized countries to-

ay.1 Time to return to work is commonly used incientific investigation to evaluate the results of treat-ent and compare treatment methods.2–17 This is par-

icularly the case in the upper extremity, where illnessnd injury account for the longest median absences

From Harvard Medical School, Boston, MA; Orthopaedic Hand and Upper ExtremityService, Massachusetts General Hospital, Boston, MA; Department of Surgery, Children’sHospital Boston, Boston, MA.

Received for publication June 5, 2008; accepted in revised form February 25, 2009.

Unrestricted research grants were received from AO Foundation, Wright Medical, Joint Active Sys-tems, Smith and Nephew, Small Bone Innovations, Biomet, Acumed, Tornier, and the Doris DukeFellowship.

Corresponding author: David Ring, MD, PhD, Orthopaedic Hand and Upper Extremity Service,Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114;e-mail: dring@partners.org.

0363-5023/09/34A06-0021$36.00/0

idoi:10.1016/j.jhsa.2009.02.030

rom work of any region of the body.18 In many studies,eturn to work is the most notable difference betweenreatment arms and is used to justify the superiority ofne treatment over another.3–7,9,13–15 Notable examplesnclude endoscopic versus open carpal tunnel releasend surgical versus nonsurgical treatment of a nondis-laced scaphoid fracture.3–7,9,13–15

Use of return to work as an outcome measure hasersisted in spite of recommendations that it is not auitable measure of treatment efficacy or effective-ess.19 It has been demonstrated to be a complex,ultifactorial process determined only in part by the

atient’s condition and medical care and influencedreatly by factors specific to the patient, his or herocation, and medicolegal compensation issues.20 Anxtensive body of scientific literature documents thatsychosocial factors are often dominant determinants ofeturn to work, especially among patients with muscu-oskeletal conditions, and chronic musculoskeletal pain

n particular.21–25 Ultimately, however, it is medical

© Published by Elsevier, Inc. on behalf of the ASSH. � 1111

1112 SUBJECTIVE INFLUENCES ON RETURN TO WORK CLEARANCE

clearance from the treating physician that typically re-leases a patient back into the workplace, and there existfew published data regarding the variability and influ-ence of physician-specific factors in return to work.

Medical clearance is an inherently subjective processthat is likely subject to physician belief, bias, and emo-tion—in particular, physician susceptibility to the pa-tient’s motivation and complaints of pain. Limited priorinvestigation of this concept among physicians treatinglow back pain has demonstrated that physicians’ beliefsand attitudes about pain vary widely and in one studywere demonstrated to be the best predictor of return towork recommendations.26–28 Further, activity recom-mendations have been found to be overly restrictive andfrequently discrepant with evidence-based practiceguidelines aimed at minimizing disability.28–31 It islikely that if patients’ subjective complaints of paininfluence physician return to work recommendations,then patient motivation may also be influential in returnto work decisions. This concept is supported amongnumerous other authors; however, adequate investiga-tion of this concept is lacking.8,32,33

Ideally, medical clearance would rely on objective,standardized criteria—fracture union, for instance—andlead to predictable and uniform physician recommen-dations for return to work. In this study, we conducteda survey of hand surgeons to investigate factors otherthan fracture union that determine medical clearance forwork duty. Our hypothesis was that “subjective” fac-tors, such as patient motivation and complaints of pain,influence physicians’ recommendations regarding re-turning patients to work after accounting for objectivefactors.

MATERIALS AND METHODSThe human research committee at our institution re-viewed and approved this investigation. An online sur-vey was developed using survey software (SurveyMonkey; http://www.surveymonkey.com). The surveywas sent by e-mail to members of the American Societyfor Surgery of the Hand (ASSH) and was also posted onthe ASSH listserv. The invitation was for volunteers,and our goal was sufficient power rather than completeparticipation. One hundred twenty-five surgeons com-pleted the survey. The survey described a 25-year-oldpatient with diaphyseal fractures of both the radius andthe ulna treated with open reduction and plate andscrew fixation. Four scenarios were presented: (1) anAmerican football player on a Super Bowl–bound teambegging to play, (2) a receptionist who is anxious aboutreturning to work, (3) a laborer anxious about returning

to the job on which the injury was sustained, and (4) a

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self-employed truck driver begging to return to work(Appendix 1; this appendix may be viewed at the Jour-nal’s Web site, www.jhandsurg.org). For each scenario,the following factors were varied, and physicians wereasked if the patient would be released for work: (1) timesince injury (6, 24, and 52 weeks), (2) complaints ofpain, and (3) radiographic union.

Statistical analysis

A generalized estimating equations strategy was used toanalyze the survey response data to ascertain the influ-ence of 5 predictors: the presence or absence of radio-graphic union and pain, as well as time since injury (6,24, and 52 weeks), type of activity (athlete, officeworker, laborer), and motivation (yes/no).34 Binary re-sponses (return to work or do not return to work) wereanalyzed with respect to 4 different scenarios, eachpertaining to type of activity and patient motivation. Forthe purposes of analysis, the football player “begging toplay” and the truck driver “begging to return to work”were both considered motivated, whereas the reception-ist “anxious about returning to work” and the laborer“anxious about returning to his job” were consideredunmotivated. The truck driver and the “laborer” wereconsidered to place high demand on the arm, the recep-tionist low demand, and the sports activity was consid-ered separately. Each scenario was treated as a repeated-measures factor as each of the 125 surgeons respondedto all 4 scenarios. In the logistic regression modeling,the decision to return or not return a patient to workwas the binary response, the probability distributionwas binomial, the link function was logit, and theworking correlation matrix structure was exchange-able.35 Combinations of union, pain, and time sinceinjury were used to estimate the probability of returnto work with a 95% Wald confidence interval (CI) foreach scenario. Scenario-by-pain and scenario-by-time 2-way interactions were fit to assess whether theinfluence of pain and time since injury varied be-tween the different patient scenarios. The Wald chi-square test was used to assess significance of the 5predictor variables based on regression coefficientsand differences between combinations of predictorsin returning patients to work.36 The quasi-likelihoodunder independence criterion was used to judge theaccuracy of the final multivariate model to the data.Two-tailed values of p � .05 were considered statis-tically significant. Statistical analysis was performedusing the GENLIN procedure in the SPSS package(version 16.0; SPSS Inc., Chicago, IL). Power anal-ysis indicated that a sample size of 125 surgeons

providing responses to each of the 4 scenarios (10

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SUBJECTIVE INFLUENCES ON RETURN TO WORK CLEARANCE 1113

questions each pertaining to union, pain, and timesince injury) provided 90% power (� � .05, � � .10)to determine the significance of each predictor vari-able based on returning a patient to work/activityusing a logistic regression model (nQuery Advisorversion 7.0; Statistical Solutions, Saugus, MA).

RESULTSMultivariable logistic regression analysis (logit linkfunction, binomial probability distribution) demon-strated that all 5 predictor variables were highly signif-icant in influencing surgeons’ decisions to return apatient to work or sports activity (p � .001 for eachvariable). The analysis provided excellent fit to thesurvey responses as demonstrated by the quasi-likelihood goodness-of-fit criterion. Because there were4 different scenarios (based on type of activity andpatient motivation), we tested whether the influenceregarding presence or absence of radiographic union,pain, and time since injury (6, 24 and 52 weeks) de-pended on the specific scenario. There was clearly ahighly significant scenario effect indicating interactionswith time and pain (p � .001), which implies that these2 variables have an inherent dependency. We thereforederived the probability that a return to work decisionwould be recommended based on combinations ofunion, pain, and time since injury for each scenario(Tables 1, 2). In each of the scenarios, whenever a

TABLE 1. Surgeon Recommendation of Return to W

6 wk

Patient Scenario Probability, % (CI)

Motivated athlete

Pain —

No pain —

Unmotivated office worker

Pain —

No pain —

Unmotivated laborer

Pain —

No pain —

Motivated laborer

Pain —

No pain —

*Data represent the probability that a surgeon will recommend returnconfidence intervals in parentheses.

patient had radiographic union and no pain at 24 or 52

JHS �Vol A, July

weeks, 100% of surgeons responded that they wouldreturn the patient to work, and hence the predictedprobability is 100%. Note that, because union cannot bejudged early on, there was no combination of radio-graphic union and pain at 6 weeks, and therefore eachscenario contains 10 different probabilities (rather than12) according to combinations of union, pain, and timesince injury.

Survey results of return to activity at 6, 24, and 52weeks for all patient scenarios are illustrated in Figure1. In scenario 1, the probability of returning a motivatedathlete to activity was 100% at both 24 and 52 weeksfor the combination of radiographic union and no pain.For an athlete with union and pain, probability of returnto activity recommendation was 85% at 24 weeks and88% at 52 weeks, and these probabilities were signifi-cantly lower (p � .05). In the variation with radio-graphic nonunion and no pain, the probability of return-ing an athlete to activity at 24 weeks (50%) and 52weeks (44%) was significantly lower than that in pa-tients with union and either pain or no pain (all p �.001). There was a significant effect of time since injuryamong all athletes with nonunion in which recommen-dation of return to activity increased with time sinceinjury (p � .001), although it remained very low, at 52weeks in patients with nonunion and pain (18%).

Scenario 2 involves return to work recommendationfor an unmotivated office worker. Radiographic union

With Radiographic Union*

Time Since Injury

24 wk 52 wk

Probability, % (CI) Probability, % (CI)

85 (78–90) 88 (82–92)

100 (99–100) 100 (99–100)

98 (97–99) 99 (97–99)

100 (99–100) 100 (99–100)

85 (78–90) 89 (84–93)

100 (99–100) 100 (99–100)

96 (93–97) 96 (94–98)

100 (99–100) 100 (99–100)

ork based on the presence of radiographic union and pain with 95%

ork

to w

was the dominant factor influencing surgeons’ deci-

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1114 SUBJECTIVE INFLUENCES ON RETURN TO WORK CLEARANCE

sions in this scenario, as demonstrated by the very highprobability of return to work recommendation in pa-tients with presence of union with or without pain(100% for patients with no pain and 98% for patientswith pain at both 24 and 52 weeks). With radiographicnonunion and no pain, the likelihood of returning thepatient to work was 94% to 96% at all 3 of the timepoints. In contrast, the probability of return to workrecommendation in patients with nonunion and painwas significantly lower at 6 weeks (62%), 24 weeks(67%), and 52 weeks (68%), respectively (p � .001 foreach). In this scenario, time did not have a notableinfluence on surgeons’ decision making. Thus, for anyof the 4 combinations of union and pain, the probabilityof return to work was flat across the different timepoints from 6 to 52 weeks.

Survey results of return to work for an unmotivatedand motivated laborer are illustrated in Figure 2. Mul-tivariable logistic regression analysis revealed that bothscenarios had similar return to work patterns for thecombinations of radiographic union, pain, and timesince injury, except that the probability of returning apatient to work was higher for patients with high mo-tivation to get back to work (p � .001). In both moti-vated and unmotivated patients, there was a 100% prob-ability of return to work at 52 weeks in cases withradiographic union and absence of pain. However,when nonunion was present, the subjective effects of

TABLE 2. Surgeon Recommendation of Return to W

6 wk

Patient Scenario Probability, % (CI)

Motivated athlete

Pain 7 (4–10)

No pain 24 (17–32)

Unmotivated office worker

Pain 62 (53–70)

No pain 94 (88–97)

Unmotivated laborer

Pain 4 (2–6)

No pain 13 (8–21)

Motivated laborer

Pain 25 (18–33)

No pain 59 (49–67)

*Data represent the probability that a surgeon will recommend returnconfidence intervals in parentheses.

patient motivation and pain were far more influential.

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For example, at 24 weeks since injury, the probabilityof return to work with no pain and with pain were 74%and 40%, respectively, in the motivated laborer versus43% and 15%, respectively, in the unmotivated laborer.Statistical analysis demonstrated highly significant ef-fects of both patient motivation (p � .001) and pain(p � .001). In laborers with nonunion, there was asignificant effect of time since injury, with the percent-age of surgeons who recommended return to workhigher in patients 24 and 52 weeks since injury com-pared with that for 6 weeks out (p � 0.001).

DISCUSSIONDespite the central role of the treating physician in thereturn-to-work process, few studies have investigatedphysician biases in return-to-work practice decisions.The current study demonstrates that although objectivefactors such as radiographic union and job demands arethe primary influences of recommendations to returnthe patient to work, physicians are also influenced bytheir patients’ motivation and complaints of pain. In allof the 4 scenarios examined, subjective factors influ-enced recommendation of return to work, with bothpain and diminished motivation significantly associatedwith decreased probability of return to work. Further,pain and motivation were demonstrated to be indepen-dent predictors of return to work time after accountingfor the potential confounding relationship between pain

With Radiographic Nonunion*

Time Since Injury

24 wk 52 wk

Probability, % (CI) Probability, % (CI)

15 (10–22) 18 (13–25)

44 (36–53) 50 (41–58)

67 (57–75) 68 (59–76)

95 (90–98) 96 (90–98)

15 (10–22) 20 (15–28)

43 (34–52) 52 (43–60)

40 (32–49) 45 (36–53)

74 (66–81) 77 (70–84)

ork based on the presence of radiographic union and pain with 95%

ork

to w

and motivation in which patients with less pain may be

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SUBJECTIVE INFLUENCES ON RETURN TO WORK CLEARANCE 1115

FIGURE 1: The probability of a surgeon recommending return to activity in cases of radiographic nonunion at A 6 weeks, B 24weeks, and C 52 weeks. Logistic regression modeling was used to determine the probability at each time since injury. The R2

values indicated more than 50% of the variance explained for modeling the probability at 6 weeks (R2 � 0.517), 24 weeks (R2 �

0.552), and 52 weeks (R2 � 0.569). The significant influence of pain on return to work recommendation is significant across all 4

patient scenarios at each of the 3 time points (p � .001).

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1116 SUBJECTIVE INFLUENCES ON RETURN TO WORK CLEARANCE

more motivated to return to work and vice versa. Theinfluence of pain and motivation on return to work wasparticularly notable in cases of nonunion, where boththe influence of pain and motivation on return-to-workdecision making were found to be most prominent.

In scientific investigation, return to work as an “event”is commonly seen and used to compare different treat-ment methods. Prior authors have warned of potentialbiases in return to work8,32 and have noted that explicitreturn-to-work criteria are seldom reported.33,37,38 Forexample, in the vast majority of studies examiningapproaches to carpal tunnel release as well as treat-ment of nondisplaced scaphoid fractures, criteria forreturn to work are vague, subjective, or absent alto-gether.3,5–12,16,17,39,40 This is concerning becausemost surgical trials are difficult to blind, and it is thetreating surgeon who usually determines appropriate-ness of return to work. A physician’s susceptibility tosubjective patient factors, such as pain and motiva-tion, may threaten the validity of the study, as thesefactors may be influenced by treatment assignment,particularly if one treatment offers some appeal relatedto technology, marketing, or preconceptions amongpatients.

The findings of the current study are relevant topatient care. If physicians are expected by society to bethe objective arbiters of medical clearance for workduty, it can be argued that they should not be influenced

FIGURE 2: Probability of a surgeon recommending return tononunion at 6, 24, and 52 weeks. The logistic regression movariance explained (R2 � 0.593). Both pain and motivation sig3 time points (p � .001).

by subjective factors such as pain and motivation that

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can reflect illness behavior as much as impairment ordisease.20,41–44 This is particularly important becausephysicians vary widely in their beliefs and attitudesabout pain.26,27 For instance, in the current study, vari-ation in physician recommendations in patients withunited forearm bones 52 weeks after surgery wouldseem to have little objective basis as the fracture wouldbe considered ready for all activity at this time.

Previous work has sought to elucidate reasons for thevariability in return to work practice behavior. Numer-ous authors have shown that physicians, like patients,may demonstrate so-called “fear-avoidance behavior”in which their beliefs about pain are associated withvarying degrees of worry, fear, and subsequent pain-avoidant behavior.31,45 These cognitive patterns mayinfluence interpretation of the clinical importance of apatient’s pain and may, as a result, influence practicerecommendations for activity or return to work.31 Theimplications of allowing subjective factors such as painand motivation to influence return to work are poten-tially deleterious, as it has been suggested that physi-cians who provide information that reinforces patients’misconceptions and fear-avoidance behaviors may re-inforce longer-term patient disability.46 Furthermore,the return to work process may benefit from maintain-ing an objective focus, both by physician and patient, asevidenced by prior work by Guzman and colleagues

ity for a motivated and unmotivated laborer with radiographicndicated a moderately high R2, indicating almost 60% of thently influence return to activity recommendation at each of the

activdel inifica

demonstrating the most important barriers in return to

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SUBJECTIVE INFLUENCES ON RETURN TO WORK CLEARANCE 1117

work to be patients’ subjective misunderstandings andfears about their condition.29

The findings in this study must be interpreted in lightof its limitations. To standardize the patient scenarios,clinical vignettes were used, and data were thereforelimited to physician clearance for return to work asopposed to actual time of return to work. Binary return-to-work responses focused on release to usual (full)duties, allowing for a more straightforward analysis,and thus did not include the opportunity to releasepatients to limited duties. In focusing on physicianclearance, the study successfully captures the subjectiv-ity of return to work recommendation and is likely to behighly internally and externally valid. However, it wasnot possible to capture the complexity of an actualsituation and predict when a patient would actuallyreturn to work (independent of surgeon clearance). Thevignettes included time since injury as well as radio-graphic union but did not present other objective factors(eg, grip strength and range of motion), as the 2 criteriachosen were believed to represent the least debatableobjective criteria. Furthermore, these simplistic vi-gnettes assume that no new diseases have occurred (eg,complex regional pain syndrome or tendon irritationfrom implants). In addition, this study does not addressthe quality of activity after injury, it only addresseswhether or not a doctor would clear them to return to anactivity.

Regarding study responders, only a small group ofsurgeons (and only hand surgeon members of theASSH) participated in the study. Although our resultsmay not be generalizable owing to the small, nonran-dom sample and the potential for responder bias, theprincipal findings that both pain and motivation influ-ence return to work would be unlikely to change. It wasnot possible to determine how many surgeons receivedand read the survey sent by e-mail or viewed the post-ing of the survey on the ASSH listserv. Thus, theparticipants were a select group of computer-activevolunteers and may not represent all ASSH members.

In spite of the study’s limitations, however, it seemsreasonable to assume that the results of this investiga-tion reflect aspects of surgeon behavior. Pain and mo-tivation influence a surgeon’s decision to return a pa-tient to work. Our data demonstrate that both scientificinvestigation and patient care may be well served byestablishing specific professional standards for recom-mendations on return to work.

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Appendix 1: Survey on Work Restrictions Among Members of the American Society for Surgery of theHandThe Injury and Treatment: Diaphyseal fractures of both bones of the forearm treated with plate and screwfixation.Clinical Scenarios1. A 25-year-old American football player on a Super Bowl–bound team begging to play.

Time Since Injury Pain Radiographic Union Allow Him to Play? (Y/N)

a. 6 weeks No No

b. 6 weeks Yes No

c. 6 months No No

d. 6 months No Yes

e. 6 months Yes No

f. 6 months Yes Yes

g. 1 year No Yes

h. 1 year No No

i. 1 year Yes No

j. 1 year Yes Yes

2. A 25-year-old receptionist anxious about returning to work.

Time Since Injury Pain Radiographic Union Clear Her for Work Duty? (Y/N)

a. 6 weeks No No

b. 6 weeks Yes No

c. 6 months No No

d. 6 months No Yes

e. 6 months Yes No

f. 6 months Yes Yes

g. 1 year No Yes

h. 1 year No No

i. 1 year Yes No

j. 1 year Yes Yes

3. A 25-year-old laborer anxious about returning to the job on which the injury was sustained.

Time Since Injury Pain Radiographic Union Clear Him for Work Duty? (Y/N)

a. 6 weeks No No

b. 6 weeks Yes No

c. 6 months No No

d. 6 months No Yes

e. 6 months Yes No

f. 6 months Yes Yes

g. 1 year No Yes

h. 1 year No No

i. 1 year Yes No

j. 1 year Yes Yes

JHS �Vol A, July–August

1118.e2 SUBJECTIVE INFLUENCES ON RETURN TO WORK CLEARANCE

4. A 25-year-old self-employed truck driver begging to return to work.

Time Since Injury Pain Radiographic Union Clear Him for Work Duty? (Y/N)

a. 6 weeks No No

b. 6 weeks Yes No

c. 6 months No No

d. 6 months No Yes

e. 6 months Yes No

f. 6 months Yes Yes

g. 1 year No Yes

h. 1 year No No

i. 1 year Yes No

j. 1 year Yes Yes

JHS �Vol A, July–August