Preventing Needless Work Disability by Helping People Stay

Employed
6/27/2006
Copyright © 2006 American College of Occupational and Environmental Medicine
Published in September 2006 JOEM
Introduction/Background
Each year, millions of American workers develop health problems that may temporarily or permanently
prevent them from re-entering the workforce. In most cases, employees are able to stay at work or return to
work after a brief recovery period. However, approximately 10 percent of these workers incur significant work
absences and/or life disruptions that can lead to prolonged or permanent withdrawal from the workforce.
During this non-working period, these individuals are described as “disabled,” and many become involved with
in one or more of the existing disability benefit systems and laws – e.g., sick leave, workers’ compensation,
short-term disability (STD), long-term disability (LTD), Social Security Disability Insurance (SSDI), the Family
Medical Leave Act (FMLA), and the American’s with Disabilities Act (ADA). The estimated total annual cost of
disability benefits paid under all these systems exceeds $100 billion.

This report focuses on the large number of people who due to a medical condition that should normally result
in only a few days of work absence, end up withdrawing from work either permanently or for prolonged
periods. For many of these workers, their conditions began as a common problem (e.g., a sprain, strain,
depression, or anxiety), but escalated resulting in short-term, long-term, or permanent disability. This
potentially preventable disability absence has unfortunate consequences for both the employer and the
employee.

The fundamental reason for most lost workdays and lost jobs is not medical necessity, but the non-medical
decision-making involved in and the poor functioning of a little-known, but fundamental practice employed by
U.S. and Canadian disability benefits systems – the stay-at-work/return-to-work (SAW/RTW) process. This
process determines whether a worker stays at work despite a medical condition or whether, when, and how a
worker returns to work during or after recovery. The SAW/RTW process presently focuses on “managing” or
“evaluating” a disability rather than preventing it. This report describes the SAW/RTW process, presents
recommendations to improve the process, and provides information on current best practices and initiatives.

WHAT IS THE SAW/RTW PROCESS?

The usual steps included in the SAW/RTW process are as follows:

1. The SAW/RTW process is triggered when a medical condition or another precipitating event occurs – in this
example, a worker with a badly infected cut on his foot – raising the question whether the worker can or
should do his usual job today.
2. The worker’s current ability to work is assessed on three important dimensions:
 Functional capacity – what can he do today? Has the infection made him so sick he simply can’t
function at all? If not, what can he do in his current condition?
 Functional impairments or limitations – what can’t the worker do now that he normally could? The
acute pain makes it uncomfortable to wear regular shoes and conduct activities that require being
one’s feet.
 Medically-based restrictions – what he should not do lest specific medical harm occur? Would walking,
standing, and being on his feet all day actually worsen the infection or delay healing?

3. Next, the demands of the usual job and/or available temporary alternative tasks are compared with the
worker’s current functional capacity, limitations, and medical restrictions.
 To make this comparison, the functional demands of the tasks or job must be known, including what
knowledge, skills, and abilities – physical, cognitive, and social – are required.
 Specific medical qualification standards (such as those for airline pilots), legal requirements (such as
those for truck drivers and crane operators), company policies, or concerns about the safety of co-
workers, the public, or the business may also apply.
4. Finally, the actions necessary to resolve the situation and return the worker to work are identified.
 If the worker can be safe and comfortable doing his or her usual job or can independently make any
necessary modifications, he or she should be able to return to work.
 If the worker is only able to do temporary alternative work that requires the cooperation of others, or
if permanent modifications to the job must be made, the employer must make arrangements and
implement them. If that happens, the worker can go to work.
 If not, the worker remains out of work until either the medical condition resolves or the situation
changes.

If the job does not demand too much use of the impaired body part or function, the medical condition is
minor, and the worker wants to go to work, the preceding steps are accomplished rapidly. However, some
situations do not resolve as quickly and require additional steps. At this stage, the SAW/RTW process evolves
into a negotiation between the employee (and his advisors) and the employer (and its advisors) regarding
whether the employee can return to work. Therefore, Steps 2 through 4 above may need to be repeated at
each level. During each repetition, more participants tend to become involved and the situation can escalate
with progressively more opinions, data, resources, and time being required to decide when and if the
employee can return to work.

For example, in more difficult situations, successive passes require additional assistance from more specialists
such as a nurse case manager, physical therapist, an occupational medicine physician, an independent medical
examiner, a lawyer, and/or other experts. Functional capacity evaluations may be required to document work
capacity. Job analyses may need to be done to document the job demands. The additional effort and
resources often produce a paradoxical effect of clouding the situation rather than clarifying it by obscuring
basic issues, causing confusion, hardening positions, and polarizing participants.

Table 1 displays the escalation levels of the SAW/RTW process, moving from simplest to most complex. The
process ends when a definitive answer is reached – the worker will or will not return to work. However, the
three basic questions requiring factual answers always remain the same:

 What are the worker’s current work capacity, medical restrictions, and functional limitations?
 What are the functional demands of the intended job?
 If the worker’s functional capacity matches the functional demands, what is required to affect an actual
return to work?
Table 1 – The Stay at Work/Return to Work Process Escalation Levels
The process triggers when a precipitating event, usually health-related, raises the question whether a
worker can/should remain at work.
How are job demands
How is current work What triggers
determined (both
EscalationLevel Who is involved? capacity the actual
usual job and
determined? return to work?
alternatives)?
0 Worker Personal knowledge Personal knowledge Personal decision

Worker and Discussion Discussion Discussion

Supervisor
1
Worker and Discussion Verbal description of Discussion
Physician RTW note from usual job
physician
Worker Formal inquiry List of job’s functional Discussion
Physician Simple physical demands
2
Claims capacities form
adjuster/case completed by MD
manager
 Worker Objective testing Video of job Written offer of
Physician Functional capacity Ergonomic analysis of employment
Claims evaluation job Formal return to work
adjuster/case Independent medical On-site workplace visit plan
manager opinion Sign-off by all parties
3 Physical therapist
Ergonomist or
vocational
consultant
IME examiner
Union steward
Lawyer

Medical conditions vary considerably, as do their impact on work. Table 2 provides examples of the
circumstances under which the SAW/RTW process takes place.

Table 2 – Examples of the Variability of Medical Conditions and Their Impact on Work
Medical condition A “Cold” Sprained Femur Fracture Bipolar Disorder
or or
or Ankle
Abdominal Surgery Multiple Sclerosis
Acute Food or or or
Poisoning Influenza Treatable Cancer Congestive Heart Failure
or Asthma or
Attack Major Depression
Length of time away None/Days Days Weeks Weeks/Months
from work
Biological Trivial Minor Moderate Moderate /Severe
Impairment Isolated Isolated Isolated episode Chronic/Recurring
episodes episode May recur May be progressive
Medical care None Single Several providers Multiple providers
required provider Several curative On-going services
1-2 visits visits/service Relapse prevention required
Relapse prevention may be
necessary
Likelihood of full Always Always Usually Unlikely
resolution Some residual impairment Fluctuation in functional ability
possible common
Time course of the Days Days Weeks Months/Years
illness/condition
Career Impact None Irrelevant Significant temporary impact Progressive impairment often
(Residual, but stable affects ability to perform
permanent impairment may essential job functions long
affect ability to perform term
essential job functions)
Number of other 0-1 0-2 0-3 Multiple
professionals
involved
SAW/RTW 0-1 0-1 0-3 Multiple
information
exchanges required

The SAW/RTW process does not occur in isolation. While it has been overlooked because of the incorrect
assumption that if the medical condition is promptly and properly treated, the worker will naturally return to
work, the process occurs in parallel or is influenced by the following four other well-known processes:

 Personal adjustment process deals with the disruption resulting from the illness or injury.
  If the medical situation calls for treatment, the SAW/RTW process occurs in parallel with the medical
care processcomprising diagnosis and treatment.
 If the initial SAW/RTW process results in the worker staying home and if coverage under one or more
disability benefit programs is possible, the disabilitybenefits administration process begins, operating in
parallel with SAW/RTW.
 If permanent or long-term alteration of work capacity occurs, the ADA“reasonable accommodation”
process might be triggered. It operates in parallel with SAW/RTW. If ADA applies, it will heavily
influence what occurs in SAW/RTW.
Table 3 – Five Parallel Processes Triggered By a Health Event that Affects Ability to Function

Disability
Personal ADAReasonable
SAW/RTW Medical Care Benefits
Adjustment Accommodation
Process Process Administration
Process Process
Process
Fundamental Dealing with life Will this person What is the Does this episode Will this change in
Issues disruption: recover on the diagnosis & qualify under the work capacity be
job? prognosis? rules of our plan? longstanding?
 physical When is it Is this curable Is this person Does this person
 logistical medically safe to or treatable? eligible for qualify for
 financial resume normal What benefits? protection under
 emotional activity? treatment is How much benefit the ADA law?
 social What adjustments warranted? is due? Is there an
 psychological to the usual job Is there any accommodation
Can I cope with this will be required & evidence of that can make full
life challenge? for how long? benefit fraud? productivity
Am I healthy or sick? Will this person possible? Is it
Am I in charge here? ever return to the “reasonable”?
What does this mean same
for my future? job/employer/
vocation?
Participants Employee Employer Treating Benefit or claims Employee
(Leader is in Employee Clinician agent Employer
italics) Treating Employee Employee
Clinician Health care
Benefit or claims provider
agent
Activities Thinking (See Table 1) Delivery of Fact-finding Fact-finding
Feeling Fact-finding medical care Data-gathering Data-gathering
Reacting Negotiation services Claim processing Negotiations
Talking Making Calculation
Coping arrangements
Adapting
Results Interpretation Staying home Healing Benefit decisions Employment
Decisions/ strategies Staying at work Symptom and exchange of decision
Possible change in Going back to resolution money
self-concept work Failure to Claim closure
(identity) New job improve
Monitoring

The outcomes produced by the SAW/RTW process profoundly impact the overall health and well-being of
patients, their families, employers, and communities, by determining whether people stay engaged in or
withdraw from work and all the consequences that derive from that decision. However, the SAW/RTW process
has been hidden by complex technical, financial, and legal details of multiple disability benefit programs. This
little-studied and under-resourced process has enormous personal and economic consequences for millions of
people and deserves attention.

OBSERVATIONS AND RECOMMENDATIONS

The following portion of this report, grouped under four general recommendations, discusses 16 specific areas
in which the SAWRTW process can be improved:

1. Adopt a disability prevention model.

2. Address behavioral and circumstantial realities that create and prolong work disability.
3. Acknowledge the contribution of motivation on outcomes and make changes to improve incentive
alignment.
4. Invest in system and infrastructure improvements.
For each of the 16 parts, specific recommendations for achieving optimal outcomes are described and ways to
implement these recommendations suggested. When possible, concrete examples are provided of existing
improvement initiatives or of programs that achieve better-than-average results by using best practices.

I. ADOPT A DISABILITY PREVENTION MODEL

1. Increase Awareness of How Rarely Disability is Medically Required
Only a small fraction of medically excused days off work is medically required – meaning work of any kind is
medically contraindicated. The remaining days off work result from a variety of non-medical factors such as
administrative delays of treatment and specialty referral, lack of transitional work, ineffective
communications, lax management, and logistical problems. These days off are based on non-medical decisions
and are either discretionary or clearly unnecessary. Participants in the disability benefits system seem largely
unaware that so much disability is not medically required. Absence from work is “excused” and benefits are
generally awarded based on a physician’s decision confirming that a medical condition exists. This implies that
a diagnosis creates disability.
However, from a strictly medical point of view, people can generally work at something productive as soon as
there is no specific medical condition to keep them from working (see Table 4). The key question is what kind
of work? Many obstacles that appear to be medical are really situation-specific. For example, an employee
with a cast on the right foot cannot drive a forklift, but can perform other tasks until the cast is removed. A
person recovering from surgery may not be able to work a full day in the office, but could work half days. In
fact, people often sit home collecting benefits because their employers don’t take advantage of their
available work capacity. Today, these decisions generally are misclassified as “medical,” and as such are not
examined.

Recommendation: Stop assuming that absence from work is medically required and that only correct medical
diagnosis and treatment can reduce disability. Pay attention to the non-medical causes that underlie
discretionary and unnecessary disability. Reduce discretionary disability by increasing the likelihood that
employers will provide on-the-job recovery. Reduce unnecessary disability by removing administrative delays
and bureaucratic obstacles, strengthening flabby management, and by following other recommendations in
this report. Instruct all participants about the nature and extent of preventable disability. Educate employers
about their powerful role in determining SAW/RTW results.
Current Initiatives/Best Practices: Clinicians, employers, and insurers can now use the following criteria (see
Table 4) to determine whether a disability is medically required, discretionary, or unnecessary. If all parties
use these definitions, clearer communication and better decision making will result. In particular, physicians
will no longer have to make employment decisions, and employers will stop misclassifying business decisions as
medical decisions.
Table 4 – When is a Disability Medically Required, Medically Discretionary, or Medically Unnecessary?
(Source: ACOEM Practice Guidelines, 2nd edition, Chapter 5,
Cornerstones of Disability Prevention and Management, pp 80-82)
Medically Required Medically Discretionary Medically Unnecessary
Absence is medically required Medically discretionary disability is Medically unnecessary disability
when: time away from work at the occurs whenever a person stays away
discretion of a patient or employer from work because of non-medical
  Attendance is required at a that is: issues such as:
place of care (hospital,
physician’s office, physical
therapy).  Associated with a diagnosable  The perception that a diagnosis
medical condition that may alone (without demonstrable
 Recovery (or quarantine)
have created some functional functional impairment) justifies
requires confinement to
impairment but left other work absence.
bed or home.
functional abilities still intact.  Other problems that
 Being in the workplace or
 Most commonly due to a masquerade as medical issues,
traveling to work is
patient’s or employer’s e.g., job dissatisfaction, anger,
medically contra-indicated
decision not to make the extra fear, or other psychosocial
(poses a specific hazard to
effort required to find a way factors.
the public, coworkers, or to
for the patient to stay at work  Poor information flow or
the worker personally, i.e.,
during illness or recovery. inadequate communications.
risks damage to tissues or
delays healing).  Administrative or procedural
delay.

2. Urgency is Required Because Prolonged Time Away from Work is Harmful

Unnecessary prolonged work absence work can cause needless, but significant harm to a person’s well-being.
While on extended disability many patients lose social relationships with co-workers, self-respect that comes
from earning a living, and their major identity component – what they do for a living. Many key players in the
SAW/RTW process do not fully realize the potential harm that prolonged medically excused time away from
work can cause. Many think that being away from work reduces stress or allows healing and do not consider
that the worker’s daily life has been disrupted. With these attitudes system-induced disability becomes a
significant risk.
An article by Harris in the Journal of the American Medical Association reconfirmed that workers receiving
disability benefits recover less quickly and have poorer clinical outcomes than those with the same medical
conditions who don’t receive disability benefits. The researchers reported that 175 of the 211 studies meeting
their inclusion criteria reported worse surgical outcomes for patients on workers’ compensation or involved in
litigation. (Only one study reported better outcomes in compensated patients; 35 studies reported no
difference.) Of the 86 studies which excluded patients in litigation, the odds of an unsatisfactory outcome
were nearly four times higher for the patients on workers’ compensation than for those not receiving
compensation. These findings are similar to those of other studies, including two previous meta-analyses of
outcomes studies, one for workers with chronic pain and the other for closed-head injuries.
Early intervention is the key to preventing disability. Research confirms that people who never lose time from
work have better outcomes than people who lose some time from work. Studies have shown that the odds for
return to full employment drop to 50-50 after six months of absence. Even less encouraging is the finding that
the odds of a worker ever returning to work drop 50 percent by just the 12th week. The current practice of
focusing disability management effort on those who are already out of work rarely succeeds.

Recommendation: Shift the focus from “managing” disability to “preventing” it and shorten the response time.
Revamp disability benefits systems to reflect the reality that resolving disability episodes is an urgent matter,
given the short window of opportunity to re-normalize life. Emphasize prevention or immediately ending
unnecessary time away from work, thus preventing development of the disabled mindset, and disseminate an
educational campaign supporting this position. Whenever possible, incorporate mechanisms into the SAW/RTW
process that prevent or minimize withdrawal from work. On the individual level, the health care team should
keep patients’ lives as normal as possible during illness and recovery while establishing treatments that allow
for the fastest possible return to function and resumption of the fullest possible participation in life.
Current Initiatives/Best Practices: Many employers and some insurers now begin return-to-work efforts on the
first day of absence or within 72 hours of being notified of a claim. One large workers’ compensation insurer
established a group of “pre-injury consultants” to help employers prepare to respond from the moment of
injury to avert needless lost work days. Attempts are also underway to detect workers with pre-existing risk
factors for prolonged disability in order to manage them more intensively from the onset. Colledge, et al.,
developed a Disability Apgar test, which evaluates a situation and assigns a risk score. The State Fund of
California recently completed a pilot program that assesses risk factors at claim intake and makes suggestions
for claim management. A workers’ compensation insurer in Australia uses an evidence-based assessment
questionnaire at claim intake and specific intervals to speed detection (and intervention) on claims showing
signs of delayed recovery.
II. ADDRESS BEHAVIORAL AND CIRCUMSTANTIAL REALITIES THAT CREATE AND PROLONG
WORK DISABILITY
3. Acknowledging and Dealing with Normal Human Reactions
Injuries and illnesses disrupt lives. Even a minor injury may seem like a major occurrence because it is
different. People may fear getting into trouble, the need for surgery, or that the injury may end their career.
Frequently, they also must learn to deal with unfamiliar workers’ compensation and/or disability benefits
systems and rules. Employers and insurers often neglect to inform injured or ill employees much about how
their disability benefit programs work, what to expect, and how to make the process work smoothly.
Physicians often fail to tell their patients much about their condition, and what they can do to achieve the
best possible result.
Many injured or ill workers experience stress because coping with these uncertainties can be difficult. The
amount of stress a specific individual experiences in a specific situation will vary widely based on factors such
as the magnitude of the medical problem, the personal and family situation at the time, and the job situation.
According to medical anthropologists, patients take on the “sick role” and the “dependent patient role” after
becoming ill or injured. To recover, they must relinquish these roles. The sick role exempts people from their
normal responsibilities while giving them the right to receive care from others and be free of fault. Those who
have trouble coping with their circumstances are likely to resist relinquishing those roles, using them instead
to feel good about themselves and ensure their future security.
The ability to function and deal with life’s problems varies from individual to individual. When people are
under stress they function less well and are more susceptible to illness or injury. If the demands of a situation
exceed an individual’s ability to cope, and no assistance is provided, the personal adjustment process will stall
and recovery and return to work will be delayed. Experience shows that the current processes do not
acknowledge these emotional realities. Workers are typically left alone to cope regardless of their situation
and their coping skills. Little effort has been devoted to reducing uncertainty and other sources of stress.
Individuals caught up in stress that they cannot handle alone are not identified.

Even when SAW/RTW process participants recognize emotional factors, effective assistance is not usually
available. Because benefit programs do not cover medical treatment costs, paying for supportive services that
will help non-occupational disability patients recover and return to work is usually not considered. In workers’
compensation, claims adjusters are reluctant to acknowledge these issues and authorize mental health
services, fearing that doing so will lead to a claim for a psychological illness and drastically increased claim
cost. However, most of these sick or injured people do not need psychiatric care. They need the education,
minor supportive counseling, and reassurance that a friend, family member, social worker, or employee
assistance program can provide. Treating physicians could remove much uncertainty and stress by clearly
pointing out the functional aspects of medical conditions, options, and length of treatment, thus empowering
people to cope on their own.

Recommendation: Encourage all participants to expand their SAW/RTW model to include appropriate handling
of the normal human emotional reactions that accompany temporary disability to prevent it becoming
permanent. Encourage payers to devise methods to provide these services or pay for them.
Current Initiatives/Best Practices: Some U.S. employers are creating links between their disability benefit
programs (workers’ compensation, short- and long-term disability), and their employee assistance programs
(EAPs), and/or their disease management programs to assure that employees know they can tap into existing
support services. A New Jersey insurance agency makes immediate solicitous inquiries after a work-related
injury occurs, ensuring that injured workers feel cared for and their questions are answered.

4. Investigate and Address Social and Workplace Realities

Research shows that an individual’s social connection to the workplace affects the occurrence of injury and
illness as well as the outcome of the SAW/RTW process. Does the worker like his job? How much pressure and
decision latitude does the employee have at work? Does the worker get along with his supervisor? These types
of factors can play a major role in a person’s willingness to return to work, especially when coupled with the
emotional adjustment issues. Job dissatisfaction has been shown to be one of the strongest statistical
predictors of disability. Home/family considerations may also pose problems for the worker entering the
SAW/RTW process. The worker may be tempted to resolve such problems by prolonging disability benefits.
Although many players in the SAW/RTW process acknowledge the importance of these factors, little has been
done to effectively address them. Employers and workers often use the disability benefit system to sidestep
difficult workplace issues that are obvious to them, but not disclosed to outside parties, i.e., physicians,
insurance adjusters. Unless these parties exert a significant effort to discover the underlying facts,
interventions to address the real issues are seldom attempted. When key parties to the SAW/RTW process do
not know what is actually happening because they lack “inside information,” any effort expended on
SAW/RTW may be misguided or futile and a waste of resources and time.

Recommendation: The SAW/RTW process should routinely involve inquiry into and articulation of workplace
and social realities; establish better communication between SAW/RTW parties; develop and disseminate
screening instruments that flag workplace and social issues for investigation; and conduct pilot programs to
discover the effectiveness of various interventions.
Current Initiatives/Best Practices: An innovative program that is now being used successfully by several
employers and insurers, particularly in Canada, involves a trained facilitator conducting face-to-face
discussions between the employee and the first-line supervisor. Each session focuses on “what part of your job
can you do today?” All other parties become resources and advisors for the two key participants as they work
to resolve the situation. Substantial increases in both employee and supervisor satisfaction with the way these
situations are handled and the near-total de-medicalization of the SAW/RTW process are among this program’s
benefits.
5. Find a Way to Effectively Address Psychiatric Conditions
When a person with underlying psychiatric illness incurs a potentially disabling physical illness or injury, the
risk of permanent disability increases unless the psychiatric problem is treated. A significant psychiatric
disorder becomes symptomatic during a period of serious medical illness in more than 50 percent of cases,
especially those with a history of a major psychiatric disorder. Many more previously undiagnosed workers also
are vulnerable to developing their first episode of anxiety or depression when sick or injured. In these cases,
the physical illness or injury precipitates the psychiatric episode.
Mental health treatment is required for these cases because the patient’s mental condition significantly
affects his reaction to the illness, adherence to medical treatment, the course of illness, its impact on
function, and functional recovery from the physical condition. Psychiatric factors can contribute significantly
to permanent disability unless treatment is active and effective. However, the current SAW/RTW process
often ignores or doesn’t detect or address psychiatric issues. The reluctance of treating physicians to make a
psychiatric diagnosis comes primarily from lack of awareness and stigma. Patients often do not want these
diagnoses.

Even when a psychiatric diagnosis is made, treatment is often inadequate or inappropriate. Limited benefits
coverage and shortages of skilled mental health professionals often mean that expert treatment is unavailable.
And, although all health care professionals understand the need to protect and foster role functioning in
personal relationships, they often overlook the importance of role functioning at work. Faced with a patient
who describes stress due to difficulties at work, leaving work is often seen as the solution.

Dramatic improvements in psychiatric diagnosis and treatment have occurred during the past 15 years.
Although some employers know that psychiatric treatments are potentially cost effective, they also have spent
considerable sums on ineffective, expensive therapy. They correctly believe that many mental health
providers do not focus on functional recovery but continue with treatments that show no apparent benefit.
Payers have not conditioned access and payment on providers’ adherence to current treatment principles. As
with other chronic conditions, psychiatric disorders may require intermittent intensive early treatment of new
episodes as well as long-term, low-level treatment to prevent recurrence.

Recommendation: Adopt effective means to acknowledge and treat psychiatric co-morbidities; teach
SAW/RTW participants about the interaction of psychiatric and physical problems and better prepare them to
deal with these problems; perform psychiatric assessments of people with slower-than-expected recoveries
routine; make payment for psychiatric treatment dependent on evidence-based, cost-effective treatments of
demonstrated effectiveness.
Current Initiatives/Best Practices: The Washington State Department of Labor and Industries pioneered an
innovative program that provides psychiatric services to injured workers. The agency handles all workers’
compensation claims and pays all benefits for the state’s insured employers. The agency reached agreement
with the state medical association to pay for up to 90 days of psychiatric treatment “as an aid to cure” a
physical work-related injury if the initial evaluation, treatment plan, and progress report notes meet certain
specifications. Showing a clear connection between the diagnosis and specific barriers to resume working is
essential, as is a connection between the treatment plan and removal of those barriers. As long progress is
documented, payment continues for up to 90 days.
6. Reduce Distortion of the Medical Treatment Process by Hidden Financial Agendas
In disability cases, the medical treatment process is often distorted by non-medical factors, with patients
often seeking particular diagnoses or treatments to obtain or maximize benefits. Distortion also occurs when
employers or benefits claims administrators ask naive physicians precise questions and elicit particular
language that that later becomes the basis for benefit, claim, or employment determinations.
One cause is the complex and differing sets of rules for eligibility and benefit determination in the various
disability benefit programs. With thousands of different disability benefit plan designs, few physicians can
accurately determine the impact their actions may have on a given patient’s benefit payments or where
hidden agendas may lie. Physicians are uncomfortable when they suspect patients, employers or payers of
making requests based on hidden agendas. They often practice “don’t ask, don’t tell” in such situations,
knowing they won’t be paid for time spent investigating specifics.

Recommendation: Develop effective ways and best practices for dealing with these situations. Instruct
clinicians on how to respond when they sense hidden agendas. Educate providers about financial aspects that
could distort the process. Procedures meant to ensure independence of medical caregivers should not keep the
physician “above it all” and in the dark about the actual factors at work. Limited, non-adversarial
participation by impartial physicians may be helpful. For example, ask an occupational medicine physician to
brief the treating clinician. Where possible, reduce the differences between benefit programs that create
incentives to distort. Employers are in a better position to do this than other payers.
Current Initiatives/Best Practices: Many employers examine their benefit programs to determine whether they
create unwanted incentives for employees to behave in a certain way. For example, some employers have set
up paid time-off banks in lieu of sick leave to decrease abuse and increase the predictability of employee
absence. Others have redesigned their short-term disability program benefits to more closely match the
workers’ compensation benefit and vice versa. An increasing number of employers are expanding their
workers’ compensation return-to-work programs to cover non-occupational conditions as well.
III. ACKNOWLEDGE THE CONTRIBUTION OF MOTIVATION ON OUTCOMES AND MAKE CHANGES
TO IMPROVE INCENTIVE ALIGNMENT
7. Pay Physicians for Disability Prevention Work to Increase Their Professional Commitment
Physicians seldom receive extra compensation for their time and effort in the disability prevention and
management aspects of the SAW/RTW process. As a result, they may give those aspects low priority, believing
they have no market value. In more complex situations that could benefit from the physician’s initiative or
active participation, the monetary disincentive reflected by lack of payment often deters the physician from
responding quickly or making the extra effort, often delaying SAW/RTW.
Because most physicians don’t consider disability prevention their responsibility, their passivity does not
represent a failure to carry out their perceived duty. Although employers and insurers may assert that
disability management should be included in the price of the medical visit, such assertions have little impact
on physician behavior.

Recommendation: Develop ways to compensate physicians for the cognitive work and time spent evaluating
patients and providing needed information to employer and insurers as well as on resolving SAW/RTW issues.
ACOEM developed a proposal for new multilevel CPT codes for disability management that reveals the variety
and extent of the intellectual work physicians must do in performing this task. Adopting a new CPT code (and
payment schema) for functionally assessing and triaging patients could achieve similar goals. Payers may be
understandably reluctant to pay all physicians new fees for disability management because of reasonable
concerns about billing abuses – extra costs without improvement in outcomes. Make billing for these services a
privilege, not a right, for providers and make that privilege contingent on completion of training and an
ongoing pattern of evidence-based care and good-faith effort to achieve optimal functional outcomes.
Current Initiatives/Best Practices:
 An innovative Australian operation builds relationships between selected local providers and employers.
Instead of contracting for discounted fees, the employer customers agree to pay full fees in exchange for
the selected providers’ agreement to learn about the employer’s programs and collaborate and
communicate promptly. The selected providers are also paid additional fees for the extra effort spent on
communications.
 A workers’ compensation insurer in Massachusetts selected and trained a network of primary
occupational medicine providers and asked them to help manage the situation caused by the injury or
illness. The insurer paid these providers their full fee-schedule rates for medical care plus a modest fixed
fee for “situation management” for every case they handled. Half of the new fee was held back and paid
as a bonus if the pattern of care revealed good overall results – appropriate medical costs, patient and
employer satisfaction, and low-disability rates. The program taught employers to channel to the
providers – many channeled more than 85 percent. Workers’ compensation injuries that became lost-time
injuries decreased between six and eight percent when the treating physician was a provider.
8. Support Appropriate Patient Advocacy by Getting Treating Physicians Out of a Loyalties Bind
Government agencies, insurers, and employers expect physicians to provide unbiased information that verifies
what their claimants/employees have said about their medical conditions and ability to work. Some of this
information will be used to validate claims and manage attendance and may be used to award or deny benefits
or as the basis for personnel actions. Physicians are often made aware of this by their patients. The medical
profession does not acknowledge any duty to play this role as corroborator of fact for third parties, especially
because negative financial consequences for patients may result. In fact, the physician must advocate for the
patient and consider the patient's interest first.
However, many physicians have not thought carefully about patient advocacy in the context of SAW/RTW.
Frequently, being a patient's health and safety advocate means promoting employment and full social
participation. But the scope of “patient advocacy” varies from physician to physician, with some using their
role as physician to advocate for whatever their patient wants. Historically, employers and insurers have dealt
with this primarily through the independent medical examination process.

Recommendation: The SAW/RTW process should recognize the treating physician’s allegiance; reinforce the
primary commitment to the patient/employee’s health and safety and avoid putting the treating physician in a
conflict-of-interest situation; focus on reducing split loyalties and avoid breaches of confidentiality; use
simpler, less adversarial means to obtain corroborative information; and develop creative ways for treating
physicians to participate in SAW/RTW without compromising their loyalty to their patients.
Current Initiatives/Best Practices: Employers and insurers who get the best return-to-work results and have
the lowest disability rates:
 Take charge of the process from the start, never let it appear that the physician is in charge of making
employment decisions;
 Inform treating physicians that the employer has a temporary transitional work program and that most
workers are expected to recover on the job;
 Make it clear that they can provide work within a wide range of functional abilities and will carefully
abide by any guidelines the physician sets;
 Stop asking physicians to set return-to-work dates, asking them instead to provide functional capacities,
restrictions, and limitations; and
 Use metrics such as work days lost per 100 injury/illness episodes to track the effectiveness of their
programs.
9. Increase “Real-Time” Availability of On-the-job Recovery, Transitional Work Programs, and Permanent
Job Modifications
Allowing workers to recover on the job is a cornerstone of disability prevention. This often takes the form of
transitional work programs (also known as temporary modified work, alternative duties, or light duty) that
allow workers return to work at partial capacity while they recuperate. On-the-job recovery usually involves a
temporary change in job tasks, work schedule, or work environment; and often requires reduced performance
expectations for the limited duration of the assignment, generally not more than 90 days. Workers in on-the-
job recovery programs are expected to return to their usual jobs, with or without permanent accommodations,
once they have completed the temporary assignment.
Permanent job modifications such as task redesign or switching to ergonomically designed tools may also allow
for recovery on the job. Permanent modifications usually enable employees to continue working their usual
jobs without interruption while meeting that job’s regular performance expectations.

Currently, there are three problems that can prevent workers from recovering on the job:

 Failure to provide temporary modified work. Many employers still refuse to provide temporarily
modified work and many labor agreements prohibit it. Insurers offering discounts to employers who claim
to have transitional work programs typically fail to confirm that such programs are actually used. Few
employers provide financial incentives to supervisors to make arrangements for on-the-job recovery by
subsidizing the labor cost of transitional work programs. Few also appropriately allocate the cost of
disability benefits to the operating units whose failure to keep workers safe or provide transitional work
created the lost workdays.
 The bad reputation of “light duty.” Based on past experience, employers and workers may see light
duty as a dead-end for favored or aging workers who can no longer keep up. Others view it as a
punishment and resist it for fear they will be given meaningless or no work or will be isolated or
harassed.
 Long lag times. Many companies don’t use their return-to-work programs promptly. When one of their
workers becomes ill or injured they wait for the physician to write restrictions or the physical therapist
to recommend job modifications rather than anticipating the need for transitional work assignments.
Recommendation: Encourage or require employers to use transitional work programs; adopt clearly written
policies and procedures that instruct and direct people in carrying out their responsibilities; hold supervisors
accountable for the cost of benefits if temporary transitional work is not available to their injured/ill
employees; consult wit unions to design on-the-job recovery programs; require worker participation with
ombudsman services available to guard against abuse; make ongoing expert resources available to employers
to help them implement and manage these programs.
Current Initiatives/Best Practices: Successful transitional work programs are now in place in many well-
managed organizations. As a result, these organizations experienced significant reductions in costs and
absenteeism. The Ohio Bureau of Workers’ Compensation’s statewide Transitional Work Program (TWP) makes
employers eligible for a state-funded grant of up to $5,200 to develop a TWP. California’s recent workers’
compensation reform legislation includes a program to reimburse small employers up to $2,500 for purchasing
adaptive equipment or otherwise modifying jobs for injured workers. An employer consortium, sponsored by
the occupational medicine program at a clinic in Illinois, provides guidance and support to local employers in
setting up and running their transitional work programs. The Australian state of New South Wales requires all
employers with more than 200 employees to appoint an in-house injury manager, who is responsible for
creating return-to-work plans.
10. Be Rigorous, Yet Fair in Order to Reduce Minor Abuses and Cynicism
The disability benefit system is often used inappropriately to solve other problems – for example, taking sick
leave to stay home and care for a child. Rules also are stretched to receive benefits without medical
justification. If these minor abuses continue unchecked, more people assume everyone engages in such
behavior. Eventually, anyone filing a claim is treated with cynicism or suspicion. Those with legitimate needs
may be treated unkindly, and the SAW/RTW process may become unpleasant for them. Additionally, if
transitional work programs are allowed to become permanent havens for non-productive workers, both
employees and supervisors lose enthusiasm for them. If used to demean, harass, or ostracize workers, light-
duty programs may become counterproductive.
Recommendation: Encourage programs that allow employees take time off without requiring a medical excuse;
learn more about the negative effect of ignoring inappropriate use of disability benefit programs; discourage
petty corruption by consistent, rigorous program administration; develop and use methods to reduce
management and worker cynicism for disability benefit programs; train all parties to face situations without
becoming adversaries; and be fair and kind to workers in the SAW/RTW process.
11. Devise Better Strategies to Deal with Bad-Faith Behavior
Employees and their families, supervisors, employer management, treating clinician(s), insurance carriers,
benefits administrators, case managers, union representatives, and lawyers are involved in the disability
benefits system. Some individuals in each group manipulate the SAW/RTW process to the point of serious
abuse or clearly fraudulent activity. For example, an employer pressures a worker not to report a work-related
injury. Employers and insurers expend considerable effort identifying and dealing with employees who take
advantage of the system and to a lesser extent with physicians who do the same. In comparison, little
attention has been paid to the harm done to injured or ill employees when their claims adjuster or employer
gives them poor service or behaves inappropriately or illegally.
Often, a lawyer is the only recourse available to the injured worker. Most workers seeking counsel do so only
after a problem arises. People who feel they have been ill-served and retain lawyers get involved in an
adversarial system that hardens and polarizes positions, prolongs needless disability, and increases the
likelihood of poor functional outcomes. One multi-state insurer’s analysis shows that the median cost of
workers’ compensation claims of those with legal representation is about $30,000 more than those without
representation. The median cost of represented claims ranges between 10 and 20 times higher than the
median cost of unrepresented ones.

Recommendation: Devote more effort to identifying and dealing with employers or insurers that use SAW/RTW
efforts unfairly and show no respect for the legitimate needs of employees with a medical condition; make a
complaint investigation and resolution service – an ombudsman, for example – available to employees who feel
they received poor service or unfair treatment.
IV. INVEST IN SYSTEM AND INFRASTRUCTURE IMPROVEMENTS
12. Educate Physicians on “Why” and “How” to Play a Role in Preventing Disability
Few physicians, except those in occupational medicine and physiatry, ever receive training in disability
prevention and management. Although function is now acknowledged as having a greater impact on quality of
life than serious illness, most medical schools have not integrated evaluation of function into their curricula.
Yet the average physician who treats working-age adults usually signs five or more work-related letters or
notes to employers and payers per week, and is by definition a regular participant in SAW/RTW. As a result,
he/she may allow workers to return to work who should not and disable those who could be working.
Recommendation: Educate all treating physicians in basic disability prevention/management and their role in
the SAW/RTW process; provide advanced training using the most effective methods; make appropriate
privileges and reimbursements available to trained physicians; focus attention on treatment guidelines where
adequate supporting medical evidence exists; make the knowledge and skills to be taught consistent with
current recommendations that medicine shift to a proactive health-oriented paradigm from a reactive,
disease-oriented paradigm.
Current Initiatives/Best Practices: ACOEM and the American Academy of Orthopedic Surgeons have active
educational efforts underway, with courses on disability-related topics at all annual conferences. Several
employers in West Virginia and Idaho award quality points towards bonuses to those local physicians who
attend a training session or take a short, web-based course in disability prevention and return-to-work
communications. Two workers’ compensation health care provider networks in California and Florida strongly
encourage their physicians to take a course in disability prevention. Other networks are developing similar
programs. The State Compensation Insurance Fund of California recently made disability management training
a requirement for key clinicians in its medical provider network.
13. Disseminate Medical Evidence Regarding Recovery Benefits of Staying at Work and Being Active
Strong evidence suggests that activity hastens optimal recovery while inactivity delays it. Moreover, simple
aerobic physical activity has been shown to be an effective treatment for chronic pain, fibromyalgia, and
chronic fatigue syndrome. Other evidence indicates that remaining at or promptly returning to some form of
productive work improves clinical outcomes as compared to passive medical rehabilitation programs. The
ACOEM Practice Guidelines recommend exercise, active self-care, and the earliest possible safe return to
work. Despite this evidence, inactivity, work avoidance, and passive medical rehabilitation programs are often
prescribed as treatment.
Recommendation: Undertake large-scale educational efforts so that activity recommendations become a
routine part of medical treatment plans and treating clinicians prescribe inactivity only when medically
required; specify that medical care must be consistent with current medical best practices; or preferably,
adopt an evidence-based guideline as the standard of care.
Current Initiatives/Best Practices: California recently adopted ACOEM’s Practice Guidelines as the best
available evidence-based standard of care for new workers’ compensation injuries. California law says that the
Guidelines shall be “presumptively correct on the issue of extent and scope of medical treatment.” Colorado
also developed evidence-based treatment guidelines, and requires those who perform independent medical
evaluations to take a rigorous state-sponsored training course. Their opinions must conform to state standards.
14. Simplify/Standardize Information Exchange Methods between Employers/Payers and Medical Offices
Although physicians play an important role in the SAW/RTW process, they are typically given too little
information to act effectively. Employees often are the physicians’ only source of information because
employers usually do not send any information to the physician about an employee’s functional job
requirements, their SAW/RTW programs, their commitment (or lack of it) to employee well-being, how to
quickly answer questions or address problems.
Claim ad, ministrators often request information from the physician to help in managing their claim. They tend
to use a generic approach that does not match the information requested with the simplicity or complexity of
the situation. Questions often seem designed to determine eligibility for benefits rather than to find a way to
help the worker return to work. Discussion of patient functionality, which is not subject to confidentiality
restrictions, lacks sufficient focus. Employers and claims administrators often find it easier and more efficient
to send volumes of material to the physician instead of reducing it to the essential questions for the
physician’s convenience.

Many physicians seem unaware of employers’ and benefit administrators’ needs for information. When
physicians receive poorly conceived requests for guidance or opinions, they have li, ttle tolerance or time to
review irrelevant or redundant information to, find the few useful pieces of data. Many physicians simply don’t
know how their delays or inadequate responses impact optimal functional outcomes for their patients. Both
sides are exasperated by the enormous variability in the other’s paper forms.

Recommendation: Encourage employers, insurers, and benefits administrators to use communication methods
that respect physicians’ time; spend time digesting, excerpting and highlighting key information so physicians
can quickly spot the most important issues and meet the need for prompt, pertinent information; encourage
all parties to learn to discuss the issues – verbally and in writing – in functional terms and mutually seek ways
to eliminate obstacles.
Current Initiatives/Best Practices: Training can increase awareness among employer and insurer staff
members about the practical realities of the physician’s office and teach them how to make more-successful
information requests that match these realities.Successful case managers often fax a single page to the
physician’s office the day before a patient’s appointment. It should contain one or more questions or options,
accompanied by checkboxes the physician can use to answer them. Several new companies are seeking to link
medical provider offices with employers and insurers, using various business models to help make the process
valuable for all participants.
15. Improve/Standardize Methods and Tools that Provide Data for SAW-RTW Decision-Making
Everyone involved in a worker’s SAW/RTW process needs data about work capacity and job demands in order
to make informed decisions. Considering their impact on thousands of work disability episodes per year,
existing methods and tools for obtaining and analyzing data are nonstandard and often crude.
In the time-pressured setting of patient care, treating physicians typically make educated guesses to
determine work capacity, medical restrictions, and functional limitations. Similarly, employees and employers
typically make educated guesses to describe the functional demands of workplace tasks, a method that seems
to work well most of the time. But whenever ability to work is uncertain or disputed, everyone – especially the
courts – develops an appetite for “hard facts” and data. The private sector developed most of the proprietary
methods and technologies currently used to determine work capacity.
Although almost all commercial methods/machines claim to have been scientifically tested, very little high-
quality research has been published in rigorously peer-reviewed scientific journals. One major study showed
that functional capacity evaluations (FCEs) were worse than no testing to facilitate appropriate job
placement. In that study, a group of patients underwent functional capacity evaluations. Those whose
physicians used data from the FCEs as the basis for their return-to-work advice did worse than those whose
physicians ignored the FCE results and simply reassured and returned the workers to their usual jobs. Another
major study showed that patients who had functional capacity evaluations (FCEs) to facilitate appropriate job
placement fared worse than those whose physicians ignored the FCE results and simply returned the workers
to their usual jobs.
Table 5 provides examples of the methods physicians commonly use to obtain the data needed for SAW/RTW
decision-making. For each question or issue to be resolved, the table shows the low-cost or simple method
typically used in an everyday medical office visit compared to a high-cost or complex method typically used in
a complex or litigated situation. The table indicates the wide range in technical sophistication, time required,
and cost. However, one important reference has not yet been developed. Physicians looking for authoritative
information have no resource for the occupational implications of various specific medical conditions or
descriptions of patient-specific or task-specific considerations that would generate the need for specific
medical restrictions.

Table 5 – Methods of Obtaining Data for the SAW/RTW Decision-making Process

Question/Issue Low-Cost and/or Simple Method High-Cost and/or Complex Method
To Be Resolved
What are the Physician asks the worker what he/she Physician relies on data from a job analysis.
functional demands usually does at work. Physician reads a multi-page comprehensive
of the worker’s usual functional job description possibly with digital
job? photos/video. The report has been prepared by
a trained expert hired by the employer or
insurer. The expert did a formal job analysis
including making actual measurements at the
worksite.

What is the worker’s Physician asks what the worker can’t
current work do; observes the worker’s behavior in
capacity and the exam room; performs a physical
functional exam – and then mentally projects
limitations? those answers and observations into
likely workplace activities.
Use data from tests such as treadmill testing
(aerobic exercise capacity), functional capacity
evaluation (musculoskeletal work capacity) or
neuropsychological testing (cognitive ability).
Tests of other capacities are available but
much more rarely used. Physician reads a
report of the worker’s visit to a special testing
facility, in which he/she performed a set of
maneuvers to ascertain the worker’s maximum
work capacity.

Is there a medical Physician uses his/her own knowledge Other than disability duration guidelines that
reason why the of workplaces and jobs, then thinks specify the length of time people are typically
worker should be about potential situations that might absent from work for various conditions, no
removed from work? pose a risk to the health/safety of the clinical resource is available. We are unaware
Is there any specific worker or others – and writes medical of any reference that systematically reviews
activity/exposure restrictions to avoid them. the occupational implications (medical
the worker should concerns and functional issues) of various
avoid for medical medical conditions. Neither a consensus-based
reasons? encyclopedic reference nor a systematic and
compre-hensive review of evidence-based
medical literature exists yet.

Can this worker with Make an informed guess. The Physician relies on data from functional testing.
this functional physician uses whatever information is Using information about a particular job, a
capacity and these available to decide whether the testing facility devises a set of maneuvers that
medical restrictions worker’s current capabilities match duplicate the maximum functional demands
do this particular with the job demands. required by the tasks of that particular job.
job? OR Then the worker attempts to perform those
The employer or insurer looks for a critical tasks. The areas of mismatch are the
match. They compare the employee’s tasks that the worker cannot perform.
abilities as portrayed in a physician’s
note with the demands of available
jobs.
Ways of modifying The physician makes a suggestion Physician relies on data in a report written by a
jobs/ making based on his/her previous life and
accommodations. practice experience. The employer
may seek advice from a consulting
physician with occupational medicine
expertise.
vocational counselor or similarly trained and
qualified professional who has evaluated the
situation in detail and made recommendations.

Recommendation: Help physicians participate more effectively in the SAW/RTW process by standardizing key
information and processes; persuade employers to prepare accurate, up-to-date functional job descriptions
(focused on the job’s maximum demands) in advance and keep them at the benefits administrator’s facility;
send them to physicians at the onset of disability; teach physicians practical methods to determine and
document functional capacity; and require purveyors of functional capacity evaluation methods and machines
to provide published evidence in high-quality, peer-reviewed trials comparing their adequacy to other
methods.
Current Best Practices/Initiatives: Many occupational medicine physicians ask workers carefully designed
questions about everyday activities or observe them while they perform a simple set of office-based
maneuvers to quickly obtain objective information on which to base their opinions. Occupational medicine
specialists commonly tour the plants of their industrial clients to familiarize themselves with the physical work
environment and the tasks of specific jobs. Many employers have developed detailed functional job
descriptions as part of their ADA compliance program. Some have modified their claim intake process to
include mailing the worker’s job description to the treating physician. Some large companies are developing a
computerized database of all tasks including each task’s critical (most difficult) functional demands. A few
companies use job-specific functional testing at time of hire as well as at routine intervals after injury or
illness to assure that workers are assigned tasks within their capabilities. Both vendors and purchasers of
evaluation methodologies are beginning to understand the need to demonstrate validity and reliability in well-
designed and controlled peer-reviewed trials.
16. Increase the Study of and Knowledge about SAW/RTW
The SAW/RTW process has not been systematically and formally studied in sufficient detail. Little solid
methodological foundation or medical evidence exists to support or improve commonly used methods and
tools. While millions of dollars have been spent studying the adequacy of health care services, very little
funding or research has addressed outcomes for those covered by the workers’ compensation system. As with
workers’ compensation, the failure to address these issues may point to a need for a federal agenda.
Recommendation: Complete and distribute a description of the SAW/RTW process with recommendations on
how best to achieve desired results in disability outcomes; establish and fund industry-specific, broad-based
research programs, perhaps in the form of independent institutes or as enhanced university programs; collect,
analyze, and publish existing research; formulate research to better understand current practices and
outcomes, determine best practices and test alternative solutions to problems; develop a way to effectively
communicate the findings of completed research to all decision makers; and solicit needs for future research.
A sampling of research topics of interest might include:

 Develop screening tools to accurately predict relative risk of long-term functional disability and provide a
basis for therapeutic interventions.
 Document the long-term history of prolonged absence or withdrawal from work.
 Design controlled trials of various claims and clinical interventions for improving medical and functional
outcomes.
 Assess and catalog the functional implications and occupational considerations related to the 300+
medical conditions that cause most disability.
 Compare ways to assess work ability capacity.
 Devise ways to standardize and increase the availability and usability of functional job descriptions.
 Study physician behavior in dealing with role conflict.
 Develop controlled trials to compare different methods for training physicians in disability prevention
and assessing the impact of that training on clinical, functional, and financial outcomes.
 Discover ways to increase the recognition and effective treatment of psychiatric co-morbidities.
 Develop effective ways to streamline communications between participants in SAW/RTW.
  Compare different methods to reward physicians for active participation in the SAW/RTW process.
CONCLUSION
Although most injured or ill people can cope with their problem and make either temporary or permanent life
and work adjustments, a large minority cannot. This minority does not recover successfully, adopts a disabled
self-concept, and experiences either a needlessly prolonged absence or a permanent withdrawal from work. In
problematic situations, the SAW/RTW process is usually inadequate and ill-suited to detect and effectively
address the most important issues related to the outcome. It also accounts for the majority of needless
expenditures for disability benefits. Because this minority accounts for such a large portion of all disability
program costs, a one percent reduction in cases with prolonged disability should generate a substantially
larger reduction in overall system cost. Therefore, the focus of the SAW/RTW process should shift away from
“managing” or “evaluating” disability to preventing it. The fundamental reason for most lost workdays/lost
jobs is not medical necessity, but the non-medical decision-making and poor functioning of the SAW/RTW
process.

Employers, insurance carriers, and government agencies currently burdened by the costs of preventable
disability, and worried about the future implications of the aging workforce, should consider underwriting
efforts to more effectively prevent disability. Recommendations to improve the SAW/RTW process will
require:

 a sense of urgency;
 attention and priority;
 research;
 experimentation with new methods and interventions;
 infrastructure development;
 policy revision;
 methodological improvement and dissemination;
 education and training;
 incentive alignment; and
 funding.
Common sense evidence abounds that keeping people productively employed is good for them and for society.
Avoiding the unfortunate outcome of iatrogenic or system-induced disability is worthwhile. Improving the
appropriateness and usefulness of services available to people coping with illness and injury is also of value. It
also is sensible, if not urgent, to curtail needlessly using resources and losing personal and industrial
productivity.
Improving the SAW/RTW process will require sustained attention and effort as well as a willingness to explore
new approaches. This report will, perhaps, stimulate thinking and begin a regular dialogue with other
stakeholders to explore this topic in progressively greater depth.
ACKNOWLEDGEMENTS
This ACOEM guideline was derived from a 34-page committee report prepared by the College’s Stay-at-Work
and Return-to-Work Process Improvement Committee under the auspices of the Council on Occupational and
Environmental Medicine Practice. The report was peer-reviewed by the committee and approved as a
committee report by the ACOEM Board of Directors on October 27, 2005. It is available in its entirety to
members only via the ACOEM web site (www.acoem.org – “Members Only,” under the Publications link).

This guideline was approved by the ACOEM Board of Directors on May 9, 2006. Contributing members of the
Stay-at-Work and Return-to-Work Process Improvement Committee are Jennifer Christian, MD, MPH, Chair;
Douglas Martin, MD, Co-Chair,David Brown, MD; Alan Colledge, MD; Constantine Gean MD, MS, MBA; Elizabeth
Genovese, MD, MBA; Natalie Hartenbaum, MD, MPH; Michael Jarrard, MD, MPH; Michel LaCerte, MD; Gideon
Letz, MD, MPH; Loren Lewis, MD, MPH; Robert MacBride, MD, DOHS; Michael McGrail, Jr, MD, MPH; J Mark
Melhorn, MD; Stanley Miller, DO, MPH; James Ross, MD; Marcia Scott, MD; Adam Seidner, MD, MPH; James
Talmage, MD; William Shaw, MD; and C. Donald Williams, MD, with additional support from David Siktberg,
MBA.

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Stansfeld SA, Fuhrer R, Head J, Ferrie J, Shipley MJ. Work and psychiatric disorder in the Whitehall II Study. J
Psychosom Res. 1997(43);73-81.
Pay Physicians for Disability Prevention Work to Increase Their Professional Commitment to It
Atcheson SG, Brunner RL, Greenwald EJ, Rivera VG, Cox JC, Bigos SJ. Paying physicians more: use of
musculoskeletal specialists and increased physician pay to decrease workers’ compensation costs. J Occup
Environ Med. 2001;43(8):672-9.
Support Appropriate Patient Advocacy by Getting Treating Physicians Out of a Loyalties Bind
Drury DL. Vasudevan SV. Denied workers’ compensation claims: what physicians can and cannot do. WMJ.
1998;97(11):20-2.
Lax MB, Manetti FA, Klein RA. Medical evaluation of work-related illness: evaluations by a treating
occupational medicine specialist and by independent medical examiners compared. Int J Occup Environ
Health. 2004;10:1-12
Radosevich DM, McGrail MP Jr, Lohman WH, Gorman R, Parker D, Calasanz M. Relationship of disability
prevention to patient health status and satisfaction with primary care provider. J Occup Environ Med.
2001;43:706-12.
Increase “Real-Time” Availability of On-the-Job Recovery, Transitional Work Programs, and Permanent
Job Modifications
Bernacki EJ, Guidera JA, Schaefer JA, Tsai S. A facilitated early return to work program at a large urban
medical center. J Occup Environ Med. 2000;42(12):1172-7.
Brooker AS, Smith JM, Cole DC, Hogg-Johnson SA. Workplace Arrangements to Return Injured Workers to
Work: Evidence from a Prospective Cohort of Workers with Soft Tissue Injuries. Toronto, Ontario: Institute
for Work and Health; 1998
Loisel P, Abenhaim L, Durand P, et al. A population-based randomized clinical trial on back pain
management. Spine. 1997(22);2911-18,
Reduce Distortion of the Medical Treatment Process by Hidden Financial Agendas
Hansen JS. Scientific decision-making in workers’ compensation: a long overdue reform. Southern Calif Law
Rev. 1986;59 S. Cal. L. Rev. 911.
Hunter SJ, Shaha S, Flint D, Tracy DM. Predicting return to work. A long-term follow-up study of railroad
workers after low back injuries. Spine. 1998;23(21):2319-28.
Silverstein M, Mirer F. Labor Unions and Occupational Health. In: Levy B, Wegman D (eds). Occupational
Health: Recognizing and Preventing Work-Related Disease and Injury. 4th ed. Philadelphia, PA: Lippincott
Williams and Williams. 2000: 99-109.
Voiss DV. Occupational injury: fact, fantasy, or fraud? Neurol Clin. 1995:13;431-46.
Be Rigorous Yet Fair in Order to Reduce Minor Abuses and Cynicism
Bush T, Cherkin D, Barlow W. The impact of physician attitudes on patient satisfaction with care for low back
pain. Arch FamMed. 1993;2:301.
Hardberger P. Texas workers’ compensation: a ten-year survey: strengths, weaknesses, and
recommendations. S. Mary’s Law J. 2000. 32 St. Mary’s L. J. 1.
Sawney P. Current issues in fitness for work certification. Br J Gen Prac. 2002 Mar;52(476):217-22.
Devise Better Strategies to Deal with Bad Faith Behavior
Dworkin RH, Handlin DS, Richlin DM, et al. Unraveling the effects of compensation, litigation and
employment on treatment response in chronic pain. Pain. 1985;49-59.
Rogers R. Clinical Assessment of Malingering and Deception. New York, NY: Guilford Press; 1998.
Wyman DO. Evaluating patients for return to work. Am Fam Phys. 1999;36(1):2-9.
Educate Physicians on Why and How to Play Their Role in Preventing Disability
American College of Occupational and Environmental Medicine. The Attending Physician’s Role in Helping
Patients Return to Work After an Illness or Injury. Consensus Opinion Statement. April 2002.
American Association of Orthopedic Surgeons/American Academy of Orthopedic Surgery. Early Return to Work
Programs, Position Statement, September 2000.
Abenhaim L, Rossignol M, Gobeille D, Bonvalot Y, Fines P, Scott S. The prognostic consequences in the making
of the initial medical diagnosis of work-related back injuries. Spine. 1995;20:791-5.
Canadian Medical Association. The Physician’s Role in Helping Patients Return to Work After an Illness or
Injury, Policy Statement. 1997, updated 2000.
Hartvigsen J, Kyvik KO, Leboeuf-Yde C, Lings S, Bakketig L. Ambiguous relation between physical workload
and low back pain: a twin control study. Occup Environ Med. 2003;60(2):109-14.
Himmelstein J, Pransky G, Sweet C. Ability to Work and the Evaluation of Disability. In: Levy B, Wegman D
(eds). Occupational Health: Recognizing and Preventing Work-Related Disease and Injury. 4th ed. Phildelphia,
PA: Lippincott Williams & Williams, 2000:268-70.
Pransky G, Katz JN, Benjamin K, Himmelstein J. Improving the physician role in evaluating work ability and
managing disability: a survey of primary care practitioners. Disabil Rehabil. 2002;24:867-74.
Disseminate Medical Evidence Regarding Recovery Benefits of Staying at Work and Being Active
Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful
evaluation. Lancet. 1999;354(9186):1229-33.
Gilbert S, Kerley A, Lowdermilk A, Panus PC. Nontreatment variables affecting return-to-work in Tennessee-
based employees with complaints of low back pain. Tennessee Med. 2000;93:167-71.
Hilde G. Hagen KB. Jantvedt G. Winnem M. Advice to stay active as a single treatment for low back pain and
sciatica.Cochrane Database Sys Rev. 2002;(2):CD003632
Malmivaara A, Hakkinen U, Aro T, Heinrichs ML, Koskenniemi L, Kuosma E, et al. The treatment of acute low
back pain – bed rest, exercises, or ordinary activity? N Engl J Med. 1995;332(6):351-5.
Melhorn JM. CTD Injuries: an outcome study for work survivability. J Workers Comp. 1996;5(3):18-30.
Simplify/Standardize Methods of Information Exchange between Employers/Payers and Medical Offices
Colledge AL, Johns RE Jr. Unified fitness report for the workplace. Occup Med. 2000;15(4):723-37.
Lax MB, Manetti F. Access to medical care for individuals with worker’s compensation claims. New Solutions.
2001;11:325-48.
Singer M, Baer H. Critical Medical Anthropology. Amityville, NY: Baywood, 1995.
Improve and Standardize the Methods and Tools that Provide Data for SAW/RTW Decision-Making
Arvey RD, Landon TE, Nutting SM, Maxwell SE. Development of physical ability tests for police officers: a
construct validity approach. J Applied Psychology. 1992;77:996-1009.
Blakley BR, Quinones MA, Crawford MS, Jago IA. The validity of isometric strength tests. Personnel
Psychology. 1994;47:247-274.
Gouttebarge V, Wind H, Kuijer PP, Frings-Dresen MH. Reliability and validity of functional capacity evaluation
methods: a systematic review with reference to Blankenship system, Ergos work simulator, Ergo-Kit and
Isernhagen work system. J Occup Rehabil. 2004;14(3):217-29.
Gross DP, Battie MC, Cassidy JD The prognostic value of functional capacity evaluation in patients with
chronic low back pain: Parts 1-2. Spine. 2004;29(8):914-924.
Larrabee G. Exaggerated MMPI-2 symptom report in personal injury litigants with malingered neurocognitive
deficit. Arch Clin Neuropsych. 2003;8:673-86.
Myers DC, Gebhardt DL, Crump CE, Fleishman EA. The dimensions of human performance: factor analysis of
strength, stamina, flexibility, and body composition measures. Human Performance. 1993;6:309-44.
Slick DJ, Sherman EMS, Grant LI ,Diagnostic criteria for malingered neurocognitive dysfunction: Proposed
standards for clinical practice and research. Clin Neuropsych. 1999;13(4):545-61.
Sproule CF, Schneider RE, Nelson EK, Bennett PJ. Physical Ability Test Development and Validation Report.
Harrisburg,PA: State of Pennsylvania. 1998. Summary atwww.ipmaac.org/cgi-
bin/phb.pl/acn/oct98/physical.html?Sproule#first_hit.
Tredgett MW, Davis TRC. Rapid repeat testing of grip strength for detection of faked hand weakness. J Hand
Surg (British and European Volume). 2000;25B(4):372-375.
von Restorff W. Physical fitness of young women: carrying simulated patients. Ergonomics. 2000;43:728-43.
Increase the Study of and Knowledge about SAW/RTW
American College of Occupational and Environmental Medicine. The Attending Physician’s Role in Helping
Patients Return to Work After an Illness or Injury. Consensus Opinion Statement, April 2002.
American Association of Orthopedic Surgeons/American Academy of Orthopedic Surgery, Early Return to Work
Programs, Position Statement. September 2000.
Abenhaim L, Rossignol M, Gobeille D, Bonvalot Y, Fines P, Scott S. The prognostic consequences in the making
of the initial medical diagnosis of work-related back injuries. Spine. 1995;20:791-5.
Canadian Medical Association, The Physician’s Role in Helping Patients Return to Work After an Illness or
Injury, Policy Statement, 1997, updated 2000.
Devine EC. Effects of psychoeducational care for adult surgical patients: a meta-analysis of 191
studies. Patient Educ Couns. 1992;19(2):129-42.
Elders LA, van der Beek AJ, Burdorf A. Return to work after sickness absence due to back disorders – a
systematic review on intervention strategies. Int Arch Occup Environ Health. 2000;73(5):339-348.
Hendler N. Return to work barriers: how to overcome them. J Workers Comp. 1995;5(Summer):9-20.
Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes
of chronic disease. Med Care. 1989;27(3 Suppl):S110-27.
Mannion AF, Junge A, Taimela S, Muntener M, Lorenzo K, Dvorak J. Active therapy for chronic low back pain:
part 3. Factors influencing self-rated disability and its change following therapy. Spine. 2001;26:920-9.
Reiso H, Nygard J, Jorgensen G, Holanger R, Soldal D, Bruusgaard D. Back to work: predictors of return to
work among patients with back disorders certified as sick: a two-year follow-up study. Spine.
2003;28(13):1468-73.
Waddell G, Burton AK, Main CJ. Screening to Identify People at Risk of Long-term Incapacity for Work – A
Conceptual and Scientific Review. London: The Royal Society of Medicine Press; 2003.
Increase “Real-Time” Availability of On-the-Job Recovery, Transitional Work Programs, and Permanent
Job Modifications
Bernacki EJ. Guidera JA. Schaefer JA. Tsai S. A facilitated early return to work program at a large urban
medical center.JOccup Environ Med. 2000;42(12):1172-7.
Brooker A-S. Smith JM. Cole DC. Hogg-Johnson SA. Workplace Arrangements to Return Injured Workers to
Work: Evidence from a Prospective Cohort of Workers with Soft Tissue Injuries. Toronto, Ontario: Institute
for Work and Health; 1998.
Devise Better Strategies to Deal with Bad Faith Behavior
Dworkin RH. Handlin DS. Richlin DM, et al. Unraveling the effects of compensation, litigation and
employment on treatment response in chronic pain. Pain. 1985;49-59.
Rogers R. Clinical Assessment of Malingering and Deception. New York, NY: Guilford Press; 1998.
Wyman DO. Evaluating patients for return to work. Am Fam Physician. 1999 Feb;36(1):2-9.
Increase the Study of and Knowledge About SAW/RTW
Butler RJ, Johnson WG, Baldwin ML. Managing work disability: why first return to work is not a measure of
success. Ind Labor Rel Rev. 1995;48:452-69.
Devine EC. Effects of psychoeducational care for adult surgical patients: a meta-analysis of 191
studies. Patient Educ Couns. 1992;19(2):129-42.
Elders LA, van der Beek AJ, Burdorf A. Return to work after sickness absence due to back disorders – a
systematic review on intervention strategies. Int Arch Occup Environ Health. 2000;73(5):339-48.
Ellenberger JN. The battle over worker’s compensation. New Solutions. 2000:10;217-36.
Hendler N. Return to work barriers: how to overcome them. J Workers Comp. 1995;5(Summer):9-20.
Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes
of chronic disease. Med Care. 1989;27(3 Suppl):S110-27.
LaDou J. Occupational medicine: the case for reform. Am J Prev Med. 2005;28(4):396-402.
LaDou J. The rise and fall of occupational medicine in the United States. Am J Prev Med. 2002;22(4):285-95.
Mannion AF, Junge A, Taimela S, Muntener M, Lorenzo K, Dvorak J. Active therapy for chronic low back pain:
part 3. Factors influencing self-rated disability and its change following therapy. Spine. 2001;26:920-9.
Morton WE. The rise and fall of occupational medicine in the United States. Am J Prev Med. 2002:23;309.
Reiso H, Nygard J, Jorgensen G, Holanger R, Soldal D, Bruusgaard D. Back to work: predictors of return to
work among patients with back disorders certified as sick: a two-year follow-up study. Spine.
2003;28(13):1468-73.
Waddell G, Burton AK, Main CJ. Screening to Identify People At Risk of Long-Term Incapacity for Work – A
Conceptual And Scientific Review. London: The Royal Society of Medicine Press; 2003.

Use of Contact Lenses in an Industrial Environment

9/18/2008
More than 34 million Americans wear some type of contact lenses and many of these individuals are employed
as part of the industrial workforce. On occasion, contact lens wearers have been disqualified from industrial
employment. As the health professional most familiar with the hazards encountered in the industrial setting,
the occupational and environmental medicine physician must be able to address employee and employer
concerns regarding the proper use of contact lenses in this setting. This guideline of the American College of
Occupational and Environmental Medicine (ACOEM) addresses the use of contact lenses and personal protective
equipment by the industrial worker under the guidelines of the Occupational Safety and Health Administration
(OSHA). It is also intended to inform the occupational and environmental physician of specific standards
regarding the use of contact lenses as authorized by OSHA.2,3
OSHA Regulations
Regardless of the reason for wearing them, contact lenses do not fulfill the personal protective equipment
requirements for ocular safety when worn by individuals performing eye hazardous tasks. OSHA, in the Code of
Federal Regulations,4 requires individuals who wear contact lenses in the workplace to combine them with
appropriate industrial safety eyewear.
OSHA has codified the voluntary ANSI Z87.15 consensus standard, which makes compliance mandatory. The
OSHA rule states, “The required industrial-safety eyewear for the specific hazard identified in ANSI Z87.1 must
be worn over the contact lenses.” Therefore, individuals who wear contact lenses are required to combine
them with appropriate industrial safety eyewear (ANSI Z87.1) since contact lenses do not provide ocular
protection from hazards such as particles, chemicals, and radiant energy. For example, personnel must wear
eye and face safety equipment to protect themselves from chemical vapors/eye irritants, optical radiation-
glare, optical injurious radiation, and biologic hazards. Many harmful agents are transmitted by contact with
the eye in the form of an aerosol droplet or splash. In an effort to protect the medical personnel, OSHA
published the Occupational Exposure to Bloodborne Pathogens, Standard 29 CFR 1910.1030. 6 It states in the
regulation that personal protective equipment (PPE) must be used to prevent blood or other infectious fluids
from passing through to or contacting the employees’ work or street clothes, undergarments, skin, eyes,
mouth or other mucous membranes.
Zelnick et al., showed that when a respirator was worn even without spectacles, there was a loss of visual
field, which varied depending on the type of full-face respirator.7 Since the frames of glasses have been shown
to be an obstruction of the full field of vision, the combined use of a respirator plus glasses compounds the
loss of visual field. The use of “intra mask corrections” (lenses suspended inside mask) and lenses built into a
facepiece as a substitute for spectacles, leads to poor visual ergonomics. Individuals who wear soft contact
lenses may present with symptoms of “dry eyes” due to dehydration of the contact lenses especially if there is
a low blink rate. For those whose tear flow is not adequate, sometimes using artificial tears and increasing the
blink rate are necessary to minimize these symptoms. This may be worse in air fed respirators, but the
problem is minimal in return for better visual function, work proficiency, and safety.
Challenges to federal regulations8 and voluntary ANSI standards9 which disallowed the use of contact lenses
with a respirator, resulted in an OSHA-funded research project conducted by Lawrence Livermore National
Laboratories (LLNL).10 The research concluded that the “prohibition against wearing contact lenses while using
a full-facepiece respirator should be revoked or withdrawn in spite of the limitations stated. Wearers of
corrective lenses should have the option of wearing either contacts or eyeglasses with their full-facepiece
respirators.” In consideration of LLNL’s research and other articles that support contact lens use, OSHA
considered the prohibition unwarranted. OSHA published an enforcement procedure authorizing the use of
rigid gas-permeable and soft contact lenses in all workplaces and with all types of respirators. 11
Contact lenses provide the best visual ergonomics for users of full face respirator masks. For those unable to
wear contacts or those who experience problems with the contacts when using the mask (i.e. dryness),
spectacles can be used. The spectacles must be of a type that will not interfere with the seal of the mask
(elastic strap, intra-mask lenses).

OSHA, in paragraph (g) 1 (iii) of its preamble to Respiratory Protection rule states that “Because the final
standard allows contact lenses to be worn, full facepiece respirators can be worn by persons needing
corrective lenses; contact lenses obviously do not interfere with facepiece seal.”12
Further, the preamble of the Personal Protective Equipment (PPE) for General Industry rule states, “Based on
the rulemaking record, OSHA believes that contact lenses do not pose additional hazards to the wearer, and
has determined that additional regulation addressing the use of contact lenses is unnecessary. The Agency
wants to make it clear, however, that contact lenses are not eye protective devices. If eye hazards are
present, appropriate eye protection must be worn instead of, or in conjunction with, contact lenses.” 13
Currently, OSHA statutes/rules recommends against contact lens use when working with acrylonitrile, 1,2
dibromo-3-chloropropane, ethylene oxide, methylene chloride, and 4,4’-methylene dianiline chemicals. These
recommendations are presumably based on best professional judgment of 1978, as no specific bases are
provided in the preamble to these standards, and they must be adhered to until the rule is changed.

The 1978 National Institute for Occupational Safety and Health (NIOSH) Pocket Guide to Chemical
Hazards recommended that workers not wear contact lenses during work with chemicals that present an eye
irritation or injury hazard.14 This policy was recommended by the 1978 Standards Completion Program and is
based on the “best professional opinion of the committee membership based on literature data” (NIOSH 1978).
The policy was also consistent at that time with general industry practice. The NIOSH Pocket Guide to
Chemical Hazards, Table 6 – Codes for First Aid Data (February 2004) – no longer states that “contact lenses
should not be worn when working with these chemicals.”
Recommendations
The following recommendations for contact lens use in an eye-hazardous environment will guide occupational
safety and health professionals to safely implement the contact lens use policy.
1. Establish a Written Policy. Establish a written policy documenting general safety requirements for the
wearing of contact lenses, including the required eye and face protection, and contact lens wear
restrictions, if any, by work location or task. Evaluate restrictions on contact lens wear on a case-by-case
basis. Take into account the visual requirements of individual workers wearing contact lenses as
recommended by a qualified ophthalmologist or optometrist, in order to be able to perform the essential
visual functions, and this policy statement.
2. Conduct an Eye Hazard Evaluation. Conduct an eye injury hazard evaluation in the workplace that includes
an assessment of eye-hazardous environments per OSHA Personnel Protection Standards (29CFR 1910.132),
and appropriate eye and face protection for contact lens wearers (OSHA 29CFR 1910.133 and ANSI Z87.1A
2003). The eye injury hazard evaluation should be conducted by a competent, qualified individual such as
a certified industrial hygienist, a certified safety professional, toxicologist, or occupational health
physician or nurse as appropriate. This information should be provided to the examining occupational
health nurse or occupational medicine physician.
3. Provide Training. In addition to providing the general training required by the OSHA personal protective
equipment standard (29 CFR 1910.132), provide training on employer policies on contact lens use, and first
aid for contact lens wearers with a chemical exposure. Routinely train medical and first aid personnel in
the removal of contact lenses, management of pain, blepherospasm, and the appropriate equipment
available. In the event of a chemical exposure, begin eye irrigation immediately and remove contact lenses
as soon as practical. Do not delay irrigation while waiting for contact lens removal as the lens may come
out with the irrigation or can be removed when irrigation is complete. Instruct workers who wear contact
lenses to remove the lenses at the first signs of eye redness or irritation. Removal of contact lenses should
only be done in a clean environment and after the worker has washed his or her hands. Evaluate continued
lens wear with the worker and an ophthalmologist (Eye MD). Encourage workers to routinely inspect their
contact lenses for damage and/or replace them regularly.
4. Provide Personal Protective Equipment. Comply with current OSHA regulations on contact lens wear and
eye and face protection. The Code of Federal Regulations Preamble on Respiratory
Protectors (29 CFR 1910.134) and Personal Protective Equipment (PPE) (CFR 1910.132) allows contact
lenses to be worn under full-face respirators and other PPE for the eyes. Provide suitable eye and face
protection for all workers exposed to eye injury hazards, regardless of contact lens wear. The wearing of
 contact lenses does not appear to require enhanced eye and face protection. For chemical liquid or caustic
hazards, the minimum protection consists of well-fitting indirectly vented goggles or full-facepiece
respirators. Close-fitting safety glasses with side shields provide limited chemical protection, but do not
prevent chemicals from bypassing the protection. Face shields should be worn over other eye protection
when deemed necessary for additional face protection, but workers should not wear face shields instead of
goggles or safety glasses regardless of contact lens wear.
5. Notification to Visitors. Notify employees and visitors of any denied areas where contact lenses are
restricted without appropriate eye and face protection.
6. Notification to Supervisors, First Aid Responders and EMS Responders. Identify to supervisors and first aid
responders all contact lens wearers working in eye hazardous environments.
Conclusion
ACOEM recommends that workers be permitted to wear contact lenses when handling hazardous chemicals and
in other eye hazardous environments provided that the safety guidelines listed above are followed and that
contact lenses are: 1) not banned by regulation; or 2) not contraindicated by medical or industrial hygiene
recommendations. In addition under current OSHA rules, contact lenses should not be worn while working with
acrylonitrile, 1,2 dibromo-3-chloropropane, ethylene oxide, methylene chloride, and 4,4' -methylene dianiline.
ACOEM concurs contact lenses are not eye protective devices and that contact lens wear does not reduce the
requirement for eye and face protection.
The National Institute for Occupational Safety and Health (NIOSH) in its Current Intelligence Bulletin (CIB)
59, Contact Lens Use in a Chemical Environment, states that several professional groups (i.e. American College
of Occupational and Environmental Medicine, American Optometric Association, American Academy of
Ophthalmology, etc.) have issued guidelines removing restrictions regarding contact lens use in the industrial
environment.15 NIOSH has reviewed these guidelines, company policies on contact lens use and injury
incidents, and the limited literature on contact lens use in a chemical environment. It concluded that injury
data are insufficient to support the previous recommendation that wearing of contact lenses should be
restricted during work with hazardous chemicals. Therefore, NIOSH recommends that contact lens wear be
permitted provided safety guidelines in CIB 59 are followed.
AcknowledgementsThis ACOEM guideline was developed by the ACOEM Sensory Perception Committee under
the auspices of the Council on Scientific Affairs. It was originally peer-reviewed by the Committee and Council
and approved by the ACOEM Board of Directors on May 4, 2003. The Guideline was updated by the Committee
and reviewed by the Council on Scientific Affairs. It was approved by the ACOEM Board of Directors on July 27,
2008.
References
1. Code of Federal Regulations – Parts 1900 to 1910 Personal Protective Equipment. 29 CF2R 1910.132.
Revised 1994.
2. Blais BR. Does wearing of contact lenses in the workplace pose a direct threat? Occup Environ Med Rep.
1998;12(3):17-31.
3. Blais BR. Discrimination against contact lens wearers. J Occup Environ Med. 1998;40(10):876-80.
4. Code of Federal Regulations – Parts 1900 to 1910 Personal Protective Equipment. 29 CF2R 1910.133.
Revised 1994.
5. American National Standards Institute, Inc. ANSI Z87.1 1979 and Subsequent Revision.
6. Code of Federal Regulations – Part 1910 Occupational Exposure to Bloodborne Pathogens. Standard
29 CFR 1910.1030.Federal Register. Vol. 56. No. 235; pp 64004; Dec 6, 1991; Effective March 6, 1992.
7. Zelnick SD, McKay RT, Lockey JE. Visual field loss while wearing full-face respirator protection. Am Ind
Hyg Assoc J. 1994;55(4):315-21.
8. Code of Federal Regulations – Parts 1900 to 1910 Respiratory Protection, 29 CFR 1910.134 (e) (5) (ii),
Revised July l, 1990.
9. American National Standards Institute, Inc. ANSI Z88.6: Physical Qualifications for Respirator Use. 1984.
10. DaRoza RA, Weaver C. Is it safe to wear contact lenses with a full-facepiece respirator? Berkeley, CA:
Lawrence Livermore National Laboratory (UCRL – 53653), August 16, 1985.
11. US DOL Memorandum to Regional Administrators Regarding Contact Lenses Used with Respirators, 29 CFR
1910.34 (5) (ii), February 1988.
12. Code of Federal Regulations – Parts 1910 and 1926 Respiratory protection final rule. Federal Register. Vol.
63. No. 5, Jan. 5, 1998 Rules & Regulations pp 1162.
13. Code of Federal Regulations – Parts 1910 Personal Protection Equipment for General Industry. Final Rule,
CFR 29, 1910.132 effective July 5, 1994, Federal Register. Vol. 59, no. 66, April 6, 1994 Rules and
Regulations pp 16343.
14. Pocket Guide to Chemical Hazards. National Institute for Occupational Safety and Health, 1978 edition.
15. Shulte PA, Ahlers HW, Jackson LL, et al. NIOSH Current Intelligence Bulletin 59, Contact Lens Use in a
Chemical Environment, DHHS (NIOSH) Publication Number 2005-139, June 2005.
HIV and AIDS in the Workplace
11/17/2008
From the early 1980s through 2006, an estimated 565,000 deaths from acquired immunodeficiency syndrome
(AIDS) have occurred in the United States, and approximately one million Americans are currently infected
with human immunodeficiency virus (HIV).1 Worldwide, more than 33 million are estimated to be infected, and
during 2007 alone, AIDS caused the deaths of an estimated 2 million people, while 2.7 million became newly
infected.2 Of new HIV diagnoses during 2006 in the U.S., approximately 78 percent have occurred in persons
aged 25-54, substantially impacting the American workplace.1 One in six large U.S. worksites (>50 employees)
and one in 15 small U.S. worksites (<50 employees) have had an employee or employees with HIV infection or
AIDS.3
In addition to the sheer number of young people affected, the profound impact of AIDS upon the
American workplace and the special attention garnered by the disease have stemmed from a wide range of
sensitive medical, social, and political issues. From the onset of the epidemic, AIDS struck disproportionately
members of certain stigmatized groups, such as gay men and intravenous drug abusers, triggering concerns in
the workplace around confidentiality and discrimination. Because it is an infectious illness, widespread
ignorance regarding disease transmission, particularly during the early years of the epidemic, led to an
increased risk of ostracism at work. The episodic nature of an illness marked by recurrent opportunistic
infections also presented difficulties to both employers and to those infected individuals trying to remain
occupationally productive. Today, as more AIDS patients benefit from highly effective antiretroviral therapy,
their re-integration into the workplace adds yet another layer of complexity.

Occupational and environmental medicine (OEM) physicians, uniquely positioned as medical professionals
responsive to both employees and employers, play a pivotal role in addressing issues of HIV infection and AIDS
in the workplace. This guidance statement of the American College of Occupational and Environmental
Medicine (ACOEM) addresses general issues of HIV and AIDS in the workplace, including the role of the OEM
physician within the context of the Americans with Disabilities Act of 1990 and the Family and Medical Leave
Act of 1993. In addition, workplace issues specific to the health care industry, including the infected health
care worker, exposure prevention, and prophylactic therapy are addressed.

ADA and FMLA

AIDS and HIV infection are considered disabilities under the Americans with Disabilities Act (ADA) of 1990. 4-
7 The Act applies to all employers with at least 15 employees working at least 20 weeks in the current or

preceding calendar year, and expands upon the protections of the Federal Rehabilitation Act of 1973, which
applied only to workplaces receiving federal funding.8 Under ADA, discrimination is prohibited in all
employment practices including recruitment, hiring, promotion, training, layoffs, pay, firing, job assignments,
leave, and benefits. Only individuals who are qualified for a particular job and who can perform the job, with
or without reasonable accommodation, are protected. Because the act applies to people with disabilities and
perceived disabilities, ADA protects not only those who are infected with HIV, but also those who are
perceived as such.9-10
The act requires that employers provide “reasonable accommodation” for disabled employees. Reasonable
accommodation is a change or adjustment to a work environment that permits a qualified individual to
participate in the job application process, to perform the essential functions of the job, or to enjoy the
benefits and privileges of employment equal to those enjoyed by employees without disabilities. Reasonable
accommodations must be provided only for known physical or mental limitations resulting from a disability.

If an individual with HIV infection or AIDS is temporarily unable to perform the essential functions of the job,
she/he may come under the protection of the Family and Medical Leave Act (FMLA) of 1993. 11 This legislation
applies to employees with at least one year of service (>1,250 work hours during the year) at a workplace with
50 or more employees within a 75-mile radius. Under FMLA, HIV infection and AIDS are considered “serious
health conditions,” which may qualify the affected individual for up to 12 weeks of unpaid leave per 12-month
period. FMLA also provides unpaid leave for employees who must care for a spouse, child, or parent with a
serious medical condition, including HIV infection and AIDS. Employees may be required to provide advanced
notice when the leave is “foreseeable,” and employers may require medical certification to support a request
for leave, as well as second or third medical opinions at the employer’s expense.
In order for individuals with HIV infection or AIDS to invoke the protections of either Act, the disclosure of
medical information to the employer may be required. (Employers are not required to provide reasonable
accommodation under ADA nor unpaid medical leave under FMLA if they are not informed that a disability or
serious medical condition exists.) If an employee makes an employer aware of AIDS, HIV infection, or any other
disability or serious medical condition, the law requires that that information be held in strict confidence, and
that it be maintained in a separate, locked file which is not part of the personnel file. The handling of
sensitive medical information, as well as the complexities of designing reasonable accommodations and
evaluating the appropriateness of FMLA leaves, is a process in which OEM physicians should play an integral
role.

Recommendations:
 During the preplacement medical examination the OEM physician should inquire whether the newly hired
employee is able to perform the essential functions of the job, and whether any accommodations are
necessary. The physician should be familiar with both the employee’s job description and the
circumstances under which the employee will work. The decision to disclose HIV status is the prerogative
of the HIV-positive individual, and the OEM physician should not inquire regarding HIV status, nor should
HIV serological screening be undertaken as part of a pre-placement examination.
 For employees reporting HIV infection or AIDS under ADA, reasonable accommodations might include
modifying physical facilities to enhance access, restructuring jobs, changing schedules, or transferring
marginal functions to another employee. The goal of accommodations in the general workplace is to
address the medical needs of the affected employee, not to establish unnecessary precautions against
HIV transmission to other workers. The special case of an HIV-infected healthcare worker is addressed in
the next section. The OEM physician should work with administrative and supervisory personnel during
the design and implementation process of workplace accommodations, as well as with the primary
healthcare provider of the employee, to make certain that accommodations are appropriately
implemented. Consistent with the ACOEM Position on the Confidentiality of Medical Information in the
Workplace,12,13 the OEM physician should not reveal to managerial/supervisory staff the employee’s
health condition, only the necessary work restrictions.
 More broadly, the OEM physician should be intimately involved in the development of institutional
policies addressing AIDS and HIV in the workplace, assuring that at a minimum such policies encompass
the requirements of ADA and FMLA, and that they are appropriate from medical and infection control
perspectives.
 The OEM physician should assume a leadership role in the design and implementation of workplace
educational programs around HIV infection and AIDS, making certain that such programs educate
employees about the following: 1) HIV transmission and prevention; 2) non-discrimination; and 3) the
ADA and FMLA. Depending upon the specific workplace, employees should also be educated about the
Standard (Universal) Precautions and the OSHA Bloodborne Pathogen Standard. The OEM physician should
also serve as a resource to provide advice as needed to both employers and employees about HIV
infection and AIDS, and be prepared to respond to an HIV- or AIDS-related medical problem with
appropriate triage or care.
The HIV-infected Health Care Worker
According to the U.S. Centers for Disease Control and Prevention (CDC), 57 health care workers have acquired
HIV due to workplace exposures, representing a tiny fraction of the thousands of healthcare workers who are
HIV-positive.14 Health care workers enjoy the same protections under the ADA and FMLA as do employees in
other industries. However, because some perform medical procedures in which there is a small risk of viral
transmission to patients, they are subject to additional guidelines.
Since the onset of the AIDS epidemic there have been two instances in which health care workers transmitted
HIV to patients. The first was a well-publicized case in which a Florida dentist transmitted HIV to six patients
in his practice.15-19 More recently, a French orthopedic surgeon who likely became infected on the job in 1983
transmitted HIV to a patient on whom he performed a 10-hour surgical procedure in 1992.20 Of the 982 other
patients who underwent procedures with the same surgeon, serological testing revealed no other
transmissions.21 Numerous serological surveys of patients treated by other HIV-positive health care workers,
including dentists, surgeons, obstetricians, and other physicians, have revealed no other transmissions of HIV
from healthcare workers to patients.22-26 In contrast, more than 350 patients have become infected with
hepatitis B following procedures by hepatitis B-infected health care workers.27,28 Transmissions have taken
place during dental procedures prior to widespread use of examining gloves, and during vaginal
hysterectomies, major pelvic surgeries, and cardiac surgeries, and nearly all transmissions were linked to
hepatitis B e-antigen-positive healthcare providers. Clusters in which hepatitis C was transmitted from
healthcare providers to patients have also been reported. 29,30 CDC has estimated that the risk for transmission
of HIV or hepatitis B lies between 1/42,000 and 1/420,000.
On July 12, 1991, CDC issued guidelines addressing HIV and hepatitis B infection of health care workers,
particularly among those who performed certain “exposure prone” procedures. 31 The guidelines stated that
infected health care workers who adhere to universal precautions and who do not perform invasive procedures
pose no risk for transmitting HIV or hepatitis B to patients, but that those who perform certain exposure-prone
procedures pose a small risk for transmitting hepatitis B or HIV. Exposure-prone procedures were characterized
as those in which a needle tip was digitally palpated in a body cavity or a health care worker’s fingers and a
needle or other sharp instrument or object are simultaneously present in a poorly visualized or highly confined
anatomic site. Initial efforts to develop standard lists of procedures meeting these criteria were abandoned
shortly after the guidelines were issued.
The guidelines stated further that health care workers performing exposure-prone procedures should know
their HIV antibody status, and if non-immune to hepatitis B, their hepatitis B surface antigen and hepatitis B e-
antigen status. Health care workers infected with HIV or hepatitis B (and e-antigen positive) were further
instructed not to perform exposure-prone procedures unless they had sought counsel from an expert review
panel and been advised under what circumstances, if any, they might continue to perform these procedures.
Such circumstances would include notifying prospective patients of the health care worker’s seropositivity
before they underwent exposure-prone invasive procedures. Mandatory testing of health care workers for HIV
antibody, hepatitis B surface antigen or hepatitis B e-antigen was not recommended.

Several court decisions have rejected health care workers’ discrimination claims regarding forced alterations
of medical practice.32 The Fifth Circuit Court of Appeals held in 1994 that a hospital did not violate the
Rehabilitation Act of 1973 in reassigning an HIV-positive surgical assistant to a position as procurement
assistant in a purchasing department.33 A New Jersey court held that a hospital’s policy of restricting an HIV-
infected surgeon’s staff privileges was substantially justified by a reasonable probability of harm to the
patient.34 A U.S. District Court found in favor of a hospital which suspended, then reinstated a surgeon’s
privileges contingent on his informing patients of his HIV status before he performed an invasive
procedure.35,36
A number of professional organizations also responded to the July 12, 1991, guidelines. The Society for
Healthcare Epidemiology of America (SHEA) distinguished the very low potential for transmission of hepatitis C
and HIV from the somewhat higher potential for transmission from a hepatitis B e-antigen positive health care
worker performing invasive procedures. SHEA also stated that patients should not be informed of a surgeon’s
serological status unless a clear exposure had taken place.37
The American College of Physicians (ACP) and the Infectious Disease Society of America (IDSA) generally
reflected the CDC Guidelines, but stressed the need for case by case evaluations of practice restrictions and
the ethical obligations of individual physicians.38 The American College of Surgeons (ACS) distinguished
between HIV and hepatitis B, stating that HIV-infected surgeons should be allowed to continue to practice and
perform invasive procedures unless there were clear evidence that a significant risk of transmission existed,
but that surgeons who were hepatitis B e-antigen positive should seek counsel from an unbiased expert review
panel.39,40
In contrast, the American Academy of Orthopedic Surgeons (AAOS) stated that HIV-infected orthopedic
surgeons should not perform invasive surgical procedures where there is substantial risk that the patient will
come into contact with the surgeon’s blood. AAOS was the only professional organization which sought to
define “exposure-prone” procedures, characterizing them as those of long duration involving blind probing or
use of internal fixation devices or implanted wires.41 The American Hospital Association (AHA) stated that if an
expert panel has already made a determination that a health care worker poses no reasonable risk to a
patient, disclosure of the health care worker’s infection status unnecessarily invades the health care worker’s
privacy. AHA stated further that providing patients with the HIV status of their caregivers is unacceptable. 42
Recommendations:
In consideration of the minimal additional evidence for transmission of HIV from health care workers to
patients in the years since CDC’s Guidelines were issued, ACOEM makes the following position statement with
regard to the HIV-infected health care worker:
  The HIV-infected health care worker should practice standard (universal) precautions at all times. HIV-
infected health care workers who carry out invasive procedures should double glove during all procedures
and minimize to the extent possible digital palpation of needle tips and blind probing in poorly visualized
or highly confined anatomic sites. Surgical gloves should be changed following portions of surgical
procedures linked with glove failure, such as tying sternal wires or forceful contact with sharp edges.
Surgical gloves should be changed at least every 2 hours during longer procedures.
 Based on the accumulated evidence, ACOEM does not consider that any invasive medical procedure has
distinguished itself as “exposure-prone” with respect to HIV transmission from health care worker to
patient. Hence, ACOEM finds no basis to otherwise restrict the practice of health care workers infected
with HIV who perform invasive procedures, and does not support notification of patients of a health care
worker’s HIV status unless an exposure has taken place.
HIV Exposure Prevention
During 2001, the Needlestick Safety and Prevention Act was incorporated into the OSHA Bloodborne Pathogens
Standard (29 CFR 1910.1030). 43,44 The amendment requires that employers review and update their exposure
control plans required under the Bloodborne Pathogens Standard to “reflect changes in technology that
eliminate or reduce exposure to bloodborne pathogens,” and “document consideration and implementation of
appropriate commercially available and effective safer medical devices designed to eliminate or minimize
occupational exposure.” In addition, employers are required to establish and maintain a sharps injury log to
record percutaneous injuries from contaminated sharps. The log must be maintained in such a manner as to
protect the confidentiality of the injured employee and it must contain information regarding: 1) the type and
brand of device involved in the incident; 2) the department or work area where the exposure incident
occurred; and 3) an explanation of how the incident occurred. Employers must also solicit input from non-
managerial employees responsible for direct patient care to assist in identifying, evaluating, and selecting
effective safety devices and work practice controls.
The Needlestick Safety and Prevention Act was the federal government’s response to a substantial body of
evidence that safer medical devices are associated with reductions in percutaneous injuries among health care
workers. Significant reductions in injury rates among health care workers have been demonstrated for
phlebotomy devices with engineered safety features and for needleless intravenous delivery systems. 45-
48 Several studies have documented reduction in percutaneous injury rates among operating room staff

following implementation of blunt needles for certain procedures.49-51 In addition, a number of studies have
demonstrated the benefit of educational programs addressing safe use of phlebotomy equipment and safe
methods of operating room instrument usage.52-57
Recommendations:
 ACOEM embraces the amended Bloodborne Pathogen Standard as an effective piece of legislation to
reduce percutaneous injuries and the risk of bloodborne pathogen transmission to health care workers.
 OEM physicians in practice settings where employees have potential bloodborne exposures should involve
themselves substantially in workplace education efforts addressing bloodborne pathogen exposure
reduction. Such educational programs should address standard (universal) precautions, proper usage of
specific medical devices, and procedures for immediate exposure triage.
 OEM physicians should take a leadership role in identifying and implementing safety devices in the
workplace, conducting institutional reviews of sharps injury logs to determine the circumstances under
which exposures occur, and working with other professionals in the health care setting toward effective
solutions.
Acute Exposure to HIV
On June 7, 1996, the U.S. Public Health Service (USPHS) published provisional recommendations for
chemoprophylaxis after occupational exposure to HIV, which were made final May 15,1998, and updated June
29,2001, and September 30, 2005.58-61 The USPHS recommendations were based primarily upon a case-control
study of health care workers who seroconverted following HIV-positive blood exposures, a clinical trial of
zidovudine administration to HIV-positive pregnant women, and a number of animal studies of antiretroviral
prophylaxis. The case-control study assessed risk factors for seroconversion in 33 health care workers who
became HIV positive following bloodborne occupational exposure to HIV. 62,63 Compared to a control group who
did not seroconvert, cases were significantly less likely to have used anti-retroviral prophylactic medication
(zidovudine) when adjusted for other HIV transmission risk factors. The second study cited in support of the
guidelines was the AIDS Clinical Trials Group protocol 076, in which zidovudine was administered to HIV-
positive pregnant women.64,65 The trial was halted due to the markedly lower transmission of HIV to the fetus
in the treated vs. the placebo group (7.6 percent transmission in treatment group, 22.6 percent transmission
in placebo group, p<0.001). Viral load testing at a later date revealed that a relatively small proportion of the
difference could be attributed to reduction in maternal viral load, suggesting that zidovudine may have acted
prophylactically in the fetus.66 Animal studies have shown mixed results, but generally have demonstrated a
greater effect when medications were administered immediately following exposure.67-70
The current guidelines stratify exposed health care workers into risk levels based on source patient
characteristics and nature of exposure. Combination therapy with antiretroviral agents is tailored to risk level
and probable patterns of resistance in the source patient virus.

Several authors have reported on the experiences of large medical centers in implementing the USPHS
guidelines, pointing out a number of challenges for the OEM physician practicing in such settings. More often
than not, the HIV status of the patient to whom the health care worker is exposed is not known at the time
exposure occurs. Because of frequent logistic difficulties in obtaining blood from the source patient, many
health care workers receive prophylaxis as a precautionary step while awaiting source patient HIV testing.
Most such individuals are later demonstrated to have been exposed to HIV-negative source patients, and are
treated for fewer than four days.71,72 However, despite the importance of source patient serological testing,
some authors have reported that it is obtained in only about 50 percent of cases. 73,74
Because prophylactic medications should be administered as rapidly as possible, emergency departments are
often relied upon to carry out the initial evaluations of exposed health care workers on nights and weekends
when on-site occupational health clinics are not open. This requires both familiarity of emergency department
clinicians with the USPHS Guidelines and concerted efforts to coordinate follow-up testing, treatment, and
counseling. Coordination of exposure evaluation and treatment by the OEM physician is even more challenging
when occupational health clinics serve exposed personnel who do not work within the hospital environment,
(e.g., police officers, firefighters, and nursing home employees), or when they serve health care workers
employed in HIV-endemic areas of the developing world where antiretroviral medications may not be
immediately available in the event of exposure.75
Although the USPHS guidelines are based on best evidence to date, ACOEM recognizes that issues remain to be
resolved regarding whether and to what degree combination antiretroviral therapy may benefit HIV-exposed
health care workers. To date, epidemiological studies of prophylaxis in health care workers have evaluated
only the effect of zidovudine,62,63 although recent studies reveal possible benefit of combination antiretroviral
therapy following potential non-occupational exposure to HIV through sexual contact or injection drug
use.76 Laboratory studies of health care workers exposed to HIV also leave unanswered questions. It has been
shown that individuals exposed to HIV who do not seroconvert may develop markers of T-cell mediated
response to the virus,77-79 but that HIV-exposed health care workers treated with antiretroviral prophylaxis are
less likely to develop the response.80 It is not known whether that indicates non-viability of the virus in the
setting of early prophylactic therapy. To date, there have been 22 cases of HIV seroconversion among health
care workers despite use of prophylaxis, and 6 of those cases were administered combination therapy (Elise
Beltrami, personal communication, March 2001). The side effects of antiretroviral prophylaxis also cannot be
ignored. The recent report of an HIV-exposed health care worker who suffered fulminant hepatic failure
requiring liver transplantation following antiretroviral prophylaxis with a nevirapine-containing regimen strikes
a cautionary note.81 Because a randomized, placebo-controlled clinical trial of antiretroviral prophylaxis is not
likely to take place, judgment regarding the efficacy of currently recommended prophylactic regimens awaits
the accumulation of sufficient numbers of exposed subjects for additional retrospective studies to be
conducted.
Recommendations:
 OEM physicians who treat health care workers or other individuals with potential for exposure to
bloodborne pathogens should thoroughly familiarize themselves with current CDC guidelines for
evaluation and treatment of such exposures.
 OEM physicians should ensure that workplaces for which they have responsibility provide training for
employees addressing immediate steps to take in the event of a potential bloodborne pathogen
exposure. Medical coverage should be available 24 hours/day to evaluate and treat exposures, assess
exposure risk, provide counseling, and administer post-exposure prophylaxis where appropriate. OEM
physicians who treat exposures should be familiar with the pharmacologic action, toxicities and drug
interactions of antiretroviral medications.
 OEM physicians who treat workers with potential for exposure to bloodborne pathogens should be aware
of possible drug resistance in the viral strains to which their patients are exposed, and combination
antiretroviral therapeutic regimens should be designed appropriately. When exposure occurs to a source
patient who may harbor resistant virus (based on that patient’s clinical course, history of antiretroviral
 medication use, or patterns of viral resistance in a community), expert advice should be sought from an
infectious disease physician, ideally one familiar with the source patient’s clinical course. Initial therapy,
however, should not be delayed while an ideal therapeutic regimen is designed, and the OEM physician
should strive to initiate prophylactic treatment as soon as possible following exposure.
 Although it has been recommended in the past that prophylaxis should begin within 1-2 hours following
exposure, the time period after which initiation of prophylaxis is no longer indicated has not been
established. When an exposed individual does not seek evaluation and treatment until many hours after
exposure, initiation of prophylaxis may still be indicated, even if the interval since exposure exceeds 36
hours.
 Because the HIV serology of a source patient is often not known at the time of exposure, the OEM
physician should base initiation of prophylaxis on an assessment of the likelihood of source patient HIV
positivity. Testing of the source patient’s blood should be accomplished as quickly as possible and
applicable state laws regarding that process should be followed. A rapid HIV assay, which can provide a
result within hours, is recommended in order to minimize the amount of medication taken by individuals
exposed to HIV-negative patients. Once the source patient is established to be HIV-negative, prophylaxis
should be discontinued.
 Individuals exposed to HIV-positive source patients and prescribed antiretrovirals should be monitored for
the specific side effects associated with those medications, and prophylaxis should be administered for a
4-week period. Serological follow-up to determine whether HIV seroconversion has taken place should be
carried out at 6 weeks, 3 months, and 6 months following exposure. ELISA testing is currently considered
to be the test of choice for such monitoring. If an individual is exposed to both HIV and hepatitis C, and
becomes infected with hepatitis C, monitoring for HIV seroconversion should be extended to 12 months,
due to a possible delay of HIV seroconversion in hepatitis C-infected individuals.82
Summary
Since the onset of the HIV epidemic, AIDS and HIV infection have presented tremendous challenges to infected
individuals seeking to remain productive in the workplace, to employers coping with the special needs of such
individuals, and to physicians who treat and counsel exposed or infected personnel. OEM physicians should
strive to ensure that employers are familiar with legislation and guidelines protecting the rights of infected
employees, and support rational workplace policies applying to employees with HIV infection or AIDS. Where
there is potential for occupational HIV exposure, OEM physicians should assure that adequate training around
exposure prevention, triage, and treatment is provided. OEM physicians who treat individuals with
occupational HIV exposures should involve themselves in institutional efforts to prevent exposures through use
of safer devices and procedures, and should assure that immediate and adequate clinical evaluation of
exposures is available at all times.
Acknowledgments
This ACOEM guidance statement is a revision of the 2002 statement. The revision was prepared by Mark Russi,
MD, under the auspices of the Medical Center Occupational Health Section. It was peer-reviewed by the
section and was approved by the ACOEM Board of Directors on November 8, 2008. Dr. Russi is Associate
Professor of Medicine at Yale-New Haven Hospital in New Haven, Conn.
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Ethical Guidelines for Occupational and Environmental

Medicine Physicians Serving as Expert Witnesses
10/25/2007
Purpose or Goal of Expert Testimony
As a professional with special training and experience, the occupational and environmental medicine physician
has an ethical obligation to provide expert assistance in legal, administrative, and legislative proceedings, and
to testify in hearings or trials as an expert witness when appropriate. The physician must clearly understand
that the role of the medical expert witness is to provide credible information which assists the court or other
forum in understanding complex medical or scientific issues.
Need for Ethical and Professional Guidelines
Criteria or guidelines for qualifying medical or other scientific expert witnesses are sometimes inadequate
and, as a result, any physician may testify as an expert witness regardless of training, experience, or
demonstrated competence. It is in the public interest that occupational and environmental medicine expert
testimony be competent, readily available, objective, and unbiased. To limit uninformed and possibly
misleading testimony, occupational and environmental medicine expert witnesses should be qualified for their
role and should follow a clear and consistent set of ethical guidelines. The following guidelines were
developed jointly by the Occupational Health Law and Policy Section, and the Committee on Ethical Practice
in Occupational and Environmental Medicine of the American College of Occupational and Environmental
Medicine (ACOEM) to define the recommended qualifications and behavior for the occupational and
environmental physician expert witness.
Qualifications of an Expert Medical Witness
A witness who testifies authoritatively should have current experience and ongoing knowledge in the medical
or scientific discipline which is the subject of his or her testimony. It should be kept in mind that expert
knowledge in one field does not imply or confer expertise in all fields. A physician expert witness who offers
testimony regarding issues of clinical medicine should have appropriate knowledge and experience regarding
the area of clinical medicine in which they offer expert testimony. To ensure that the public obtains the
benefit of testimony by medical experts with demonstrated competence, a physician who testifies as a
medical expert should be certified by or have satisfactorily completed the equivalent requirements of a
relevant specialty board recognized by the American Board of Medical Specialties. In addition, the expert
should be qualified by training or experience to testify as an expert in the specific subject matter of the
case/proceeding.
Basis of Expert Medical Testimony
The testimony of an expert medical witness should be founded on a thorough and critical review of the
pertinent medical and scientific facts, available data, and relevant literature. The expert should specify
whether his or her opinion is based on personal experience, specific reference to peer-reviewed literature, or
generally accepted professional opinion in the specialty field.
Objectivity of Expert Medical Testimony
The medical expert witness is expected to be objective and has an ethical obligation to prevent personal
relationships or bias from interfering with their medical or scientific opinion. He or she can have no direct
personal or pecuniary interest in the outcome of the case, and review of the medical facts should be thorough,
fair, and impartial and should not exclude any relevant information in order to create a view favoring any
party.
Conduct of the Expert Medical Witness
The physician expert must demonstrate adherence to the strictest of personal and professional ethics.
Truthfulness is essential, and misrepresentation of a personal theory or opinion as scientific doctrine may be
harmful to individual parties, the profession, and the public. The physician shall testify honestly, fully, and
impartially to his or her qualifications regarding the medical or other scientific issues involved in the case. The
medical expert must strive to avoid even the slightest appearance of impropriety or partiality. The physician
has an ethical responsibility to fully disclose competing relationships that may result or appear to result in a
conflict of interest. The expert must conduct him or herself with professional decorum and avoid personal
attacks, insults, or deprecatory remarks directed at other witnesses or parties.
Peer Review and Discipline
Medical experts should be aware that transcripts of depositions and courtroom testimony are public records,
subject to independent peer review by colleagues and professional organizations, and that testimony in some
states may be subject to the jurisdiction and review of appropriate licensing or disciplinary boards.
Compensation of the Expert Witness
The acceptance of fees that are disproportionate to those customary for professional services can be
misconstrued as influencing the testimony given by the witness. Therefore fees should be reasonable and
commensurate with the time and effort given to reviewing records and pertinent literature, writing reports,
and appearing for deposition or testimony. It is always unethical for a physician to accept compensation that is
contingent upon the outcome of litigation.
These guidelines, originally drafted by Thomas Weir, MD, JD, and Gary Rischitelli, MD, JD, MPH, were
modeled after similar guidelines prepared by the American Medical Association, the American College of
Physicians, the American College of Surgeons, the American Academy of Orthopedic Surgeons, the American
College of Obstetricians and Gynecologists, and the American College of Radiologists. The authors gratefully
acknowledge the contributions of the following individuals who supplied comments or acted as reviewers: Ron
Teichman, MD, MPH; Susan Cassidy, MD, JD; and Raja Khuri, MD, from the ACOEM Committee on Ethical
Practice in Occupational Medicine; and Charles Lucey, MD, JD, MPH; Patrick Joyce, JD, MD, MPH; Marcia
Scott, MD; Modesto Fontanez, MD, JD; Gregg Stave, MD, JD, MPH; and Andrew Campbell, MD, from the
ACOEM Occupational Health Law and Policy Section.
The guidelines were subsequently reviewed, revised, and reaffirmed by the ACOEM Committee on Ethical
Practice in Occupational Medicine in August 2007 and reaffirmed by the ACOEM Board of Directors on October
25, 2007.