By Dr. Taryl Felhaber (biography and disclosures) Disclosures: Given talks for UBC and BCCA, for which honoraria were received. Medical advisor for WorkSafeBC. Mitigating Potential Bias: Treatments or recommendations in this article are unrelated to products/services/treatments involved in disclosure statements. Recommendations are consistent with current practice patterns.
What I Did Before
Every day family doctors are faced with patients who have gone off work for injury or illness of some kind. Focus groups with family doctors have shown that the doctors often do not consider determining a patient’s ability to work is within their role . Although they do the best they can with limited information, and often with only a cursory understanding of what a person’s job duties entail, concerns remain that discussions about returning to work can cause friction in the doctor-patient relationship. When should a family doctor’s care extend beyond providing support and management for health-related issues only to the management of long-term effects of worklessness?
What Changed My Practice
Discovering the research on worklessness, and the fact that the relative risk of increased mortality for being unemployed (2.79) is greater that that of diabetes (1.85), hypertension (1.75), smoking (1.80), obesity (1.29), or poverty (1.75) was a revelation. Worklessness is associated with increased rates of death, suicide, obesity, heart attack, depression, alcohol consumption, illicit drug use, accidents, poverty, alienation and criminality. Once a person has been off work for 6 months, they have a less than 50% chance of EVER returning to work, and the longer they are off the lower their chances of returning. Few people return to any form of work after a one to two year absence. 
There are a number of studies from several countries that evaluate the risks of being off work. A study by Duke University researchers found that unemployment status, multiple job losses, and short periods without work are all significant risk factors for cardiovascular events . An NHS review from the UK also found an association between unemployment and mortality due to health conditions such as cardiovascular disease. This study further noted that the rate of hospital admissions doubles and heart disease and hypertension increase during the anticipation and termination phase of factory closure. This NHS study revealed a strong relationship between unemployment and psychiatric morbidity, stating that while the direction of causality is difficult to determine, unemployment itself is a significant cause of psychological distress .
A systematic review by Lynge in 1997 showed unemployed men had an excess mortality of close to 25% (mainly from lung cancer) compared with all men in the labour force; the risk persisted long after the start of unemployment and did not disappear after controlling for social class, smoking, alcohol intake and previous sick leave. 
Public health analyses of unemployment rates and mortality in 15 western European countries and the USA since the Second World War have shown the higher the unemployment rate in a given year, the higher the mortality rate over the following 10 to15 years. Suicide increases within a year of job loss and cardiovascular mortality accelerates after 2 or 3 years and continues for the next 10-15 years .
A study by Lucinda Platt in the UK found that children growing up in households where no adult member is in paid work are not only likely to be growing up in poverty, but are at risk of that worklessness being handed down to their generation .
Studies have also looked at the hours of work and health, as well as the effects of early retirement. A systematic review meta-analysis found that working more than 48 hours per week is detrimental to physiological and psychological health . After adjusting for socioeconomic status, employees who retired early at 55 had greater mortality than those who retired at 65 – the mortality was about twice as high in the first 10 years after retirement. Early retirees who survived to 65 had higher post-65 mortality than those who had continued working. Mortality was similar in those who retired at 60 and 65. Mortality did not differ for the first 5 years after retirement at 60 compared with continuing work .
What I Do Now
Why should physicians encourage early and ultimate return to work whenever they can? In a nutshell, because it is usually in the patient’s best interest to remain in the workforce .
Productive activity has a role in determining both short-term and long-term health. The negative consequences of economic inactivity, unemployment, and/or underemployment include:
- Physical health – elevated risk of specific diseases, suppressed immunological function or early death;
- Psychological health – elevated risk of general distress or specific disorders including depression, anxiety, somatisation, or suicidal behaviour; and
- Health behaviours – elevated risk of commencing tobacco smoking, increased use of health services .
The Canadian Medical Association’s Policy Statement from 1997 stated “prolonged absence from one’s normal roles, including absence from the workplace, is detrimental to a person’s mental, physical and social well-being. Physician should therefore encourage a patient’s return to function and work as soon as possible after an illness or injury, provided that return to work does not endanger the patient, his or her co-workers or society. A safe and timely return to work benefits the patient and his or her family by enhancing recovery and reducing disability.”  This was echoed in the Consensus opinion statement from the American College of Occupational and Environmental Medicine in 2002  and a recent ACOEM Position Statement .
The principles of best clinical practice should include:
- Avoiding the assumption that the workplace is a harmful environment when a person has an illness or injury
- An ill or injured person should not automatically be advised time off work (unless there is a significant safety factor or public health issue such as infection).
Clinicians should be encouraged to assume a safe and sustainable return to productive activity will result in the best health benefit to their patient, rather than assuming that absence from work will enhance outcomes .
Retention of existing employment is preferable to either unemployment or seeking work with a different employer. Using the existing workplace as an integral part of the rehabilitation process is more effective than viewing it as a place to return an injured or sick employee to following completion of (medical) rehabilitation [11, 16].
Rehabilitation for common health problems is about identifying and addressing obstacles to recovery. The best “window of opportunity” for effective rehabilitation is between 1 and 6+ months off work. Every health professional that treats patients with common health problems should be interested in and take responsibility for rehabilitation and occupational outcomes – the heart of what good clinical management is about .
A U.K. pamphlet for GPs on advising patients about work notes several topics that doctors may discuss with their patients: view full document or a one page leaflet. These include: the health benefits of work, the ill effects of prolonged periods out of work, work as therapy and rehabilitation, the risk of drifting into long-term sickness, what is preventing their returning to work, what could be done to overcome their obstacles to returning to work, modified duties and the workplace duty to accommodate, and discussion about what patients are able to do rather than what they cannot . Treatment that includes early emphasis on functional ability in rehabilitation of patients, be it from injury, illness or chronic pain, is recommended [18, 19].
- Cohen D, Marfell N, Webb K, Robling M, Aylward M. Managing long-term worklessness in primary care: a focus group study. Med. 2010;60:121-126. (Request with CPSBC or view UBC) DOI: 10.1093/occmed/kqp169
- Department for Work and Pension. Patients, their Employment and their Health – How to Help your Patients Stay in Work. London, UK: Department for Work and Pensions; 2003.
- Dupre ME, George LK, Liu G, Peterson ED. The cumulative effect of unemployment on risks for acute myocardial infarction. Intern. Med. 2012;172:1731-1737. (Request with CPSBC or view UBC) DOI: 10.1001/2013.jamainternmed.447
- McLean C, Carmona C, Francis S, Wohlgemuth C. and Mulcihill C. Worklessness and Health – What do we Know about the Causal Relationship? London, UK: Health Development Agency; 2005. (View)
- Lynge E. Unemployment and Cancer: A Literature Review. IARC Scientific Publications; 1997:343.
- Brenner MH. Employment and Public Health. Final Report to the European Commission Directorate General Employment, Industrial Relations and Social Affairs. Volume I-III. Brussels, Belgium. European Commission; 2002.
- Platt L. Ten year transitions in children’s experience of living in a workless household: variations by ethnic group. Population Trends. 2010;139:70-90. (View)
- Sparks K, Faragher B, Cooper C. Well-being and occupational health in the 21st century workplace. Occup. Organ. Psychol. 2001;74:489-509. (Request with CPSBC or view UBC) DOI: 10.1348/096317901167497
- Tsai SP, Wendt JK, Donnelly RP, Jong Gd, Ahmed FS. Age at retirement and long term survival of an industrial population: Prospective cohort study. BMJ. 2005;331:995-997. (View) DOI: 10.1136/bmj.38586.448704.E0
- Talmage JB, Melhorn JM. A Physician’s Guide to Return to Work. Chicago, Ill: AMA Press; 2005. (Request with UBC)
- Kendall N. Evidence Review: Raising the Awareness of Key Frontline Health Professionals about the Importance of Work, Job Retention, and Rehabilitation for their Patients (DWP internal document). London, UK: Department for Work and Pensions; 2003.
- Kazimirski J. Helping patients return to work. CMAJ. 1997;156:680-680. (View)
- ACOEM. ACOEM Consensus Opinion Statement. The Attending Physician’s Role in Helping Patient Return to Work after an Illness or Injury. USA: American College of Occupational and Environmental Medicine; 2002
- Jurisic M, Bean M, Harbaugh J, et al. The personal physicianʼs role in helping patients with medical conditions stay at work or return to work. J. Occup. Env. Med. 2017;59:e125-e131. (View with CPSBC or UBC) DOI: 10.1097/JOM.0000000000001055
- Waddell, G. and Burton, AK. Is Work Good For Your Health and Well-Being? London, UK: The Stationery Office; 2006. (View)
- Waddell G, Burton AK. Concepts of Rehabilitation for the Management of Common Health Problems. London, UK: The Stationery Office; 2004. (View)
- Waddell G et al. Advising Patients About Work: An Evidence-based Approach for General Practitioners and other Healthcare Professionals. London: The Stationery Office; 2007. Available at: https://www.tsoshop.co.uk/gempdf/Advising_Patients_About_Work.pdf. Accessed August 29, 2017. (View)
- Frank A, Chamberlain M. Rehabilitation: an integral part of clinical practice. Med. 2006;56:289-291. doi:10.1093/occmed/kq1027 (View)
- Schneiderhan J, Clauw D, Schwenk TL. Primary Care of Patients with Chronic Pain. JAMA. 2017;317:2367-2368. (View) doi:10.1001/jama.2017.5787
- Fit for work: Guidance for GPs. Gov.uk. Published January 2, 2015. Accessed August 29, 2017. (View)
- Work capability assessment handbook: For healthcare professionals. Gov.uk. Published March 19, 2013. Accessed August 29, 2017. (View)
- Health, work and wellbeing – evidence and research. Gov.uk. Published June 25, 2013. Accessed August 29, 2017. (View)
- Work and health: Changing how we think about health problems. Gov.uk. Published July 8, 2013. Accessed August 29, 2017. (View)
- Fit note: guidance for GPs. Gov.uk Published March 1, 2013. Accessed August 29, 2017. (View)