CASE STUDIES
Case 1 - Physician based problem solving
AJ a 47 year old 26 year employee of a large corporation presented to Ultima, referred by the return to work coordinator following 3 months of absence. He was working in middle management and his work included occasional safety sensitive duties. AJ had presented a note to his return to work co-coordinator from his Family Doc saying that he had been unable to work because of stress for the past 3 months and that he would likely be off for another 4 to 6 months. The co-coordinator had attempted to talk to AJ s physician and had been unable to get hold of him after repeated attempts.
AJ was interviewed and examined by an Ultima Physician who noted that he was a well-motivated employee who had not previously had any significant work loss in 26 years. It became apparent that he was involved in a workplace conflict with a supervisor who had recently moved his desk so that he was now directly facing and overseeing AJ In addition to this situation, there were also some family issues that AJ was encountering, involving his teenage son. He was suffering anxiety attacks and having problems with his sleep. He had seen his Family Doc 5 weeks previously, been told that he likely had depression and his Physician had started him on zoloft (an anti –depressant). AJ informed the Ultima Physician that he felt that he did not need the medication as his family conflicts had now resolved, but he was uncomfortable telling his Family Doc that he had not taken any of the medication. He had apparently phoned his Doc and asked that he be allowed back to work. The Doc believing that this was an employee with safety sensitive responsibilities, now on significant medication, wanting to return to work and not wishing to attend for review, was of course uncomfortable signing him back to work. He refused to recommend that the employee return to work.
Intervention by the Ultima Physician included a telephone call to the Family Physician (with AJs consent) and a telephone call to the return to work co- coordinator. After hearing that the employee had never actually taken the medication, the Family Physician was comfortable allowing a return to work. The return to work co coordinator was able to arrange for the Supervisor to have his desk moved down the corridor and the employee returned to regular duties two days later.
Discussion:
This case illustrates how relatively simple problem solving, involving physician to physician communication and physician to workplace communication facilitated a rapid return to work with significant cost savings to the employer. The employee appreciated that his concerns had been addressed and was motivated in his return to the work place
Case 2 – Physician Health Surveillance
Ultima physicians provide occupational expertise to a Canadian national organization with a large number of safety critical employees. On a routine basis reports are reviewed from physicians around the Province, who have examined these employees as part of a mandated bi-yearly occupational health/physical examination screening process.
In this case the Ultima physician reviewing the file of LT, noted that one of his blood tests – the PSA was slightly higher than normal.
He noted that LT was only 42 years old, his digital prostate exam was normal, but he had a positive family history for prostate cancer. The Ultima physician contacted LT and recommended that he check to make sure that his family doctor was aware of the result and discuss the importance of it with him, particularly as he had a strong, positive family history. In short order the Ultima physician was contacted once again and was informed that the family doctor had not been aware of the result but felt it was "nothing to worry about.”
The Ultima physician suggested to the individual at that point however that at the very least it would be prudent to repeat the test in a few months to ensure that it was not getting higher. The repeat test was arranged by the Ultima physician about three months after the first and in fact was found to be slightly higher (a copy was sent to the family doctor with a recommendation for a urological consultation).
The family doctor arranged for the consultation because of the insistence of his patient but the urologist at the end of his examination felt further investigations were unnecessary. LT at this point was quite frustrated and asked for the Ultima physician’s opinion. The Ultima physician, being fully aware of current best practice recommendations surrounding this scenario, advised the individual to speak to the urologist once again and insist (if necessary) that an ultrasound-guided prostate biopsy be performed as per current recommendations in the world's medical literature (references were provided). The urologist fortunately, grudgingly agreed and performed a four-quadrant biopsy a few weeks later. This was positive in all four quadrants for highly aggressive malignant cells.
This fortunate young man in a very short period of time had a successful, radical prostatectomy performed. The surgical specimen examined by the pathologist showed that his highly aggressive tumor was contained within the capsule of his prostate gland and prognostically he has been told that he has a high likelihood of being completely cured. He has been back to work at his regular position for about one year, feeling well and extremely lucky. LT was kind enough to send the Ultima physician a long, glowing testimonial asserting that without the doctor's persistence, knowledge and professionalism he would now be facing a horrible prognosis.
Discussion:
It is important to note here that besides the employee being the obvious big winner, this story has been spread far and wide in the workplace and employee satisfaction and confidence in their employer's assertion "that their employee’s welfare is of prime importance to them", has become amazingly high. This is an item that is impossible to quantify economically but most human resources specialists would agree that the positive economic impact on worker morale from just one case like this can be extraordinary.
Case 3 – Expedited Investigation and treatment
Ultima physicians deal with workers who are living and working in small urban and in some cases quite isolated communities in BC and the Yukon. There are many instances where individual employees are either injured or unwell and in the opinion of their local family doctor require specialized investigations and/or treatment interventions. These individuals may end up waiting for many months for access to a specialist assessment, followed by a wait of several more months before they are able to get required high tech. imaging studies. There may then be a wait of many, many months (often several years) before they can receive the necessary surgical procedure(s) that will allow them to return to work.
BM a 44 year old safety sensitive employee working in Prince George was referred by his Family physician to an Ultima physician. The Family Doc was very frustrated, as his patient had injured his knee 6 weeks earlier. He felt that the patient had likely torn the ACL (anterior cruciate ligament) in his knee, believed that he should have an MRI investigation and see a knee specialist for surgical repair (assuming a positive diagnosis on the MRI)
The problem was that BM would likely have to wait many months for an MRI, several more months to see an Orthopedic surgeon and then a number of months more to have the appropriate surgery. It was likely that the employee would be off work for a minimum of 1year
The Ultima physician was happy to assist the Family physician and the employee by arranging for BM to travel to Vancouver the following week, where he would have an MRI followed by a Specialist appointment the next day. MRI confirmed a torn ACL; the patient underwent primary reconstruction of his ACL three days later and returned home for rehab. With guidance from the Family Physician in liaison with the Ultima physician, BM started back to work on modified duties eight weeks later and was fully fit for his regular occupation approximately three months following surgery.
Discussion:
Ultima physicians have extremely quick access to the best specialists and sub-specialist physicians in BC. For virtually all of the cases noted above, an appointment that normally takes up to a year to obtain can be facilitated within one to two weeks. Routinely, Ultima physicians will request the company fly an injured/unwell employee to Vancouver for a specialist appointment and an MRI and/or a helical CT scan, (if necessary on the same day). If surgery is required it often can be facilitated within 48 hours - occasionally it is done the same day as the specialist appointment if the diagnosis is already confirmed. In addition, if further non-surgical interventions are required, an appointment with another non-cutting specialist can be facilitated within a day or so.
Despite the financial premium for this kind of service, most companies/organizations now realize the benefits (both financial and to the individual), of expediting treatment on a private/third party payment basis, rather than waiting for two or more years before the necessary interventions can be provided in the publicly funded medical system. Philosophically, it has become a not-so-difficult choice for Canadian companies - quickly recovering a properly treated, valued, productive, happy employee - or the alternative, usually resulting in significantly higher costs to the employer in terms of lost wages and ever increasing insurance/WCB premiums. A company that does not deal with this reality does so at it’s peril and will inevitably suffer the negative impact on its bottom line success.
Ultima believes that the role of the Physician Team is to ensure that the important, employee health component of any company's long range strategic economic plan delivers what it has promised to the bottom line.
Case 4 – Physician Periodic Medical exam
JB a 59-year-old Pilot saw an Ultima physician for his regular Pilot (MOT) medical examination. JB said he was feeling fine and had no complaints apart from some symptoms of indigestion, which were related to reflux oesophagitis. He had discussed this with his Personal physician and was taking antacids. He had undergone a treadmill cardiac stress test a few years previously and been given a clean bill of health. JB was looking forward to his retirement three months later at the age of 60 and also to the final three months of flying, during which time he planned a number of different routes and trips.
The physical examination, and other tests, including ECG were normal and the Ultima physician prepared to complete the pilot’s certification certificate. As he was dressing, JB mentioned in passing that he had also been suffering some tightness in the chest for the last few weeks, every time he carried a bag of potatoes from his garden shed to his house. He was planning to be more careful about the foods he would eat, as obviously his stomach was acting up.
Presented with this new clue the Ultima Physician was now quite concerned as to the possibility of cardiovascular disease and mentioned to the pilot that repeat treadmill cardiac stress test was indicated prior to him returning to the air as a pilot. The pilot was adamant that this was in reality a stomach problem; he had previously been through a cardiac stress test anyway and became upset with the physician.
A second Ultima Physician was consulted at this point and after some discussion with the pilot it was agreed that he would not fly until he had completed a stress test. Cardiology review occurred the following week, stress test was positive and coronary angiograms performed two days later revealed multi vessel disease. The pilot subsequently underwent (five vessel) coronary artery bypass surgery with an uneventful postoperative recovery period.
Discussion:
Notwithstanding the pilot’s denial of his symptoms and his reluctance to forgo his final trips, the Ultima docs were required to intervene in this situation, fortunately both for the pilot and also potentially for his employer.
The pilot is now enjoying his retirement and the benefits of his many years of service to the company.
Case 5 –Short term disability management,
Ultima physicians deal with workers on behalf of a number of retail organizations. In these situations concerns may be directed more at short-term disability case management (STD) than long term.
Ultima will provide a “Company Physician” who will dedicate time to that company – whether it be ½ day per week or three to four days per week, depending on need.
An employee may visit a walk-in-clinic or see a number of different physicians following an injury at work. In these situations the Ultima Company Physician may act as a co-coordinator, working with the corporate return to work co-coordinator in developing a safe and expedited return of the employee to the workplace. Frequently direct physician-to-physician(s) communication is required and in this way workplace short or long-term restrictions can be developed by the Ultima physician as needed.
Interestingly, on a small number of occasions, an employee who may not have a physician is booked to see the (Ultima Company Physician) in order to assist with his/her return to work, only to have that appointment canceled by the employee who has decided that he/she is now fit to work. Alternatively many employees are now actively seeking a consultation with an Ultima physician, with the knowledge that the physician can assist with “return to work modifications”.
Happily this role of Corporate Physician is proving cost effective and helpful to the employee who decreasingly sees this input as a “policing” function.