Physicians are often the first, and sometimes the only, stop for patients who raise concerns about how their work may be affecting their health, or how their health may be affecting their ability to work. However, many clinicians have not received formal training in occupational medicine. Occupational medicine deals with the clinical, ethical, and legal considerations that often arise when dealing with work-related issues. These include physicians’ reporting obligations, information sharing with employers and third parties, and workplace factors and systemic supports that influence a worker’s ability to work safely. Four general questions are presented as a framework to use when managing a work-related issue for a patient.

Example scenario

A 25-year-old male with a 10-year history of type 1 diabetes presents with concerns that over the past few months he has had three episodes of feeling lightheaded and confused due to hypoglycemia at work. While the focus of the visit is on reviewing the patient’s self-management and medications, he is asked what he does for work. (He operates a forklift at a furniture warehouse.)

Question #1: Beyond duties to the patient as part of the doctor–patient relationship, what other professional obligations exist? 

It is generally expected that physicians put patients’ needs first when addressing their health-related requests. However, in some situations, the distinction between patients’ wants, patients’ needs, and societal needs becomes important. When patients request clinically inappropriate tests or medications, such as an MRI of the spine for acute mechanical back pain without any red flags or antibiotics for an uncomplicated viral upper respiratory tract infection, it is a physician’s duty to be guided by evidence and avoid ordering unnecessary tests and treatments. This is done to prevent harm to a patient (e.g., misleading incidental MRI findings or side effects of antibiotics) and to society (e.g., unjustified strain on health care resources or risk of antimicrobial resistance). Similar considerations matter when dealing with requests related to return to work.

Consider that the patient in the example scenario was temporarily taken off forklift duty following an incident where he lost consciousness at work. He now wants to be cleared to return to work as an operator of heavy equipment, yet it is determined that he remains at risk of future hypoglycemic episodes, which could lead to sudden loss of consciousness on the job. He takes pride in his work and may risk a partial or total loss of income depending on his contract. His physician wants to support him in being able to return to full duties as a forklift operator (patient’s want) but should also consider the risk of the patient endangering himself (patient’s need) and others (societal need) as a result of sudden incapacitation. Operating a forklift is a safety-sensitive job, which is a position that “if not performed in a safe manner, can cause direct and significant damage to property, and/or injury to the employees, others around them, the public and/or the immediate environment.”[1] Careful consideration of an appropriate interval of time is required before clearing the patient to perform safety-sensitive tasks as a forklift operator, including his adherence to his treatment plan and when the last episode of hypoglycemia occurred. For some tasks, there may be prescriptive requirements for return to work set by the employer or related professional bodies. When there is no specific medical guidance for a safety-sensitive job, it is reasonable to consider the Canadian Medical Association’s Driver’s Guide[2] when assessing patients’ fitness to perform safety-sensitive tasks and fulfilling professional College of Physicians and Surgeons of BC reporting obligations. 

If this patient worked in a specialized environment, this might require additional expertise. For example, the Aeronautics Act[3] requires physicians and optometrists to inform aviation medical advisors of conditions likely to constitute a hazard to aviation safety. Another example would be a patient who requests a certificate clearing them to work as a commercial diver—physicians conducting such examinations require advanced training to meet standards for safety (such as CSA Z275.2 for occupational diving operations,[4] written by CSA Group). In British Columbia, the requirement for knowledge and competence in diving medicine is outlined in Section 24.10 of the Occupational Health and Safety Regulation, and WorkSafeBC keeps a list of physicians that are recognized as possessing such knowledge and competence.[5] 

The purpose of asking this question is to consider all professional obligations and determine if one is capable of fulfilling the patient’s request or if another health care provider with the required expertise should be making these determinations instead.

Question #2: What should and shouldn’t be communicated to employers and other third parties?

All physicians are well trained in the importance of safeguarding personal health information. In BC, physicians must adhere to the Freedom of Information and Protection of Privacy Act when communicating with employers. Although it is reasonable to question any unauthorized attempts from a third party to access a patient’s chart, it is important to consider the following. First, workplaces need enough information to know how to accommodate and/or safely return a patient to work by modifying any combination of that patient’s work duties, work environment, and work schedule. This does not require providing diagnostic or therapeutic information, but rather a description of the patient’s level of functioning. In the example scenario, an employer does not need to know about a worker’s diagnosis of diabetes but does need to know about the functional impacts associated with the condition (e.g., risk of loss of consciousness if glucose control is not optimal, requirements for additional breaks).  

The Canadian Human Rights Commission’s Guide for Managing the Return to Work[6] states that, in general, work supervisors are entitled to know how an employee’s health could affect their ability to complete job duties, whether it is temporary or permanent, and whether the employee has the ability to perform alternate work. The Canadian Medical Association has guidance on third-party forms that describes in greater detail physicians’ roles and responsibilities related to this.[7]

Some workplaces have occupational health professionals (including occupational physicians) who are bound to keep confidential all health information and records they receive from external health care providers that are not shared with management. These health professionals are not typically considered part of the circle of care, but they play an important role in workplace accommodation if they are able to review pertinent health details the employer must not access. If workplaces have safety-sensitive jobs, their occupational physicians may be responsible for clearing workers for duty, requiring detailed medical information to make this determination. When drafting a report for a workplace, it is important to understand who the reader will be. If the report is for the worker’s supervisor, manager, or employer, the report should be limited to information regarding the worker’s functional abilities and any medical limitations or restrictions. If the report is intended for an occupational physician, it may be helpful to provide medical information, with the patient’s consent. CSA Z1011:20: Work Disability Management System recommends that any such information be shared only with staff who are subject to a recognized professional health care code of ethics.[8]

Question #3: Are there clear clinical justifications for all recommendations and notes provided?

When a patient has concerns about an exposure or circumstance at work affecting their health and wants a remedy for this, it is important to first confirm a diagnosis that explains their symptom presentation (if any); understand what their illness experience has been and why they think it is related to work; and then consider the extent to which this could be caused by, be exacerbated by, or interfere with work. To make these determinations, it is important to identify hazardous exposure(s) in the workplace. 

If patients expect a certain remedy (e.g., a note for the workplace requesting a specific accommodation), it helps to understand what they expect as they recover from their illness or injury and the implications of granting their request. One of Choosing Wisely Canada’s recommendations for occupational medicine is “Don’t endorse clinically unnecessary absence from work,” citing both the positive link between work and health as well as the potential risk of creating further disability where such an endorsement lacks detail about a patient’s abilities and medical limitations or restrictions.[9] Employers may also have concerns with the costs associated with absenteeism. Notes stating that a patient requires absence from work should be for the minimum necessary duration, and a clear rationale should be documented in medical records. In many cases, a complete absence from work is not needed where medical limitations or restrictions can be accommodated. For the example patient who is a forklift operator, a note to the employer could say “Unable to operate heavy machinery” instead of “Unable to work.” In many situations, it would be helpful to state what the patient can do—for example, “Able to do sedentary work or physical work not involving operation of heavy machinery.” The note should clearly state the duration of the restriction and when the patient is expected to be reassessed. To reduce the risk of prolonged worklessness, the BC Workers Compensation Act was amended as of 1 January 2024 to introduce new duties for employers and workers to ensure their cooperation during the return-to-work process after a work-related injury or illness. 

When communicating with an employer about a patient’s ability to work, it is important to describe medical limitations (i.e., what a patient is unable to do because of a medical condition—the opposite of the patient’s abilities) and restrictions (i.e., what a patient should not do due to risk to their health or, if a safety-sensitive position, risk to others) that the employer can use to determine an appropriate accommodation in the workplace. Physicians and patients generally do not know what accommodations an employer can provide to workers. Given this, a physician’s note to an employer about medical limitations or restrictions should focus on what a worker can and cannot do, while avoiding specific statements about how exactly the worker should be accommodated. Some larger employers have designated staff trained to create fair and supportive accommodation plans for recovering employees. A clear outline of a patient’s abilities and medical limitations or restrictions is helpful in creating these plans. In some situations, physicians may be asked by an employer to provide details about medical limitations or restrictions that physicians are unable to answer. In these cases, a note should state what can and cannot be assessed and suggest a referral to a specialist or clinic that performs functional capacity assessments, neuropsychological testing, or an independent medical evaluation.

Question #4: Outside of clinical management, where can patients be directed for more help?

Occasionally, patients consult physicians about situations that require individuals from outside the health care sector to be involved. For example, harassment and bullying or interpersonal conflicts in the workplace may be better addressed by the employer using an administrative venue, while physicians focus on the impact of the situation on the patient’s health. 

Physicians may understand the health care system but know little about the occupational health and safety system in their jurisdiction, and they may not be aware of applicable resources. Most jurisdictions have health and safety regulators (who enforce laws to protect workers), workers’ compensation boards (that adjudicate claims for occupational illnesses and injuries and provide educational resources and information), and associations that provide assistance to workers (e.g., unions, legal clinics, occupational health clinics). In BC, WorkSafeBC functions as both health and safety regulator and workers’ compensation board.  

There are also other public agencies that provide a wealth of information on occupational health concerns. For example, the Canadian Centre for Occupational Health and Safety (www.ccohs.ca) produces resources on workplace health and safety and prevention of work-related injuries, illnesses, and deaths. It may be beneficial to learn about the organizations that exist in your jurisdiction to help support patients on issues outside a physician’s scope of practice. WorkSafeBC provides resources for health care providers on its website: www.worksafebc.com/en/health-care-providers.

Conclusions

Answers to the four questions presented here are not always straightforward, but they warrant careful, considered thought when they arise during clinical encounters in primary care. By thinking through these questions in cases that may be work-related, physicians can give themselves some peace of mind knowing they’ve done as much as they can to support their patients while also meeting their professional obligations.  

Competing interests

None declared.

This article has been peer reviewed.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Dr Rajaram is the provincial physician in the Ontario Ministry of Labour, Immigration, Training and Skills Development; is an adjunct clinical assistant professor in the Division of Occupational Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto; and has a cross-appointment with the Dalla Lana School of Public Health, University of Toronto. Dr Hudon is the senior medical consultant in the Ontario Ministry of Labour, Immigration, Training and Skills Development. Dr Afanasyeva is a medical consultant in the Ontario Ministry of Labour, Immigration, Training and Skills Development; an adjunct lecturer in the Dalla Lana School of Public Health, University of Toronto; and an adjunct professor in the School of Epidemiology and Public Health, University of Ottawa.