Hands-on approach to clinical assessment

How often should OH practitioners lay hands on our patients? This question has been much in my mind in the past few weeks. Here are some of the things that have led me to reflect.

n A manager asks two practitioners why a worker with back pain wasn’t examined. The first argues that all patients should be examined. The second argues that straight leg raising and toe touching have nothing to do with work and add little.

n A tribunal chair asks why a patient’s mental state wasn’t thoroughly assessed even though the practitioner has clearly recorded that the patient thought she was fully able to do her job (and still does). While a report on English and Welsh Disability Tribunals showed that it was extremely uncommon for evidence from OH practitioners to be heard.

n A patient resumes work after two years ‘medical suspension’ waiting for an assessment that’s never happened because the focus switched to a work assessment rather than a specialist clinical assessment.

n A specialist examination candidate begins an answer with “Of course, I’d start with a thorough history and examination”

There appear to be persuasive arguments that would lead me to examine more and equally good ones that lead me to examine less.

If the proponents of examine everyone are right then telephone assessment must be fundamentally flawed. However, while compelling “medical evidence” of the merits of telephone assessment may not be available, plenty of data is available that suggests this is successful (at least as part of a comprehensive OH service).

In addition it would be extremely hard to justify telephone services for those with acute needs, such as NHS Direct, NHS 24 and employee assistance programmes. Intuitively we accept these are valuable.

I have always found the supermarket question more valuable than clinical examination. Can the patient drive the car, push a trolley, walk 600 metres, reach the top and bottom shelves, queue, load and unload the car, and risk socialising? Even now I haven’t been able to think of a job that involves bending to touch toes.

On the contrary, my colleagues in moving and handling spend all their time advising against exactly this. In my experience the capacity to bend over at work is linked more to metaphorical and unsavoury interactions with the boss than it is to job performance.

I can’t think of any ‘medical evidence’ that robustly shows that clinical examination is linked to job performance while there is plenty of evidence that shows that a lot of sickness absence is not the result of sickness. On that basis, why bother with clinical examination at all? Then again I haven’t seen any that shows that talking to patients is linked to outcome either. (And I have seen evidence of benefit for cognitive behaviour therapy done by a computer and evidence that the health of the population has been transformed by public health practitioners without clinical examinations.)

I’ve heard one eminent practitioner argue that occupational health is public health for the workforce. I’ve heard another argue that it is primarily a clinical specialty.

So here’s the answer. This week I should definitely examine patients less, more or the same. If you can help narrow down the options then let our editor know.

Dr Richard Preece is a consultant occupational physician

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