About one in three injured workers, when brought to medical attention after an accident, find that it is the boss or company representative who tells the doctor what caused the injury. The worker doesn’t get a chance to speak. Yet, it is rare that the boss or company representative witnessed the accident.
Another one-third of injured workers tell us that both they and the boss or company representative speak with the doctor, with varying degrees of input.
Only the last third of workers are confident that the background to the injury recorded in their doctors’ notes came exclusively from them.
These are the topline findings from a recently completed survey of injured workers, jointly conducted by Healthserve and Transient Workers Count Too.
Bad habits in hospitals and clinics
In August 2013, TWC2 executive committee member Debbie Fordyce mentioned a new frustration to the committee. She had seen several cases recently when the employer argued that his worker’s injury was not work-related. The boss would tell the Ministry of Manpower (MOM) something like “he slipped while showering in the dorm,” or “he fell into a roadside drain while out at lunch”, or “he was fighting with another worker”.
Unable to decide whether to believe the worker’s assertion that the accident occurred while at work or the employer’s denial, MOM had begun to ask the first doctor seen by the worker for his records. “MOM is more often giving men a form for the doctor to complete about how the injury occurred based on the case notes,” Debbie said. But how reliable are those case notes? Whose words go into them?
This is of crucial importance. If it is a work-related injury, the worker gets to claim compensation for any resulting permanent incapacity under the Work Injury Compensation Act. If MOM accepts the employer’s denial partly based on the doctors having notated that the injury resulted from (as an example) “a fight in a coffeeshop last night” instead of a more accurate “metal formwork for pouring concrete fell on him as he reached under it to retrieve tools”, the worker may lose out by a lot.
The committee decided we needed a survey to assess the scale of the problem. Healthserve agreed to participate, and joined in to help design the questionnaire. It didn’t need to be a large or precise study. We just needed a reasonable-sized one to show how reliable or unreliable doctors’ records are. So long as we can demonstrate the fallibility of those records, MOM should not be using doctors’ notes to determine if an injury was work-related.
The results have come in, confirming our previous anecdotal observations: The sources of the information recorded in doctors’ notes are highly variable. Too often, the doctor hardly asks the worker for his story. Very often too, when the employer speaks with the doctor, it is either in a language the worker does not understand or without the worker present. It is not uncommon for a worker to tell us that at the clinic or hospital, the boss explicitly asked him to wait outside while he (the boss) spoke with the doctor. Such a request alone should be considered suspicious behaviour.
Doctors used to seeing patients with family members in tow acquire the habit of speaking with family members to obtain the patient’s history if communication with the patient himself presents difficulty. Normally, speaking with family members presents no problem, because they would likely have been the caregivers prior to admission and would be familiar with the symptoms. Family members also have the patient’s best interest at heart.
The same cannot be said of employers (or company managers and supervisors acting in their official capacity) attempting to speak for workers. They are unlikely to have witnessed the accident, and inherently, there is a conflict of interest. Most employers would be keen to save money and deny responsibility for any lapse in workplace safety. Doctors don’t realise that under these conditions, they must suppress the habit of speaking with company officials, and try their best to get the history directly from the patient — who should anyway be at the centre of their ethical responsibility.
We interviewed 254 injured workers for this survey. Healthserve reached 60 Chinese workers while TWC2 interviewed 194 Indian and Bangla workers. Interviews were conducted in September and October 2013.
About 77 percent of workers were accompanied in their first visit to a doctor. More than half (55 percent) were accompanied by the boss or a superior from the company. The remainder were accompanied by a friend or “other” — a term which includes company driver, cousin or the boss’ relative.
There is a some variation among the nationality groups, but not a lot, and until we are sure there is significance in that variation, we’ll ignore it for now. Crunching the data is still continuing.
When it came to asking workers about who was doing the talking at the first visit to a hospital or clinic, the answers were quite mixed. What was striking was that 34% of workers said that it was the boss or company representative who did all the talking.
Only 37% said it was himself, the patient, who “explained everything” to the doctor. However, 7% also said (in answer to another question) that their boss or company representative spoke privately with the doctor. We segregate out this sub-group in the analysis. Thus, you will in the table above, at the rightmost column, that 30.0 percent are classified as “I explained everything*” while 6.9 percent are placed above the ‘Subtotal’ line, joining the other categories where the boss or company person could have contaminated the case notes through intervention.
Overall, 66% of doctors notes would likely contain information not supplied by the patient, and potentially prejudicial to him — you can see the figure from the ‘Subtotal’ line in the right-most column.
The Chinese seem to be better off in this regard than the Bangladeshis or Indians. About 64% of them say “I explained everything” or “I gave most info” to the doctor. The equivalent figure for Bangladeshis is only 38%, for Indians a shade higher at 47%. This suggests that language may be a determinant. Medical practitioners may find it easier to speak with Chinese patients.
It is important for doctors to be conscious of the language barrier and try harder to overcome it, rather than take the easy way out and speak with employers and company representatives, who may have conflicting interests.
At left, the numbers from the above table are presented as a pie-chart.
Our point is a simple one: There is so much variability in the input of information into doctors’ records, the Manpower ministry should not rely on them to determine the truth as to the cause, time or place of injuries.
The survey also asked workers a more direct question: Are you worried about what the boss or company person told the doctor? Of 193 valid responses, 43% said Yes.
The Chinese seem to be more worried than the others, even though they had greater communication with their doctors. Why, is not known.
One possibility is that of the three nationality groups, the Bangladeshis speak and understand more English than the Indians and the Chinese least of all. It may be that even if the boss or the company person did part or all the explaining to the doctor (provided they weren’t speaking privately with the worker out of earshot, discussed in the section below), the Bangladeshi worker would have understood what he was overhearing. He would therefore have a better idea whether the story provided by the boss or company person was consistent with what really happened.
Employers speaking privately with doctors
The survey explored several related issues. One was whether the boss or company representative spoke privately with the doctor. Frankly, there is very little justification for doing so. Yet, a disturbing 46 percent of workers giving valid answers to this question said: Yes, they spoke privately.
Whilst 40 percent said No, it should be borne in mind that it is only a ‘No’ as far as they knew. Telephone calls may have been placed by the company office to the doctor.
That said, it should not be assumed that the sole reason why employers would want to speak to the doctor privately is to alter the medical history in the hope of covering up an industrial accident.
From TWC2’s experience assisting workers, this is less common than wanting to speak to the doctor to reduce the number of days of medical leave given to the worker.
The law says that if a worker suffers an injury requiring more than three days of medical leave, the accident has to be reported to the Work Safety Department of MOM. Many employers are keen to ensure that doctors issue fewer than three days of MC. Of course it may be argued that persuading the doctor to reduce the number of MC days to below three, thereby avoiding a mandatory report, is also an attempt to cover up an accident.
How many clinics or hospitals did you visit?
The survey explored a few related issues. One was how many clinics or hospitals the worker visited for the injury. The differences between nationality groups were striking.
The above table is presented graphically at left.
The Chinese generally stayed with one clinic or hospital through their treatment. 88 percent of them did. By contrast, 62 percent of Indians went to two clinics or hospitals, a further 16 percent went to three. The Bangladeshis were somewhere in between.
It is not possible to explain this difference from the survey results alone, but one clue lies in answers to the question as to which hospitals they were sent to.
Chinese workers were most commonly sent to Tan Tock Seng Hospital (22% of them) and National University Hospital (16% of them). Being large public hospitals, the workers sent there probably received a standard of care they were satisfied with, and had no reason to change. Moreover, doctors there are less likely to be persuaded by employers to alter records or under-prescribe medical leave.
A whopping 43 percent of Indian workers however were sent first to “other clinics/hospitals” — a term which suggests small private clinics since the major hospitals are individually listed as answer options in the survey. These places would not be able to handle serious injuries adequately. They would also be more sensitive to the wishes of employers, for billing reasons. This may be a reason why the majority of Indians choose to visit another clinic/hospital for subsequent treatment.
See also two articles by Benjamin Wong, in which he tells the stories of three workers who tell him they worry about what’s been said to doctors behind their backs: Doctors need to talk to their patients Part 1, and Part 2.