Physical therapists who claimed workers' compensation: a qualitative study.

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Several researchers (1-6) have documented the work-related musculoskeletal disorders (WMSDs) experienced by physical therapists. These studies have focused on the prevalence rather than the experiences of people with WMSDs. The data for this article came from interviews conducted to investigate the experiences of 18 physical therapists who reported making career changes because of WMSDs. (7) The purpose of this article is to describe the experiences of the 6 participants in that study who lodged a workers' compensation claim as a consequence of the WMSD.

Background

Prevalence of Work-Related Musculoskeletal Disorders in Physical Therapists

The low back and other areas of the spine are most frequently reported as the sites of WMSDs in physical therapists, followed by upper-limb disorders. (1-6) In 3 studies, (2,4,5) it was shown that a small minority of those who experienced WMSDs claimed workers' compensation as a consequence. The most recent study (2) indicated that although 91% of therapists experienced a WMSD at some time, only 7.4% ever claimed workers' compensation. This finding could be construed as meaning that those who claimed compensation had more severe WMSDs than those who did not claim compensation.

The same study, however, showed that 42% of all physical therapists surveyed compromised their activities of daily living and leisure, and 14% of them were unable to work at some stage(s) during a 12-month period. These findings suggest that a larger proportion of therapists experienced some degree of disability due to WMSDs than is indicated by compensation claims. Physical therapists apparently do not lodge worker's compensation claims in proportion to their work-related injuries. We believe there is a need to document the ways in which they respond to their work-related musculoskeletal symptoms.

The Context

This study was carried out in Victoria, Australia. In this jurisdiction, the workers' compensation system requires claimants to obtain certification from their treating health care professional to verify that they are unable to work or to document the degree to which they are able to participate in the workforce. While in most instances the certificate will be provided by the clients' own treating practitioner (medical or other), their status is verified from time to time by a review from an independent medical examiner. This medical examiner is hired by the insurer to provide an opinion of the workers' ability to work and to identify possible hindrances to a return to work. The Accident Compensation Act 1985 (Victoria) (8) requires employers to offer suitable employment to workers who experience work-related injury, and it requires workers to return to work as soon as possible after injury.

Legitimacy

Injured workers may encounter attitudes questioning the legitimacy of the injury and the need for them to modify their work. (9) Workers' compensation benefits are intended to provide financial support for injured workers. Claimants, however, have sometimes been labeled "malingerers." (10-14) in addition, medical diagnoses can reflect cultural biases against women, Jews, immigrants, and other minority groups. (11) This is a long-standing issue. For example, a social analysis demonstrated the moralistic nature of the early 20th century medical literature, which labeled compensation claimants as "drones," "pests," "prostitutes," and "sinister imposters." (11(p231)) The physician, on the other hand, was seen as the protector of society's interests. Stereotyping of patients, particularly workers' compensation clients, still occurs despite explicit warnings against the practice) (15) Women (the majority' of physical therapists are female (16)) appear particularly vulnerable to pejorative labels. In a study of semiskilled female workers with WMSDs, who also were compensation claimants, it was shown that health care professionals hired by employers and insurers commented in their reports on the workers' maternal obligations, body shapes, and the supposed therapeutic value of pregnancy. (17) How these comments related to the musculoskeletal disorders is unclear, and Reid et al (17) suggested that these comments indicated their symptoms were not considered to be as serious as if they had been male. If women's symptoms did not conform to the expectation of medical knowledge of the time, they could be judged as "guilty" (17) of fabricating their symptoms.

The assumption that a physician can judge whether symptoms are "real" and whether they are work-related underpins the workers' compensation system today. Medical practitioners, and particularly specialists, have the power to legitimize or discredit claims of work-related injuries. Despite this, physicians do not necessarily have special skill at detecting fraud). (18)

Questions about the legitimacy of WMSDs can lead those with a musculoskeletal condition (particularly a chronic condition) to seek to legitimize their experience and have their condition recognized by others as being "real." Where the condition has an unknown etiology, patients may encounter disbelief and be shunned by their co-workers. (17) Tarasuk and Eakin (9) investigated this phenomenon, specifically in relation to work-related back injuries, and found that workers felt obliged to legitimize their injury to insurance companies, employers, and co-workers. For example, an imaging report confirming structural damage to the spine could be seen as legitimizing a condition that had previously been described as "nonspecific low back pain." The disbelief of others and the subsequent need to legitimize their condition damaged relationships at work and left workers feeling vulnerable about their job security and future job prospects. (17) This pressure was increased by the lack of visible evidence of injury, which the claimants felt contributed to people not believing their injury was real, with some colleagues assuming that the claimants were fraudulently raking time off work.

The need for workers to legitimize their back injuries could be related to the inability, of medical practitioners to explain and treat their back pain and to the structure of a workers' compensation system that financially rewards employers, who have not made any claims, with lower insurance premiums. Tarasuk and Eakin (9) reported that although the majority of workers in their study felt a need to legitimize their injury to ensure job security, a more senior (and financially secure) participant in their study expressed no such concerns. They suggested that this participant's social status and seniority may have diminished his need to legitimize his injury, and they speculated that his position in the workplace may have removed him from potential criticism.

Another reason that workers may seek to legitimize their WMSDs is that they perceive that they are being morally judged by co-workers. (19) In a study of white-collar workers, Dodier (19) found that their co-workers judged workers who took sick leave, deciding whether or not the illness was a satisfactory reason for sick leave. This assessment was not necessarily related to the physician's evaluation of the illness. He related this to a "micro culture" at the workplace, (19(p125)) with workers setting expectations of normality about what does and does not constitute a valid reason for taking time off work.

Physical therapists manage patients with WMSDs. However, within the physical therapy community, questions are raised about the legitimacy of WMSDs. Use of pejorative terms such as "myth" and "false credibility" when discussing the issue of occupational injury (20) throws doubt on the legitimacy of such injuries. Hart (20) suggested that those who sought medical treatment other than first aid frequently did so for financial gain, thereby questioning their motivation for doing so, and by implication questioning the veracity of claims of occupational injuries.

The perception that workers who are compensation claimants are undesirable employees was evident in an article discussing repetitive strain injuries. (21) In this article, Cleland stated that, to an employer, a worker who was labeled as a "compensation case" (21(p238)) was identified as an unacceptable risk. Workers themselves expressed an awareness of this belief, (9) stating they felt their jobs were placed at risk because of the limitations imposed by their work-related injuries and their compensation status. This perception is consistent with French's (22) finding that physical therapists with a disability were deemed by some colleagues and employers as less competent than employees without disabilities. Although the view may be prevalent that workers with disabilities, and in particular compensation claimants, are undesirable as employees, no studies were found where employers made such all admission.

Method

The information from which this report is derived was obtained in a qualitative study in which we investigated the experience of WMSDs in 18 physical therapists who had reported changing careers because of a WMSD. (7) In the analysis of their experiences of their WMSD and its relationship to work, a theme of "workers' compensation" emerged. This theme is the subject of this article.

Unlike quantitative methods, which assume that there is an objective reality that can be measured and reported as fact, qualitative methods are "directed toward describing, explaining, or interpreting human behavior from the perspective of the persons being studied. As each person, including the researcher, perceives and interprets reality somewhat differently based on the context of his or her past experiences and present situation, the phenomenological approach focuses on multiple realities, looking for common themes or denominators that will help explain the human phenomenon under study." (23(p91))

Purposive Sampling

Participants were chosen for the original study by seeking participants who were physical therapists and who reported that they had made (or were in the process of making) a career change because of a WMSD. Physical therapists were initially contacted through therapists known to the researchers. This is described as criterion sampling. (24) The second type of purposive sampling used was "snowball sampling," (24) where participants were asked to nominate others known to them who met the criteria. Rice and Ezzy (24) noted that this type of sampling may result in a homogeneous sample. To supplement this sampling, participants also were recruited through advertising in a physical therapy newsletter (volunteer sampling). Approximately the same number of therapists was recruited by each method, and no physical therapist who was invited to participate refused. Those therapists who reported making career changes for reasons other than WMSDs were not included in the study.

Trustworthiness

Because the purpose of qualitative research is to illustrate and elucidate a range of unique personal experiences, the notion of reliability has to be understood in a different way. Shepard et al suggested that quantitative research emphasizes the reproducibility of results, whereas "the goal of the qualitative researcher is not replication of results, but rather producing an illuminating description and perspective that is based on a consistent and detailed study of that situation." (23(p93)) They stated that validity can be addressed using strategies such as peer or participant examination of the findings, quoting participants directly, and collecting data using a tape recorder.

Krefting (25) proposed that instead of judging reliability and validity as they apply to quantitative methods, qualitative research should be considered in terms of credibility and trustworthiness. She suggested several strategies, including triangulation of data sources, member checking (subject review of data), and peer examination, to enhance the credibility and trustworthiness of qualitative research. This concept of verification of the analysis by peers and participants is thought to strengthen the credibility and trustworthiness of the study. As Rice and Ezzy stated, "knowledge is legitimised when external peers, the people studied and other relevant audiences agree that interpretations and conclusions are accurate reflections of the phenomenon." (24(p37)) Krefting also suggested using the participants' words in presenting the data and giving background and contextual information as ways to allow others to assess the transferability of the findings. These strategies were used in our study to enhance the trustworthiness of the study.

Participants

To ensure confidentiality, participants' names are changed in the transcripts and all work places are anonymous. The type of work done by the therapists is deliberately described in general and vague terms rather than referring to specific specialty areas of practice. Exact ages are not used. Any other information that could be considered identifying is deliberately deleted.

Eighteen therapists were interviewed for the main study. (7) In this article, we report on one of the themes arising from that study: workers' compensation. Six of the 18 respondents had made a compensation claim; all respondents were female. Three participants (Jane, Emma, Andrea) lodged claims when they were aged in their 20s, 2 participants (Louise, Denise) were over 40 years of age, and 1 participant (Beth) was in her 30s. Claims were for injuries to the upper limb, neck, or low back. A summary of these participants' characteristics, including their study "names," is presented in the Table.

Of those participants who had made claims, 1 was studying full time at the time of the interviews, 1 had retired, 1 had left the profession, and the remaining 3 were employed as physical therapists in an alternative capacity.

Interviews

We used interviews to gain insight into the participants' understanding of their WMSDs. Each participant chose a convenient time and location for their interview to take place, with each interview lasting between 45 and 90 minutes. All interviews took place between January and April 1999. A preliminary list of questions is shown in the Appendix. "Workers' compensation" was not an issue that appeared in the initial list of questions. In analyzing the therapists' descriptions of WMSD (in response to the interview prompt in the initial list "Tell me about your work history and how injury fitted into that"), a theme of "workers' compensation" emerged. After the first interview, the following question was added to the interview prompts: "Did you ever claim workers' compensation? Tell me about it."

Data Analysis

Data analysis was carried out in a series of steps. Initially, interviews were tape recorded and transcribed by one of the researchers (JEC). As each transcript was completed, it was returned to the participant for the first member check. Transcripts were reviewed for accuracy by the participants and amended if desired.

Transcripts were then read several times, and the text was coded by a researcher (JEC) by placing a word or words adjacent to the passage. The "codes" were words that were intended to capture the meaning of the passage. Codes with similar or related meanings were then grouped together under headings designated as categories. These categories were peer checked by other researchers independently coding and grouping a sample of the transcripts. Categories that included similar or related ideas were further grouped together as thematic categories. The researcher identified relationships and interactions among the categories at this stage. Quotations were organized into separate files to illustrate the thematic categories. One of these thematic categories was called "workers' compensation." The thematic categories were then synthesized into a narrative summary. This summary aimed at reflecting the experiences and at explicating the meaning of the experiences of the participants. The second member check occurred at this point. The narratives were returned to the participants, and they were invited to comment on whether they believed the narratives were an accurate reflection of their experiences and understanding of WMSDs. The response was extremely positive, with participants expressing appreciation for the opportunity to be given a "voice."

The transcripts were coded and analyzed both during the data collection period and after all the data were collected. Although these steps in data analysis are presented sequentially, at certain points the data were revisited to assist with the clarification and interpretation of the data. An example of this was when a new category was identified; previous transcripts and codes were reviewed to identify text that might be related to the newly identified category.

Findings

Participants used phrases and terms such as "a nightmare ... it's just the pits" (Andrea, p 7), "accusatory" (Beth, p 5), and "revolting" (Emma, p 2) to describe their experiences of the workers' compensation system.

Emma stated:

   The whole WorkCover thing was just a nightmare. I just
   hated every second of it, and the stigma that went along with
   it. (p 4)

When asked to describe her experiences of workers' compensation, Jane replied:

   Almost worse than the pain ... it was just such an upsetting,
   aggressive sort of dealing. It was really unpleasant. (p4)

Employment

A number of the participants felt that a workers' compensation history could affect employment and promotion opportunities. For example:

   And, so then I just realized that it wasn't going to happen....
   [I thought] "Well, I'm not going anywhere in the
   hospital system at the moment because I can't go for grade
   2jobs ... because I'm a tainted person." I Like I felt, too, that
   that was going to work against me in trying to get jobs. You
   know, someone with a WorkCover history, you know, ...
   bad back, [that] sort of thing. That that would somehow
   discriminate against me in some way. (Emma, p 9)

The belief that a compensation claim jeopardized employment opportunities is consistent with the views expressed by other workers (9) and is recognized by medical practitioners. (21) Evidence of such discrimination, however, is difficult to obtain. Employers are likely to be reluctant to admit to a discriminatory practice such as using the workers' compensation history as a reason for not employing people.

Another consequence of lodging a workers' compensation claim for one participant was that it damaged her relationship with her employer. Andrea felt that her employer was more concerned about the financial consequences her injury had on the practice than for her personally:

   [The employer] took it as a personal assault ... [was] just
   really aggressive ... was just shocking ... just really
   aggressive. Not supportive at all. Not supportive ... and I just
   thought, "Well, God, I'm flat on my back, can't move, can't
   work ... haven't got a job, and you're worried about your
   little increase in premiums." [The employer] became a
   nightmare after I hurt nay back ... was really, really
   nasty.... I can't describe what it was like to have an
   injury and keep working at the time. (p 8)

Andrea was the only participant who experienced such a negative response from her employer. Other participants reported supportive responses from their employers and colleagues.

Beth described her manager as:

   ... very supportive, ... she was great, and helped me fill in
   the forms. And there was no problem with that. (p 4)

Janet's employer organized her workload to minimize her difficulty with the work and then recommended her for a job that she knew of through her networks.

   The physio [sic] department ... , particularly the head, was
   very good at organizing my workload around me.... I
   pretty much continued to work, but she adjusted people's
   rosters, and I did a bit of this job, a bit of that job. And [she]
   worked things in for me. As much as she could. (p 6)

   Probably [for] almost a year, till I got to the stage where I
   had to move out of nay little niche, in outpatients, and go
   into the wards. And then she was actually the one who
   suggested that I go to this private practice. Because she
   knew the people, and they were looking for someone....
   So they were very supportive in that sort of thing. (p 6)

Jane also described a "supportive environment" (p 11) and "a really understanding senior, and every help was given" (p 2). Emma reported that her employer was "great" (p 3).

The reason that Andrea's experience was negative, while other participants reported support from their employers, may be because she was employed by someone who ran a small business. Her workers' compensation claim would have had a direct and detrimental effect on the employer's insurance premium. Although a compensation claim by a worker in a large institution (hospital) would most likely cause an increase in the employer's insurance premium, this would be unlikely to affect the personal finances of either the injured worker or his or her immediate manager.

Jane, Denise, and Louise reported that they had had medical treatment while on workers' compensation, but had not had physical therapy. This is consistent with the cultural tendency of physical therapists to self-manage their injuries. (7) Although some participants reported having "heaps of physio [sic]" (Emma, p 1; Beth, p 2) after lodging their compensation claim, they did not report experiencing negative attitudes from their treating therapists. Emma expressed an awareness of other therapists (her colleagues) making slightly disparaging remarks about other workers' compensation claimants.

   I think it probably had developed though from seeing
   WorkCover patients. And the attitude of other physios often
   toward patients on WorkCover. And that had probably
   developed, perhaps a little bit from student days, but more
   from when I'd first started. And just hearing other physios
   [sic] talk about, "Oh yeah, you know, WorkCover ..., that's
   right, they've been on a WorkCover claim for you know, 12
   months, sort of thing, what do you expect?" or that type of
   talk. And that was pretty regular. The attitude, I felt.... But
   I think it was because of that, that I then felt, when I was on
   it, that other people would be thinking and saying that same
   stuff about me. (p 12)

This impression that others would be judging her in some way was in contrast to the actual experience she reported of being supported by her colleagues. Her comment, "I just hated every second of it, and the stigma that went along with it" (Emma, p 4), suggested that, having made a claim, she felt that she was at risk of being stigmatized.

Dealing With the "Workers" Compensation System"

Andrea's experience of being a compensation claimant led her to believe that "they want you to just give up. Which is what you do in the end." She stated:

   They've made it really hard. I think they just reject everything.
   They ... want to run you out ... , to get you out of
   the system, and then you just think, well I can't go on. They
   reject [the compensation claim], so then you have to go to
   a lawyer, start proceedings.... I just get the feeling ... they
   want you to just give up. Which is what you do in the end.
   I think a lot of people give up. And I'm just at crossroads
   with that at the moment, whether I'm going to give up ...,
   or whether I'm going to keep going. My feeling is that I'd
   like to give up. But at the same time, I don't think I should.
   But, I'd really like to give up. It really does take over a lot of
   your mind, and if you want to get on with yourself, ... get
   on with your life, you can't. (p 10)

Jane felt that it was important to acknowledge (and for others to acknowledge) the "huge impact" her injury, had made on her life. But, in her words:

   It was just so nasty dealing with the whole system that I just
   stopped. (p 4).

Although individual managers supported a return to work after injury, this contrasted with the attitude of personnel within the workers' compensation system. The personnel administering it seemed to have little flexibility in dealing with motivated professionals. Beth described dealing with the workers' compensation system like this:

   What I found really frustrating was the [workers' compensation]
   coordinator person at our hospital, who just had no
   idea how to deal with me.... He basically said, "Please, take
   6 months off. I don't know how to deal with someone who
   wants to come back on a modified work schedule, after only
   a month. And if you want to do that, you'll have to work it
   out yourself, because I don't know how to do it." And
   ... pay office [personnel] were mucking me around [sic],
   because they didn't know how to deal with someone who
   had reduced their hours ... so my pay was mucked up for
   months on end. They didn't know how to cope with that.
   They were only used to people who were full-time off or
   back full time but in some altered capacity. And they
   couldn't cope with me being there.... They just kept
   telling me, "Go away and take more time off. Because it's
   too difficult for us to work out how to pay you 12 hours a
   week." So they were pretty awful. (pp 4, 5)

It is unclear whether this reluctance to be directive was because the workers' compensation personnel thought physical therapists knew more about return-to-work programs than they did, and so saw formulating such a program as somehow intruding into the therapist's field of expertise. Alternatively, they may have lacked the capacity to deal with a situation that was outside of their experiences.

Louise described how an experience where "no one would take responsibility for managing [her] rehab" was like "being torn, torn in half" (p 10). Participants spoke of being "so sick of the whole thing" that they "didn't want anything to do with it any more" (Emma, p 11). The administrative personnel Beth dealt with:

   ... seemed to have so little understanding of dealing with a
   professional person [that she] just wanted to be rid of them.
   I thought, "I'll just get rid of them, and I'll just work it out
   with my manager." So that's what I did. (Beth, p 6)

Dealing With Physicians

Attitudes and expectations of workers' compensation medical examiners (as described by the participants) seemed to imply that the therapists were motivated by financial gain and that they did not want to go back to their job. Beth described being examined by a specialist, who threw doubt on her credibility:

   I then had to go and see a [workers' compensation]
   specialist, a general physician, I guess.... I found the
   process fairly intimidating.... I felt it was fairly accusatory,
   the whole examination process, about ... , "How many of
   your friends and family are unemployed?" or "How many of
   your friends and family are on [workers' compensation]?"
   These sorts of questions. (p 5)

Medical examiners made comments in their medical reports that had consequences for the financial and physical well-being of their patients. In some cases, they were quite judgmental and damning. Louise reported how a physician attributed her symptoms to a familial condition "which was a total and outright lie" (p 6). Denise described a situation where a neurologist decided she was "swinging the lead ... malingering ... " She said:

   It was wrinen on my history that I was a malingerer ... they
   virtually withdrew all pain-killing drugs ... and I actually
   got treated very badly from that point in time. (p 10)

Medical examiners, and in particular those to whom participants were referred by insurers, seemed to reflect some of the stereotypical prejudices toward claimants described by (Quintner). (26) The attitude of some medical practitioners led Jane to tim point that she wanted to terminate her claim. Jane stated that a rheumatologist had written in a report that she was using her injury as an excuse not to have children and that in choosing not to have children she was avoiding her duty to her husband (Jane, p 5). The rheumatologist implied that her problem was primarily psychological (Jane, p 5). The rheumatology report was "amazingly hostile, ... and ... out of sync [sic] with any of the other reports I've got myself" (Jane, p 6). She found the rheumatologist's report "profoundly offensive" and said that it made her "so angry," but at the same time she felt unable to show the report to anybody else (Jane, p 15).

When Jane received a summons to attend for a psychiatric assessment, her prior experience made her reluctant to comply. In her words:

   Then, I got a letter in the post. They said I had to go ... to
   their psychiatrist.... I throught "My goodness, if their
   rheumatologist can do that to me, I don't want to see what
   their psychiatrist is going to do. I'm just not going to leave
   myself open to that." And that's when I walked away. I just
   said, "Just forget it." (Jane, p 6)

Tarasuk and Eakin suggested that social status imparted some "immunity from imputations of malingering." (9(p213) This was not the experience of the participants in our study. Rather, they encountered attitudes from some medical specialists that were similar to those reported by Reid et al (17) in their study of female factory and telecommunication workers. Participants encountered attitudes suggesting that they were malingering or abusing the system. This is perhaps not surprising, given Dembe's (11(p231)) assertion that such prejudices still exist. Perhaps the physical therapists' status was not highly regarded by the medical specialists, and so they were assumed to be prone to malingering. Alternatively, it is possible that without the status of being a physical therapist, they would have been perceived even more strongly as malingering.

Another possible explanation is that the biases exhibited by some specialists were independent of the status of the worker. The biases may be directed at some other factor, such as compensation status or gender. These negative experiences did not occur during the participants' encounters with their own physicians, but rather during their encounters with medical specialists to whom they were referred by the insurer. This is consistent with the experience of the women in the study by Reid et al of certain medical practitioners "marching to the beat of the company drum" (17(p611)) (or insurer's drum) and suggests that such suppositions may indeed have some basis in fact.

Participants acknowledged that some of the discomfort with the workers' compensation system was a product of their own upbringing and background. The idea of

"working hard and paying your own way" was part of Emma's upbringing:

   So to be a compensable patient was very uncomfortable.
   (Emma, p 19)

Jane stated:

   [Workers' compensation] paid all my physio [sic] expenses.
   But perhaps stupidly, I don't know, I paid all my other
   medical expenses. I think probably mostly because I came
   from a system, a health system where you were very responsible
   for yourself. And I had trouble with accepting the help
   in some way. (p 4)

Leaving the Workers' Compensation System

A number of the participants (Beth, Emma, and Jane) left the workers' compensation system before they had achieved a satisfactory return to work. That participants did not seek to legitimize their injuries and remain in the system, but rather left the workers' compensation system, may have been because they had adequate resources at their disposal to make a career change. They also may have been able to determine their own safe working capacity and identify suitable options (of which there are several in terms of less physically demanding work) for which they were qualified. This made it possible for them to move into an alternative job without the intervention of workers' compensation personnel.

Although, as physical therapists, the participants had worked with injured claimants and dealt both with physicians and insurance personnel, they reported difficulty in negotiating the workers' compensation system themselves. Beth found the workers' compensation system was "fairly intimidating" and the "examination process ... was fairly accusatory." However, she felt that she "got a fair amount of understanding for what a lot of [her] patients had been through in the past." She said, "Imagine if I wasn't a physio [sic], how I would feel about all this" (p 5), implying that her patients may have found the process even more intimidating.

Overall, participants were unhappy with their experiences of workers' compensation. Although the workers' compensation system was intended to help injured workers return to work, participants found dealing with it bureaucratic and unpleasant.

Because of the limited size of some specialty areas within the physical therapy profession, confidentiality was identified as an important issue. Some participants referred to the negative effects that a workers' compensation claim could have on employment opportunities. This could discourage claimants from discussing their needs and the issues surrounding their injury and could contribute to feelings of isolation.

Limitations and Further Research

The findings of our study are specific to the workers who participated in the interviews. The participants' experiences, however, may provide insight into the experience of being a workers' compensation claimant, an experience not previously formally identified. In addition, the compensation system in which the participants were involved was based in Australia. Workers' compensation in other jurisdictions may be less bureaucratic and judgmental, or it could be even more burdensome. Further research is needed to investigate this issue.

Physical therapists' experiences of the workers' compensation system were consistent with the experiences of the women in the study by Reid et al (17) and concur with anecdotal reports of the system as bureaucratic and unsympathetic. Further research to investigate the experiences of claimants from other occupational groups could expand our understanding of being a workers' compensation claimant. Unlike the workers in the study by Tarasuk and Eakin, (9) the therapists in our study did not appear" to be advantaged by their social position or their seniority when it came to dealing with the workers' compensation system. Research to establish whether the attitudes of physicians varied according to the social status of injured workers may be helpful in understanding some of the issues involved in the relationship between the physician and patient.

We found that the view that workers' compensation claimants are malingering appeared evident in some of the dealings between medical practitioners and therapists. This inference, however, was drawn by the therapists involved and may have been due, in part, to the feelings the participants themselves had about being involved in the workers' compensation system. Further research to identify the attitudes of medical practitioners toward their patients would be helpful in identifying the degree to which this assumption was made by the physicians and whether therapists were interpreting their attitudes correctly.

Conclusions

Overall, the therapists were unhappy with their experiences of being workers' compensation claimants for several reasons. Participants perceived that their peers would judge them as being like other compensation claimants, and they did not want to be identified as "one of them." This perception is consistent with Rothstein's (27) observation that therapists see themselves (and want to see themselves) as different from their patients. Participants acknowledged that their background and upbringing encouraged them to be self-sufficient and to manage without the help of others. Furthermore, although the workers' compensation system was intended to help injured workers return to work, therapists found dealing with it bureaucratic and unpleasant.

The experiences of physical therapists as workers' compensation claimants are in line with those of other claimants. Participants described having their integrity questioned, particularly by medical practitioners, who were in the position of making a judgment as to the veracity of their claim.

Confidentiality was an important issue. Participants referred to their belief that having made a workers' compensation claim could limit future employment opportunities. If this is the case, therapists who are claimants may be discouraged from identifying and discussing their injuries, which could contribute to feelings of isolation or could mean that they avoid seeking appropriate treatment interventions and management for WMSDs.

The difficulties in negotiating the workers' compensation system reported by physical therapists, who routinely work with injured claimants, suggest that those with less familiarity may encounter even greater problems. Health care providers should be aware of some of the issues facing injured workers (in particular, workers' compensation claimants) and should be prepared to act as a resource and to assist in making appropriate financial and return-to-work decisions. Treating and consultant practitioners should be well informed about legislative and insurance requirements so they can inform and advise injured workers.

In our study, the process of claiming workers' compensation resulted in physical therapists being in the uncomfortable position of simultaneously being a patient and a claimant. Their discomfort arose from a number of sources, including their own backgrounds, the attitudes of colleagues to workers' compensation, and their dealings with insurance and medical personnel. Although they found this unpleasant, they gained insight into some of the issues and experiences faced by their own patients who were claimants. Unlike many of their patients, they were able to choose to extricate themselves from the situation and determine their own intervention and career changes.

Appendix.

Interview Prompts (a)

Initial Schedule of Questions

This schedule is intended as a guide only, to ensure the interviewer covers all relevant aspects of the work-related musculoskeletal disorder. The nature of qualitative research means that as new data emerge, different aspects of the interview may increase or decrease in emphasis and new areas may be investigated. It is expected that areas other than those covered in this guide may be included in the interviews.

Personal/Demographic Information

Age Sex

Work History

Years of practice as a physical therapist, areas of practice Current or most recent practice Other relevant information

* Tell me about your work history and how injury fitted into that

Causes

* How did injury occur? What caused it? Did it occur in the course of your normal work? Were there unusual circumstances surrounding the injury that may have affected the nature or extent of the injury?

* What contributed to it?

* What exacerbated it?

* What aspect of the causal factor was important in the onset of the injury? For example, if lifting was the cause, was it the excessive weight? The frequency of the lifting? The amplitude? The posture in which it occurred?

* Was there a point at which you recognized that: You were at risk of injury? You would have to change your area of practice or leave altogether?

* Do you have any other comments about the causes of your injury?

Management

* How did you manage your injury?

* Were there any skills or attributes that you had acquired as a physical therapist (or student) that helped you manage your injury better than if you had come from a different professional background?

* What would you have done differently with the benefit of hindsight?

* Did you have treatment for your symptoms?

* Do you have any other comments about your injury or the way in which it was managed?

Resolution

* How much experience had you had as a physical therapist when you made the decision to change area of practice?

* How did you choose an alternative? Was your prior experience an advantage? How?

* Did your training give you any advantages in choosing what area to go into or changing?

* Were there any skills or attributes that you had acquired as a physical therapist (or student) that helped you change the area in which you practice?

* Do you anticipate that you will make other career changes because of injury? Do you expect that you will ever practice in the original area that you left because of injury?

* Do you have any long-term limitations because of your injury?

* Are there any things you can think of that would have made the transition (both choosing and changing) easier? Do you have any other comments?

Table.
Participant Summary

                     Age (y)
"Name"   Injury      When      Cause of Injury/Current
                     Injured   Situation

Denise   Shoulder,   40s       Injury occurred as a
         neck                  result of unexpected
                               movement by patient
                               Retired

Jane     Neck        20s       Repeated heavy manual
                               handling of patients
                               No longer working as a
                               physical therapist

Beth     Low back    30s       Repeated heavy manual
                               handling of patients
                               Doing no clinical work
                               at present, entering a
                               desk-based position

Emma     Low back    20s       Left general work; injury
                               a result of patient fall
                               Currently working in
                               patient management role,
                               no manual handling
                               of patients

Andrea   Low back    20s       Prolonged static postures
                               associated with
                               manually intensive work
                               Doing no clinical work;
                               studying with a view to
                               consulting

Louise   Thumb,      40s       Prolonged holding
         knees                 and use of hands
                               Consultant, desk based

(a) Reprinted with permission of the American Theraphy Association from: Cromie JE, Robertson VJ, Best MO. Work-related musculoskeletal disorders and the culture of physical therapy. Phys Ther. 2002;82;459-472.

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JE Cromie, PT, PhD, is a Senior Lecturer, School of Occupational Therapy, La Trobe University, Bundoora, Victoria, 3086 Australia ([e-mail]). Address all correspondence to Dr Cromie.

VJ Robertson, PT, PhD, is Associate Professor, School of Physiotherapy. La Trobe University.

MO Best, PT, MPH, is Senior Ergonomist, Victorian WorkCover Authority, Victoria, Australia.

Dr Cromie provided concept/idea/research design, data collection, subjects, and clerical support. All authors provided writing, project management, and consultation (including review of manuscript before submission). Dr Cromie and Ms Best provided data analysis, and Dr Cromie and Dr Robertson provided facilities/equipment.

This study was approved by the Faculty Ethics Committee, Faculty of Health Sciences, La Trobe University.