General principles:
Every circumstance is different but some general principles apply. They are listed below:
Need for tailored advice
General practitioners and cancer clinicians, especially those who have been involved in the care of the individual over a long period are well placed to understand the physical and psychological issues of their patients. These issues vary greatly between patients and also over time with the same patient. This variability means an engaged practitioner who is able to give meaningful, individually tailored advice and assistance is the key to many successful return to work programs.
There is no substitute for the doctor having a good knowledge of the workplace involved when assisting with issues of work rehabilitation. Job titles are insufficient to understand work duties. Principles of “work hardening” (graded duties and hours) are far better tailored when one has an understanding of a workplace. A visit to the work site can be very helpful, but often this is not practically possible. In such situations, involving the assistance of a suitably trained individual such as an occupational therapist with knowledge of the workplace, or a rehabilitation or occupational physician may be helpful. Although many employers are not obliged to help by altering hours or duties, many are very willing to do so especially for a valued employee. Realistic expectations, good (repeated) communication and flexibility (being prepared to alter initial plans if necessity) are all key principles. Certification of “light duties” is rarely helpful and leaves he employee in the difficult situation of having to constantly negotiate what they can and cannot do with their employer. Sometimes unexplored options that can facilitate a successful return to work include “fitting the task to the man”, that is altering work duties or equipment to assist the worker, or altering days or hours of work to fit in with medical appointments.
Things can be particularly challenging when things change. For example a return to work program is put in place and the individual for whatever reason is unable to achieve or maintain the goals of the program. The flexibility required to negotiate through these challenges may require the assistance of a rehabilitation advisor or social worker.
Maintaining function and improving deconditioning
Central to the management of many of the physical issues related to cancer and its treatment is the need to improve the inevitable deconditioning that occurs. The need to manage this element of the process is independent of the nature of the work involved, although a return to heavy manual work is particularly challenging. Here the central role of regular, graded and sometimes targeted physical exercise program cannot be over emphasised. Individuals should aim for a program of strengthening and endurance exercise of at least half an hour’s duration on most days. If transitioning back into a physical work role, some of these sessions can be substituted by work activities. The assistance of physical therapists in the design of these programs can be useful, but often the advice can be quite “low tech” (and therefore cheap) and can be designed by patients themselves with little outside assistance.
Addressing psychological issues
These issues may be obvious to all concerned, or quite subtle and therefore more insidious and difficult to identify and manage. The key for medical practitioners to identify potential issues in this domain is to think of them. Brief interventions from suitably trained individuals may be all that is required. Alternatively on going psychological support for individuals going through the process of managing cancer and its sequelae, whilst attempting a return to work, may be required. Sometimes family members may also need psychological support during this period.
Open communication
This must be done only with the full consent of the individual involved, and verbal followed by written advice is a reasonable approach. Verbal communication with the workplace (generally the employer or at least line manager) is generally best done with the patient present to avoid potential issues around confidentiality. Supplying patients with the written advice for them to give to their employer (rather than directly to the employer) is another safeguard against potential inadvertent breaches of confidentiality. Sometimes larger organisations will have in house rehabilitation managers who might be of some assistance in the process and indeed may be sufficiently proactive to make the first contact.
The key steps in assessing fitness to work and development of return to work plan are summarised here
A return to work plan
A return to work plan can help clarifying goals and abilities. It can also help to reduce any feelings of stress and guilt about returning to work and help clarity limitations and increase confidence to move forward. Ideally, a return to work plan should be developed in consultation with one’s employer and the treating doctor. The employer may have a trained return to work coordinator who can assist with the process. The plan should be regularly reviewed and amended.
The plan should consider:
- special requirements required at work
- personal circumstances, which may impact on one’s capacity to perform certain duties at work
- industrial issues in the workplace (union rules/influences, workplace culture)
- impact on the workload of other employees
- training requirements to perform a new role prior to returning to work
For an excellent summary on how to develop a work plan, as well as strategies to seek employment, see the Cancer Council New South Wales Job Seeking Booklet (link). A copy of a return to work plan adapted from the booklet can be downloaded here (download – see below)
For further reading see:
Fitness for Work – The Medical Aspects. Fifth Edition Edited by Keith T Palmer, Ian Brown, and John Hobson Oxford University Press ISBN: 9780199643240. This is a very useful text for all practitioners interested in the subject
AMA Guide Work Ability and Return to work 2nd edition. James B Talmage J Mark Melhorn Mark H Hyman ISBN-13: 978-1603595308 This US text includes a chapter specifically on oncology.
Austroads. Assessing fitness to drive – commercial and private vehicles. https://www.austroads.com.au/drivers-vehicles/assessing-fitness-to-drive This publications assists in decision making around the sometimes difficult issues of driving and health