Occupational stress: a survey of management in general practice

Evidence is accumulating on the adverse effects of psychological stress in the workplace. While linked with coronary heart disease, hypertension, peptic ulcers and type 2 diabetes,1,2 the most direct indicator of its effect has been the dramatic increase in the number and cost of associated workers compensation claims for work-related (occupational) stress.

Most Australian States have had similar experiences to those of Western Australia (WA), where the incidence of work-related stress claims doubled between 1994 and 1997, accounting for 2.2% of all workers compensation costs by 1998. In WA, stress claims take twice as long to settle, and cost the workers compensation system twice as much as non-stress claims.3

Published Australian guidelines for the medical management of occupational stress advocate early intervention; durable, monitored return to work; and effective communication between all parties in the system.4 The principle of effective communication underpins the recent implementation of the principles of "injury management" to Australian workers compensation systems. Injury management in WA (Box 15) aims to facilitate communication and decision making between workers, employers and medical practitioners.5

Although Australian general practitioners are generally the first point of contact for entry into the workers compensation system, surprisingly few studies have investigated the role of GPs in managing workplace injuries. None have explored the role of GPs in managing work-related stress, and this study formed part of a larger investigation into the role of GPs in managing this condition.4 The published study, funded by WorkCover WA, involved literature review and qualitative data collection by focus groups and key informant interviews with significant participants in the workers compensation system in WA. Its findings informed the design of this study, which aimed to identify approaches to and barriers associated with the management of work-related stress by Western Australian GPs.

• A case vignette of a hypothetical patient with work-related stress (Box 26). Respondents were asked to indicate management decisions regarding time off work, advice concerning lodgment of a workers compensation claim, involvement of other professionals in patient care, and plans for employer contact.

• Likert-style questions giving five options across a range, ascertaining potential barriers to the effective management of work-related stress: (i) confidence in management skills, knowledge of claim requirements, and perceptions of financial and organisational barriers to management; (ii) experiences with contacting employers; and (iii) attitudes to accreditation of GPs to work within the workers compensation system.

• Demographic data (sex, age, practice location, years in general practice, number of sessions worked per week and past involvement in occupational medicine). Respondents who had worked as a company doctor or who had had special training or qualifications in occupational medicine were categorised as having "experience in occupational medicine". Rural practice location was assessed by linking postcode with the Rural and Remote Metropolitan Areas classification,7 while "urban" represented practitioners working in Perth and centres with populations over 75 000. Other locations were categorised as "rural".

Thirty-five of the original 450 GPs (7.7%) were ineligible to participate as they were no longer in general practice, on leave, or unable to be contacted. Of the remaining 415, 208 returned questionnaires (response rate, 50.1%). The sample was demographically similar to the WA GP workforce.9 The respondents consulted for an average of 7.6 sessions per week (95% CI, 7.2–8.0 sessions) and had worked in general practice for an average of 16.8 years (95% CI, 15.4–18.3 years). A fifth (19.7%; 95% CI, 14.3%–25.1%) had had some experience in occupational medicine.

GPs who would not have opened claims outlined alternative management strategies in open responses. These included the use of a cooling-off period before early review; exclusion of organic disease; and brief, non-compensated sick leave. Many suggested that a claim could be opened subsequently given informed consent. One GPs response was typical: "I would advise him to consider his options, take a few days' regular sick leave as a circuit breaker and then see how he feels. I would ask him to consider his longer term goals."

Australian guidelines for the medical management of work-related stress suggest that cases be evaluated in the light of legislative criteria. The guidelines discourage time off work and favour early referral to mental health specialists.10 The study findings suggest that Western Australian GPs have a pragmatic and reasonably cautious approach to early management. Most chose not to initiate a workers compensation claim in response to the case vignette describing a patient with work-related stress. Most would have advised this patient to take up to a week off work whether or not a claim was lodged, would have involved a psychologist in further management, and would have waited for the employer to initiate communication.

Our study had several limitations. The response rate of 50.1%, while consistent with contemporary GP questionnaire studies,11 potentially limits generalisability. Also, while case vignettes can be used as proxies for actual management decisions within general practice research, they tend to overestimate real performance.12 While a larger sample size might have clarified associations between variables, the study was primarily designed to explore management decisions and ascertain important barriers to effective care.

Our findings are consistent with those of other studies which have found that GPs formally report only a third to a half of compensable workplace conditions,10,13 and contrast with employer and insurer perceptions of doctors being too willing to initiate claims.14 We are not aware of any other studies which have found different claim rates between female and male GPs, and believe that this warrants further investigation.

At the time we conducted the survey, Western Australian GPs seeking to open a stress claim had no easily accessible information on the necessary criteria for a claim to be accepted. Given this, it was not surprising that two-thirds of the respondents (especially part-time GPs and those from rural areas) were uncertain about the legislative requirements for work-related stress claims. However, the finding that perceived knowledge of legislative requirements increased the likelihood that the respondent would initiate a claim is intriguing.

Occupationally experienced GPs were less likely to certify the hypothetical patient as totally unfit for work, a finding possibly explained by their increased familiarity with the options for flexible work arrangements for impaired workers. In isolation, this would support the recommendations of a recent review which advocated mandatory training for GPs if they were to register to practise within the Western Australian workers compensation system.4 However, these GPs were just as likely to initiate a claim, defer employer contact or be confident of legislative requirements as their peers.