Physician's Guide - Responding to Work Site Safety Issues

This Web site module is designed specifically for the physician in order to present a template and examples of responses to employers about workplace safety issues.

Q. Why do I need to know about workplace issues for my patients with epilepsy?

A.  The unemployment rate for people with epilepsy is two to three times that of the general population. For those with active seizure disorders, it may be as high as 50%. Furthermore, people with epilepsy who manage to gain employment, tend to earn less than people who do not have epilepsy. Physicians are in the unique position of being able to advocate for appropriate employment opportunities based on medical evidence.

Q. I’m just a physician. I understand medicine, not employment law and vocational rehabilitation. How can I help my patients?

A.   Physicians play a critical role in helping ensure that their patients with epilepsy are fairly considered for employment opportunities. First, if appropriate, based on the type of medical inquiry raised by the employer, the physician should confirm that the patient does indeed have epilepsy, and describe the seizure type(s), their frequency and impact on the patient’s functioning (with and without the use of anti-seizure medication). This information may help establish that an individual has a disability covered under the Americans with Disabilities Act (ADA), and therefore is protected from discrimination.1

Second, in order to support the conclusion that the individual is qualified for the position, the physician should be informed of the specific job duties involved and provide a detailed opinion on the extent to which the patient can safely perform those duties. It will be particularly helpful to provide suggestions on specific types of reasonable accommodation(s) that could be devised to enable the individual to successfully perform the job duties.

The best available evidence about an individual’s medical suitability for a job typically comes from his or her treating physician in the form of a detailed opinion letter. Frequently, employers will attempt to base their determination on the opinion of an occupational physician retained on a contract basis, even if that physician has limited expertise in the relevant area of medicine and/or knowledge about the individual’s medical history. In this case, it will be important to be able to counter the potentially conclusory opinion of that physician with an authoritative and carefully considered opinion that only the treating physician can provide. Physician advocacy in the form of employer education on epilepsy generally can also be helpful.
____________________________________________________________________________________________
¹ Under the ADA, which prohibits employers with 15 or more employees from discriminating against persons with disabilities, including epilepsy, employers are permitted to seek information and to refer an employee for physical examinations to confirm that the individual has a covered disability and is able to safely and efficiently perform the job. Importantly, the ADA requires that, prior to denying a job opportunity to an employee or applicant with epilepsy (or another disability) based on safety or health risks, the employer must conduct an individualized assessment of the person’s ability to safely perform the essential functions of the job. Such an assessment must be based on a reasonable medical judgment that relies on the most reliable and objective evidence available. The employer must determine, with the input of the applicant or employee (and/or his or her health car provider), whether there may be any type of reasonable accommodation (a change in the way the job is performed, etc.) that would eliminate the risk, if any, or reduce it to an acceptable level. Congress amended the ADA, effective January 1, 2009, to make it considerably easier for an individual to show that he or she has a disability and therefore is protected from discrimination under the law. Prior to the amendment, persons with epilepsy and other disabilities generally were not covered if their conditions were controlled with medication or other measures (e.g., prosthetic devices). As amended, the ADA covers all impairments that limit major bodily functions, including neurological functioning, even if the condition is controlled by medication and/or is episodic. Based on these provisions, it is clear that persons with epilepsy are covered under the ADA in virtually all cases.

Patients may also benefit from the services of vocational rehabilitation specialists, who can assess their suitability for job opportunities and provide technical assistance to the patient and employers. For information on these resources and others that can assist with obtaining and retaining employment, patients may be referred to the Epilepsy Foundation’s Career Support Center, a free informational online tool that assists individuals with epilepsy in their employment searches. Information is available at: www.epilepsyfoundation.org/programs/csc.cfm or by contacting the Foundation’s Programs and Resources Department at 1.800.332.1000.

Q. What type of medical information will employers wish to receive?

A. The following information will be helpful to include when filling out forms or writing letters:

A. Medical facts unique to your patient

i. Aura, or warning symptoms

ii. Seizure precipitants

iii. Seizure times of occurrence (if applicable)

iv. Seizure manifestations

v. Seizure recovery time

vi. Extent to which seizures are controlled with medication or other measures

Vii. Accommodations that you believe would minimize risks to safety resulting from seizures on this job (e.g., permitting work on a day shift, rather than at night, to minimize sleep disruption that may trigger seizures)

Viii. History of work-related injuries shoudl be considered, if relevant

b. Description of seizure first aid

c. Reassurance of workplace safety and worker reliability based on medical literature. (link to Cornaggia et al, 2006)

Q. How can I speak to my patient’s risk for having workplace accident which may harm him or others?

A.  Detailed information should be provided on reasonable precautions that can be taken to avoid harm in the event a seizure occurs (such as providing rubber matting on floors to cushion falls and protective guards around machinery) and on avoiding seizure precipitants such as sleep deprivation.  While individual factors should be taken into consideration, recent studies suggest that people who have occasional seizures are at very low risk for workplace accidents or absenteeism. This article (link to Cornaggia) may be helpful to send along with your letter.

Q. Am I legally responsible if my patient is injured at work?

A. In general (although court rulings may vary somewhat based on differences in state law), a physician would have no liability based on harm to the patient, co-workers or the public (caused by workplace accidents or other mishaps related to the patient’s epilepsy or treatment), providing the physician gives the patient and the employer accurate information concerning the patient’s epilepsy and related matters such as potential medication side effects.

Q. Do you have examples of successful advocacy letters?

A. Yes, here (link to letters) are some examples of letters that have helped to get people with epilepsy back to appropriate employment. Remember that each is specific to the individual patient’s medical condition.

Q. What can be done to optimize my patient’s safety after s/he starts work?
A. Often workplace safety can be improved with relatively modest accommodations on the part of the employer. A federally-funded resource for determining accommodation options, the Department of Labor's Job Accommodation Network (JAN), is available by calling 1-800-ADA-WORK (232-9675) or by email at jan@wvu.edu.  For more information, see JAN’s website, http://www.jan.wvu.edu/, and their resources concerning accommodations for persons with epilepsy, available at:  www.jan.wvu.edu/media/epil.htm. 
Q. My patient’s employer requires that I complete a form assessing his/her suitability for employment. How should I respond?
A. Often standardized forms have not been designed for people with paroxysmal disorders such as epilepsy. Unless the form allows you to accurately depict your patient’s condition and capacity for employment, it is often preferable to leave portions of the form incomplete, attaching a letter that fully explains the situation. The letter should highlight the individual’s ability to perform the essential functions of the job, rather than focusing on his or her limitations.  In this way, the letter can help counter any stereotyped views about epilepsy that the employer may have.
Q. In writing a letter for my patient is there anything that I should NOT say?

A. Common mistakes that may unintentionally hinder your patient’s application include:

1) Use of vague terminology such as "should avoid activities that would put himself or others at risk". Broad statements are likely to be interpreted too conservatively, often without consideration of accommodations.

2) Use of the classic "should be barred from working with moving machinery".  Almost all moving machinery has guards or can be modified for safety.  Today it is unusual if machinery has not already had such a guard system installed.

3) Suggesting limits that can easily be dealt with through accommodations such as "should be barred from heights" (there are all kinds of safety belts and attachments readily available) or "should avoid work on concrete floors" (rubber matting and other modifications can be very effective).

Medical Response Templates

Example 1:  A middle-aged man who was trained as an aircraft inspector and is having 1-2 partial complex seizures annually with a new medication.

Example 2:  A middle-aged hospital accountant with complex partial seizures – she wishes to return to work after having a seizure on the job.

Example 3:  A police officer returning to active duty after presenting with several complex partial seizures over a short period of time.

Example 4: A young man with generalized tonic-clonic seizures desires to return to a banking/mail room position.

Example 5:  A young man with nocturnal partial complex seizures in remission seeks a job as a commercial driver. He was inappropriately screened out by the occupational medicine service adn the following letter resulted in his reinstatement.