Samenvatting
In december 2006 heeft de Gezondheidsraad (GR) bij het uitbrengen van twee nieuwe protocollen (overspanning en depressieve stoornis) ook een algemene inleiding gepubliceerd. Deze heeft nog niet tot veel discussie geleid, wat toch wel verwonderlijk is. Eén van de interessante elementen is de beschrijving van de taken die de GR voor de verzekeringsarts weggelegd ziet.
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Assessing treatments: a rewarding challenge
N.H.Th. Croon
In December 2006 the Health Council of the Netherlands (HC) published a new general introduction simultaneously with the issue of two new protocols (nervous exhaustion and depressive disorder). It has not yet given rise to much of a discussion, which is somewhat surprising. One of the interesting elements is the description of the new responsibilities for the insurance physician according to the views of the HC.
The HC considers the insurance physician to have four core responsibilities regarding assessments: the assessment of the client’s social-medical history, of the functional capacity, of the expected course of the disorder (e.g. the prognosis) and finally the assessment of the current and indicated treatment. The first three will offer no surprises: the insurance physician has for years performed the assessment of the re-integration efforts in the gatekeeper period, and especially of the occupational health physician’s counseling activities, just as he has assessed the client’s capacity and its prognosis. Especially the fourth core responsibility, which recalls echoes of the Industrial Injuries Act, is relatively new. The HC wants the insurance physician to deliver a major contribution in those situations where in the preceding gatekeeper period important opportunities in the field of treatment have been left unused. In cooperation with the client, the attending physician and the occupational health physician, clearly defined treatment goals will still have to be set. But how many cases does this actually concern? After all, we can assume that most clients have received reasonable treatment during the gatekeeper period.
However, in practice we regularly encounter cases where, for all kinds of reasons, suboptimal or even ineffective treatment has been given (or sought!), where this cannot be reasonably blamed on the employee or employer. But we do not know exactly how many cases are involved. And how suboptimal does a treatment have to be before an insurance physician can decide to intervene after all? What does this mean for the client’s claim? Is the client actually obliged to cooperate when the insurance physician, in the HC’s terminology, issues ‘an unmistakable (reintegration) signal’? The instrument for doing this properly is not included in the ministerial order concerning procedures and guidelines in disability assessments, the ‘Schattingsbesluit WAO’, and neither in the monodisciplinary insurance-medical protocols. And thus legal quicksand threatens.
Multidisciplinary 3B guidelines, covering treatment, counseling and assessment by all concerned professional groups, are still in the early stages of development. They are to offer the instruments, but the actual work will have to be performed in the surgeries by maintaining multiple contacts with colleagues and clients and addressing them with possible issues. This journal, for example, features the description of the dilemma caused by an employee who preferred alternative therapy to proven conventional medication.
In a confrontational situation lots of good intentions and the increasing availability of instruments might occasionally still not prevent the attending physician and insurance physician taking their responsibilities for respectively treatment and claim assessment, whereby the client is in danger of getting the short end of the stick. So we still have to cover some ground.
Until that time insurance physicians will, guided by the protocols, very concretely focus the attention of attending physicians and clients on lacunae in treatment plans, and on treatment which is evidently without any proven effectiveness. Let’s hope the attending physicians will see this ‘interference’ in a constructive light. After all, attending physicians will have to become aware that occupational rehabilitation also forms a part of regular treatment. In the end this all concerns the client, and we are also aware that for example a depression that has been treated inadequately for two years can still be cured with proper treatment. It is still necessary for insurance physicians to have cooperation projects, communicative competency and to acquire considerable curative know-how if we want to give this core responsibility a chance. Otherwise it will slide into becoming a paper tiger and that would be a waste, because the HC is correct in identifying this rewarding task: whenever necessary to give an impulse for a renewed, and then effective, treatment!
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Croon, N.H.T. Beoordeling van behandeling: een mooie uitdaging. TVBV 15, 314–315 (2007). https://doi.org/10.1007/BF03074607
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DOI: https://doi.org/10.1007/BF03074607