Clinical Work-Integrating Care in Current Practice: A Scoping Review

Purpose Clinical work-integrating care (CWIC) refers to paying attention to work participation in a clinical setting. Working patients may benefit from CWIC. The purpose of this study is to explore the extent and nature to which medical specialists provide CWIC and what policies and guidelines oblige or recommend specialists to do. Methods A scoping review was conducted. The databases MEDLINE, EMBASE, Psychinfo, CINAHL, and Web of Science were searched for studies on the extent and nature of CWIC and supplemented by gray literature on policies and guidelines. Six main categories were defined a priori. Applying a meta-aggregative approach, subcategories were subsequently defined using qualitative data. Next, quantitative findings were integrated into these subcategories. A separate narrative of policies and guidelines using the same main categories was constructed. Results In total, 70 studies and 55 gray literature documents were included. The main findings per category were as follows: (1) collecting data on the occupation of patients varied widely; (2) most specialists did not routinely discuss work, but recent studies showed an increasing tendency to do so, which corresponds to recent policies and guidelines; (3) work-related advice ranged from general advice to patient–physician collaboration about work-related decisions; (4) CWIC was driven by legislation in many countries; (5) specialists sometimes collaborated in multidisciplinary teams to provide CWIC; and (6) medical guidelines regarding CWIC were generally not available. Conclusion Medical specialists provide a wide variety of CWIC ranging from assessing a patient’s occupation to extensive collaboration with patients and other professionals to support work participation. Lack of medical guidelines could explain the variety of these practices. Supplementary Information The online version contains supplementary material available at 10.1007/s10926-023-10143-1.


Introduction
It is important to include all patients in the labor market and stimulate their work participation [1], because working improves someone's overall quality of life and well-being [2][3][4].Furthermore, patients generally value work as it provides income, social contacts, and the ability to contribute to society [5,6].However, acquiring a disease can have an impact on work participation.To illustrate, 35% of the economically inactive people in the working age population have a chronic physical or mental health problem, illness, or disability, compared to 18% of economically active people [7].Moreover, 81% of the inactive group with health problems feels limited by their health in their daily activities.Because demographic changes in Europe are leading to an aging workforce, more people of working age are prone to acquire a disease or injury [8,9].
As a measure to stimulate work participation, it could be beneficial for all hospital-based healthcare professionals to be more aware of this domain so they can support their patients within the boundaries of their professions [10].Medical specialists are in the unique position to leverage their expert knowledge of determinants of health to positively contribute to a patient's socioeconomic needs-for example, with regard to work participation [11,12].Many physicians nowadays are being educated to be more aware of this position they hold as health advocate [13,14].Physician awareness of work participation needs can aid in early detection of problems with work participation to prevent or reduce work loss due to disease [15].Moreover, if a medical specialist is aware of a patient's occupation, the specialist can also adapt the treatment plan accordingly and understand non-adherence to a treatment plan when work participation interferes with the medical treatment [16].These are just some examples of support for work participation within the context of hospital-based care.
Providing support for work participation in hospital care settings is referred to as clinical work-integrating care (CWIC) [17].Acting within the philosophy of CWIC, healthcare professionals acknowledge that work and health mutually influence each other.This implies that they pay attention both to work as a cause of disease (e.g., occupational diseases) and to the positive effects of work participation on mental and general health, as well as attention to the impact of disease or treatment on the ability to work [17].This concept differs from the concept of work-focused healthcare, which aims to improve support for work participation within clinical healthcare [18].Work-focused healthcare puts a strong emphasis on the responsibilities that clinical healthcare professionals have for addressing obstacles to work participation within a clinical encounter.In CWIC, on the other hand, healthcare professionals are guided by the understanding that work and health (including medical decisions) affect each other to support patients.As such, CWIC necessitates a broader perspective than merely focusing on the obstacles that patients encounter for work participation.At the same time, CWIC is less compelling by leaving out what the responsibility of the clinical healthcare professional should be in comparison with work-focused healthcare.
Within hospital-based healthcare, however, CWIC is not always applied by the medical specialist [19][20][21][22].One reason for this may be that, in general, medical specialists take a disease-oriented focus instead of understanding work participation as a treatment goal [16,23].Furthermore, medical specialists can experience difficulties with the patient's trust when their professional opinion of work ability assessment differs from the patient's own opinion [10,24,25].However, it is unknown to what extent medical specialists do provide CWIC and what the nature of this care is.It is also unclear what policy documents and medical guidelines say with respect to what medical specialists are obliged to do for the provision of CWIC.To identify the key characteristics of providing CWIC, a scoping review is most suitable [26].Therefore, we conducted a scoping review to systematically map the extent and nature to which medical specialists provide CWIC.Furthermore, we augmented these findings with what is described in international policy documents and medical guidelines regarding the provision of CWIC.The following research questions were formulated: (1) To what extent do medical specialists provide CWIC and what is the nature of this care?(2) To what extent do policy documents and medical guidelines provide information on what medical specialists are obliged or recommended to do regarding the provision of CWIC?

Methods
This scoping review was conducted in accordance with the methodological framework outlined by the Joanna Briggs Institute [27,28].The framework was used to develop our protocol, which is available upon request from the corresponding author.One of the purposes of a scoping review is to identify the key characteristics of a concept, which in our case is the provision of CWIC [26].The PRISMA extension for scoping reviews (PRIMA-ScR) was used as a guideline for reporting [29].

Eligibility Criteria
All studies or documents that aimed at medical specialties treating patients within the working age population (18-67 years) with primarily somatic problems in secondary or tertiary clinical health care were included.Excluded medical specialties were pediatrics, neonatology, geriatrics, psychiatry, pathology, primary health care, and occupational health care, since these specialties either do not treat patients within the working age population, focus on mental health problems, or are not situated in secondary or tertiary clinical health care.To be included, studies from scientific literature or documents from gray literature had to address the extent or nature of the provision of CWIC by medical specialists or provide information on what specialists are obliged or recommended to do regarding CWIC.For the purpose of this study, we operationalized the provision of CWIC as collecting information on occupational status; exploring work-relatedness of a disease (etiology); opening a dialogue on work (by who and when in the patient's journey); offering support, information, or advice about work participation (including resources used by medical specialists); considering work in a treatment plan; offering work-related support regarding local regulations; and cooperating with other (medical) disciplines regarding work (interdisciplinary cooperation).To answer our first research question on the extent and nature of the provision of CWIC by medical specialists, information could either be reported by medical specialists themselves or be derived from the perspectives of patients, other healthcare professionals, or institutes in which medical specialists worked.We focused on original research and included qualitative, quantitative, and mixedmethod studies.For our second research question (i.e., to what extent do policy documents and medical guidelines provide information on what medical specialists are obliged or recommended to do regarding the provision of CWIC), gray literature was explored, and information was derived from official reports on policies and vision documents to review the societal perspective and medical guidelines to review professional standards.Studies and documents had to be published in English or Dutch to be included.

Information Sources and Search Strategy
The following bibliographic databases were searched: MED-LINE, EMBASE, Psychinfo, CINAHL, and Web of Science.We screened articles published between January 2005 and October 2021.The "PCC" mnemonic (population, concept, and context) [28], which is commonly used in the context of scoping reviews, was used to structure the search strategy.The search strategy can be found in Supplementary file 1.The search results were imported in EndNote to de-duplicate the dataset [30,31].After de-duplication, the results were exported into the online systematic review tool Rayyan Systems Inc. (rayyan.ai) for the selection process.
The scientific database search was supplemented with a search of gray literature from international governments and health organization websites.A list of websites is provided in Supplementary file 2.

Selection Process
The selection of the scientific articles was performed by all authors in two steps.After screening the titles and abstracts for relevant articles, full-text screening to check articles according to the eligibility criteria was completed.All articles were screened by the first author (LK) and independently by one of the other authors.During the full-text screening, the authors encountered 57 disagreements within the 322 selected publications (17.7%).Disagreements were first discussed one-on-one between LK and the other author who had reviewed the publication.In five cases where the conflict could not be resolved one-on-one, disagreements were discussed with the whole team until consensus was reached.It was decided that articles that used the same data would be combined and reviewed as one study.The gray literature search was performed by the first author (LK).The eligibility of the documents that were identified were discussed with the team.

Methodological Quality Appraisal
Methodological quality appraisal would not contribute to our study aims to retrieve information on the extent and nature of CWIC and what specialists are obliged to do regarding CWIC, because we expected heterogeneous results.Therefore, consistent with guidance on scoping review conduct [27,28], we did not appraise methodological quality or risk of bias of the included studies.

Data Extraction
From all included studies, we extracted data on study characteristics (i.e., author, year of publication, study aim, study design, study sample, and period and country of data collection) and key findings.Since the aim was to retrieve information on the extent and nature of providing CWIC within current practice, key findings-for example, use of existing programs to detect occupational disease or existing guideline-could in theory also be derived from introduction, methods, and discussion sections of the studies.From all included policies and guidelines, we extracted data on document characteristics (i.e., title, source, and year of publication) and key findings.
Data extraction was performed by LK and discussed with AdW.Two qualitative articles and ten quantitative articles were checked by AdW for inconsistencies in the data extraction.All findings from the gray literature were checked by AdW and discussed between LK and AdW until consensus on eligibility was reached.Any uncertainties related to data extraction were discussed with the whole team.

Data Synthesis
Data synthesis was executed in four steps.Firstly, we defined six main categories, grouping the variables according to our operationalization of the provision of CWIC into logical clusters.These categories were defined to facilitate the integration of all data sources into a coherent understanding to the current and expected provision of CWIC by medical specialists.The categories were (1) exploration of work and disease work-relatedness by medical specialists, (2) discussing work-related concerns with patients, (3) the nature of the work-related advice given to patients, (4) other workrelated support for patients, (5) interdisciplinary cooperation between medical specialists and other healthcare providers, and (6) medical guidelines integrating work and the use of these guidelines by medical specialists.
In the second step, we started with the synthesis of the qualitative articles, since qualitative research synthesis can create a renewed interpretation or conceptualization of a phenomenon-in our case, CWIC-that is not merely a summary of the original data [32].For the qualitative data synthesis, we chose a meta-aggregative approach [33].This approach consists of two procedures [33].Firstly, all qualitative findings were labeled and organized into subcategories.Next, these subcategories were classified into the six categories defined a priori in our first step.The qualitative description of these subcategories created the core of the results.
In the third step, a data extraction form was used to separate the findings of the quantitative studies into the six main categories.These findings were then integrated with the qualitative description to support each subcategory.
Lastly, a separate description was made of the policies and guidelines to describe the extent to which medical specialists are obliged or recommended to provide CWIC.To guide this description, the six categories that had been defined a priori were again utilized.

Study Selection
The selection process is visualized in Fig. 1.In total, we included 75 articles in this review.Several articles reported on the same dataset.After combining these studies, we included 70 unique studies.The gray literature search resulted in 55 additional policy documents and guidelines.

Synthesis of Findings
Table 2 provides an overview of the six main categories with their subcategories and the corresponding studies that provided the findings.Most qualitative studies contained information covering four to five categories.Most quantitative studies provided information on only one or two categories.Details of the extracted quantitative findings (organized per main category) can be found in Table 3.
Detailed descriptions of all subcategories are provided below.

Collecting Information on a Patient's Occupation
The initial step in exploring work or detecting work-related health problems is to collect information on a patient's occupation, such as by asking about the patient's current job or occupational status [38].This practice varied from 10 to 93% [61,82,83,87].One study reported that orthopedic surgeons did not collect information on their patient's occupation routinely nor in any standardized way [38].In contrast, the surgeon (5%), the rehabilitation physician (4%), and the orthomanual physician (1%) [92] Fowler 2019

Colorectal surgery
The reported surgeon's choice of treatment in a clinical scenario describing a patient with grade IV hemorrhoids with preference of prompt RTW after surgery, percentage of surgeons (n = 82): -Stapled hemorrhoidectomy or Doppler-guided hemorrhoidectomy, in concordance with guideline recommendations, 58% -Conventional excisional hemorrhoidectomy; despite the reportedly longer return to normal activities post-procedure, 36% Grevnerts 2018 Orthopedic surgery and physical therapy Percentage of orthopedic surgeons (n = 98): -Who would advise surgery when patient's occupation is physically demanding for the knee and requires knee stability: 96% -Reporting knee instability in working situations as the most important factor for advising surgery: 2% -Reporting work in combination with other factors as the most important for advising surgery: 6% [66] Grewal 2014 General surgery Acute trusts providing inguinal hernia repair (n = 128) reported a wide variation in the advice given to patients by their operating surgeons regarding the time to return to work: -Open inguinal hernia repair: From 1 week to 4-6 weeks for office work; from 2 weeks to 6-12 weeks for manual labor -Laparoscopic inguinal hernia repair: From 1 week to 2-4 weeks for office work; from 2 weeks to 2-4 weeks for manual labor [86] Hayman 2021 Emergency health care Advice to remain home for minor illness (n = 182): most physicians answered that they advise patients to remain at home for minor illnesses; however, the duration of exclusion from work varied; for influenza-like illness, the median was 4 days, 6.5% answered until fever resolves; for upper respiratory tract infection, the median was 2 days, 7.1% answered until fever resolves; and for gastroenteritis, oncologists in another study were facilitated in collecting occupational data by an interview sheet [83].

Establishing Work as the Cause of Injury or Disease
To make a proper diagnosis and treatment plan, it can be necessary to establish whether work is the cause of the injury or disease.According to medical specialists, when conducted within the context of injured workers' compensation regulations, this can be an obligatory and difficult task [43,53].It can also be routine practice in many facilities [87].To diagnose occupational disease, such as occupational asthma, history taking of workplace exposure and specific diagnostic tests are part of the clinical practice to establish work as the cause of disease [60,70,77].

Exploring the Context of Work to Provide Advice
A qualitative study stated that the initial evaluation of a medical condition relies on a biomedical model and uses a disease-centered focus, whereas when work-related advice is needed details of the patient's occupation must be explored and taken into account [53].Although work was not the most important factor, several studies revealed that work-related factors also influenced medical decision-making [36,38,45,65,66,105].This was reflected in both the medical specialists' advice as well as in the patients' decisions to have certain treatment.

To Discuss or Not to Discuss Work-Related Concerns
Most studies that addressed this category reported that discussing work was not routinely embedded in clinical care [36,37,39,44,46,48,55,56] ranging from 15 to 52% [47,58,95,96].One exception was found in rehabilitation care, in which 84% of the centers reported that obstacles for RTW were discussed in their center [87].Furthermore, in recent years, some specialists have started to address work more frequently [44,55] and 94-96% of the specialists provided RTW support when it was specifically asked for by a patient in to recent studies [72,82].

Timing of Discussing Work-Related Concerns
When work-related concerns were discussed, this could occur throughout all stages of care.Early recommendations have been shown to be critically important for those patients who receive them, since their clinical healthcare providers were the first point of contact to provide information on how to best proceed with work participation [50].Yet, the timing of discussing work-related concerns ranged from early in treatment [44,50,53] to being first discussed during followup care [36,41,44,46].

Initiator of the Discussion About Work
All studies that addressed this category reported that conversations about work were started by the patient [35,43,44,48] or reported that work-related advice was given when a patient asked for it [72,82].Patients who initiated the discussion included self-employed individuals [35], cancer survivors who asked for permission to RTW [44], patients who applied for insurance benefits and required medical information to provide to their insurer [48], and patients involved in worker injury claims [43].

Providing General Health Advice
Providing a patient with general health advice is a part of providing work-related advice, such as advice on the use of barrier creams in a case of occupational contact dermatitis [97] or advice on mental health for postpartum women in RTW consultations [98].Although general health advice is part of work-related advice, it was sometimes shown to be the only advice being provided during work-related consultations.This was regarded by medical specialists as well as patients as insufficient and lacking the necessary practical details for work-related situations [35,44,48,49].Such advice entailed, for example, providing information on side effects, fatigue, or altered general performance [35,44,48] or advice to keep wounds dry, avoid heavy lifting and 'do not force yourself' [35,79,92].

Patient-Physician Collaboration in Work-Related Advising
Some patients were guided by advice from the medical specialists [36,78,104].However, decisions about work (e.g., when to RTW, whether to make work adjustments) were in the end dominated by the patients' decisions or self-management strategies instead of being a result of collaboration with the physician [34-36, 45, 53, 69, 78, 106].

Staying at Work and RTW Advice for Temporary Conditions and Post-operative Periods
Work-related advice for temporary conditions and post-operative periods focused on appropriate recovery time before RTW (in cases when ceasing work activities was temporary recommended or assumed) [35,49,64,69,78,79,85,86,88,91,99,101,102].The judgment of whether or not a patient would be able to return to their current job following surgery was based on the physician's perception of the physical job demands (i.e., desk based versus manual labor) [35,38,64,79,85,86].However, large discrepancies in RTW advice were shown between providers [78,79,85,101].Some studies mentioned that more individually tailored RTW advice depended on the situation of the patient, including recommendations regarding work adjustments (e.g., advice to temporarily cease specific activities that might aggravate a surgical wound or impact a reduced immune system) [35,49,64,79,88].Others reported specialists paying attention to the patient's perceptions and expectations toward their conditions and prognosis [38,52,53].Patients who were limited in their work activities due to incapacity to drive to their workplace commonly received information on when they could return to driving [49,64,79].For diseases with long treatment periods, the impact of treatment on work participation was explained by the specialist (e.g., time investment during oncological treatment) [42,45,54,83].However, from a patient's point of view, this RTW advice was not always sufficiently tailored to their unique situation [49].

Work-Related Advice for Chronic Diseases
Work-related advice for chronic diseases focused on preventing exacerbation by reducing or avoiding specific work exposures [46,60,70,97] or coping with the disease in relation to work (e.g., recommending a reduction in work-related roles, to change work schedules, or to use assistive devices) [37,50,92].Furthermore, for patients who started out with a temporary condition but who could not fully recover and became chronic patients, specialists might advise to consider changing or quitting their job if the job was physical demanding [38,43,100].

Scheduling Care Around Work
In some cases, work schedules were taken into account in treatment and appointment planning [38,83].However, other patients had to deal with hospital appointments conflicting with their working hours [37].

Tailored Vocational Rehabilitation
Some rehabilitation clinics and hospitals offered dedicated vocational rehabilitation programs [87][88][89]103].However, not all patients were referred to rehabilitation programs which provided the vocational rehabilitation needed for RTW [36].

Work-Related Support Guided by Systems for the Rehabilitation of Sick and Injured Workers
Two types of work-related support that were identified are embedded within national systems (i.e., systems for sickness certification and for rehabilitation of injured workers).Within these regulations, medical specialists-or physicians in general-provide sickness certificates or assess a patient's work ability [41,52,54,88].However, some local hospital policies required that the patient must be referred to a general practitioner to get a sick note [90].Sometimes sickness certification was handled as an administrative task and provided without a personal appointment with the patient [59,80].Specialists struggled with work ability assessments [41,42] and sometimes assessed the work ability based more on the patient's opinion than their professional opinion in order to maintain the patient's trust [52].Furthermore, it is not common for specialists to assess whether work adjustments can be made to enable RTW [90].
Most of the included studies on sickness certification were from Sweden [41, 42, 52, 59, 62, 63, 67, 68, 73-76, 80, 81, 93], where it used to be quite common for some specialists to write more than 20 sick notes per week [67,68].The next most common were studies from the UK [49,58,84,90], followed by other countries such as Belgium, Canada, Japan, and the USA where it is also common for physicians to write sick notes for patients [48,54,69,72,83,88].In contrast, medical specialists play almost no role in sickness absence in the Netherlands [107].Specific systems for the rehabilitation of injured workers were described in studies from Canada [43,51] and the UK [53,60].

Providing Work-Related Support in Collaboration with Other Professionals
Work-related support in collaboration with other professionals occurred with varying frequency in multidisciplinary teams or coordination meetings with different combinations of medical specialists, nurses, occupational therapists, physiotherapists, psychologists, social workers, social insurance agents, occupational health physicians, and employers [41,42,53,62,80,83,87,89,108].To plan RTW, face-to-face meetings with all stakeholders were seen as important [42].However, work-related support is not always on the agenda for multidisciplinary meetings that do not have a specific focus on work [44].
To reach stakeholders outside teams or without an established team, communication included written or telephone contact [42,88,89] or patients being used as 'go-betweens' among stakeholders [43,87].

Medical Guidelines Integrating Work and the Use of These Guidelines by Medical Specialists
Several studies mentioned that guidelines to provide workrelated support were not available [35,48,53,70,77,82,99,102,106], which caused advice to be unreliable or not provided systematically to patients [35,48,53].Instead, advice was based on personal judgment and expert opinion and included using other information resources, like journal articles [35,53,70,82,106].In some institutions, local policies for providing work-related support, including sick listing, were available [69,81,88,89].For some patient groups or diseases, national guidelines were available [60,64,65,68,78,79,84,86,89,97].Medical specialists often were not aware of these guidelines (up to 100% of the sample in one study [64]) or did not follow or use them which ranged from 26 to 71% [68,84].Furthermore, some studies showed that there was not always consensus on the appropriate RTW advice within these guidelines [64,78,86].

The extent to which policy documents and medical guidelines provides information on what medical specialists are obliged or recommended to do regarding the provision of CWIC
We describe the findings from the gray literature from a societal perspective (i.e., policy documents) and professional medical standards (i.e., medical guidelines) that provide information on what a medical specialist should do or is recommended to do regarding the provision of CWIC.The findings of the gray literature can be found in Table 4.The sixth category (i.e., medical guidelines integrating work and the use of these guidelines by medical specialists) was omitted, since medical guidelines themselves do not provide information on their use by medical specialists and the content of the guidelines is discussed in other main categories.

Exploration of Work and Disease Work-Relatedness by Medical Specialists
In some countries (e.g., UK, Germany, Austria), medical specialists are expected to a play a voluntary role in exploring and reporting occupational diseases [111,116,117,137].As a consequence of being voluntary, medical specialists do not always prioritize reporting occupational diseases to public health authorities [113].Several guidelines state that a medical specialist should explore work when taking down a patient's history to detect work-exposure risks early [143,153,156].Furthermore, guidelines recommended that work impairments be explored to classify disease severity [152] or to start treatment [142].

Discussing Work-Related Concerns with Patients
One vision document stated that individual doctors need to have RTW as an outcome objective when treating patients [110], implying that work should be discussed.Furthermore, several guidelines stated that a medical specialist should address work throughout all treatment phases to assess vocational rehabilitation needs early on to stimulate work participation and prevent delay in RTW [140, 142, 145-148, 150, 151, 154, 155].

Nature of the Work-Related Advice Given to Patients
Although medical specialists are expected to provide work-related advice to patients, information on the nature of this advice is limited in guidelines and does not include details in terms of days to RTW [144,154,161].Furthermore, instead of including specific information themselves, several national guidelines [146-148, 154, 163] refer to two comprehensive guide dedicated to supporting people to RTW [140] and supporting work participation in cancer treatment [145], respectively.

Other Work-Related Support for Patients
To encourage people to attend cardiac rehabilitation, one guideline recommended scheduling care around the working lives of patients [141].Rehabilitation guidelines themselves often state that patients should be provided with information about work participation after rehabilitation [158,161] or include a dedicated chapter on vocational rehabilitation [157,159,160,162,163].A subcategory which was not identified from the bibliographic database search was prevention of work-related disease.This topic was covered by one research review, which stated that it is necessary to organize a multidisciplinary team, including a physician to support workers with multiple sclerosis to prevent developing musculoskeletal disorders [138].

Interdisciplinary Cooperation Between Medical Specialists and Other Healthcare Providers
In the RTW rehabilitation process, medical specialists are one group among many other stakeholders (as outlined by many European policy reports, a research review, and one guideline) [118-136, 139, 145].Coordination between these stakeholders should be maintained and encouraged, since a lack of coordination between medical doctors, vocational rehabilitation providers, and the workplace impedes or delays RTW [109,118].However, in many countries, there is little or no structure embedded within the systems to serve such cooperation, which limits the cooperation between the stakeholders [118].Several medical guidelines did recommend referring patients to vocational rehabilitation or occupational health care [147][148][149]151].Policy documents reported that medical specialists should provide some degree of CWIC [109,110,116].Consistent with this demand, a few recent studies within our review reported that work-related conversations between medical specialists and patients occurred regularly [44,55,72,82].Yet, this still was often found not to be the current practice [36-39, 44, 46-48, 55, 56, 58, 82, 83, 95, 96].Furthermore, all studies included in this review that reported on the question of who initiated the conversation about work stated that these conversations were dependent on the initiative of the patient [35,43,44,48,72,82].From the perspective of hospital-based health care, this could be explained by the fact that historically the domain of occupational health and safety was not allocated to clinical health care [164].In many countries, occupational health care was not part of primary care either, and general practitioners similarly reported that they sometimes inquire about the work of the patient but do not document this [165].This historical position of workrelated care as the sole domain of occupational health and safety could also be the reason why medical specialists are not always educated during medical training on work-related topics, as many specialists report [43,48,57,61,69,84,116,166].This lack of expertise and knowledge of occupational health and safety has been similarly indicated by general practitioners [165,[167][168][169][170][171].Furthermore, it could explain the limited information from guidelines that we found in this review [35,48,53,70,77,82,99,102,106,144].Both lack of education and lack of guidelines have influence on the specialists' work-related advice, which according to medical specialists as well as patients is often insufficient due to lack of practical applications fit for work-related situations [35,44,48,49].However, patients require personally tailored information to support them in their work-related goals as an outcome measure of good health [36,37,46,49,52,172,173].
During the gray literature search, we included most policy documents and medical guidelines from the last seven years, because older documents and guidelines did not mention aspects of CWIC that should be provided by medical specialists.This could be explained by an altered paradigm of health care in which health is increasingly regarded as the ability to adapt to the physical, emotional, and social challenges of life instead of merely the absence of pathology [174,175].Within this paradigm, health is not defined by a physician but by the person according to his or her functional needs.Secondly, more recent changes in the demographics of workforces makes it increasingly important for policy makers to take measures to maintain health, since the relative number of working patients will globally increase in the coming decades [1,8,176,177].Therefore, policy makers ask for more attention toward work from clinical health care [10,18,20,22,109,110].
Furthermore, our results show that work-related guidance is frequently embedded within legislation, such as regulations on sick leave or worker injury [41,52,54,88,118].Such national regulations could serve to stimulate more conversations about work [20,52], because they could provide financial means to increase the number of healthcare providers that support patients with their work participation.However, regulations also come with challenges of integrating the topic of work into clinical health care.Firstly, regulations can trigger tension in the physician-patient relationship [48,52].Insurance agencies often play a role in executing regulations and can have different interests and perspectives than patients have (i.e., differing opinions about the patient's capacity to RTW which influences whether the patient is eligible for disability benefits).This places the medical specialist in a difficult position when he or she is obliged to make a recommendation about work ability.Furthermore, the nature of the information that insurers can request is not always regarded to be within the medical specialists' mandate of care [43,48,51,53].For example, the insurer may ask how many pounds a patient can lift of an oncologist, which is not within the scope of interest for oncological treatment [48].This can result in a specialist responding negatively toward the insurer regarding the patient's work capacity and thereby negatively affect the patient's work integration [43,48,51,53].Moreover, to support patients with work within regulations, medical specialists need other professionals to refer their patients because providing the full scope of workrelated support is beyond most specialists' expertise [53,54].However, communication between all professionals who play a role within these regulations is often difficult, since it is hard to reach the others by telephone [43,51,87].In summary, acting in accordance with legislation has become a difficult task for many specialists, which hinders making work participation an important treatment goal [41-43, 51, 52, 90].

Methodological Considerations
We performed a comprehensive search for this scoping review using different perspectives to examine the extent and nature of providing CWIC and what is obliged or recommended regarding CWIC in current practice.By doing so, we could review the full scope of how medical specialists provide CWIC and augmented this with what specialists are obliged or recommended to do as described in policies and medical guidelines.This resulted in a heterogeneous assembly of findings.Using a qualitative analysis technique, we were able to structure the different perspectives and outcomes into a coherent narrative.
Our final search resulted in more than 20,000 results and screening and selection of these many hits was prone to selection bias.To reduce this bias, we performed all screening phases in duplicate.We attempted to reduce the number of hits by trying out different combinations of words in our search strategy and applying filters, since we were not interested in aggregated evidence, such as systematic reviews.However, to detect all studies we were beforehand familiar with a sensitive search was needed.This resulted in the comprehensive search we finally used for this scoping review.
During the gray literature search, we selected our sources based on our own expert opinion and mainly focused on European documents.However, we were limited by language restrictions and therefore, it is likely that we missed several important documents in languages other than Dutch and We especially suspect this bias with the guidelines.This could have impacted our findings, because in other countries, the professional standard might be different (for example, because legislation provides no incentive to include RTW as outcome objective in clinical care) [129].Although we suspect bias in the gray literature by limiting our sources and languages, adding the gray literature allowed for triangulation.This let us combine data sources and review the concept of CWIC from different perspectives by exploring our two research questions.From there, we could understand that in different countries, different regulations exist, which in turn have differing impact on the extent to which medical specialists provide CWIC or are obliged to do so.
The information the different evidence provided ranged from a single useable quote or outcome to a complete study about our topic of interest.Although a single quote will only have informed one subcategory, this imbalance must be considered when interpreting our results.Therefore, we provided a list of studies which covered each category (Table 2) to guide the reader with this interpretation.Reviewing this table, we suspect an underreporting in the literature on the extent to which medical specialists practice CWIC.For example, to discuss work-related concerns with a patient, a specialist will probably start by asking what occupation the patient has.Yet, studies reporting on having discussions about work did not all report on collecting occupational information (most likely due to their different study aims).This will not have affected our findings on the nature of CWIC, but more evidence on the extent to which CWIC is provided needs to be explored and reported in literature.

Implications for Practice and Further Research
Our results show that actual discussions about work with patients are lagging behind the growing demand from policies and guidelines to provide some degree of CWIC in clinical health care.Furthermore, conversations about work are often initiated by the patient.However, there is an increasing understanding among medical specialists about the importance of work in recent years.Attention to work participation from the start of a diagnosis is important, because it results in better outcomes for patients, employers, and hospital physicians [3,42,178,179].Additionally, when patients receive work-related guidance, they are better empowered to make decisions related to work participation problems [50,180].
In many countries, healthcare systems are not designed for optimal attention to work in clinical health care, which is a barrier for CWIC.National regulations to reduce sick leave actually hinder a medical specialist's ability to be open in a conversation about work due to fear of tension in the patient-physician relationship [10,48,52].However, these national regulations can also work as a stimulant for conversations about work [20,52], because they could provide financial means to increase the numbers of healthcare providers supporting patients with their work participation.It is key to improve the coordination and cooperation between all involved professionals [43,51,109,[118][119][120][121][122][123][124][125][126][127][128][129][130][131][132][133][134][135][136]139].How the existing regulations can best be used and what their corresponding limitations are will differ between countries [181].Unraveling this question could be a topic of further research, within which the influence of jurisdiction in different countries on provision and content of CWIC might also be explored.
For an individual specialist to provide CWIC, knowledge and medical training are needed.Knowledge could be captured within clinical guidelines [68,81].However, it is known that it might take decades for healthcare professionals to apply new evidence [182].Future research should focus on the aggregation of evidence in guidelines and guideline implementation strategies [68,93,178].This research might also reveal critical knowledge gaps.Furthermore, medical training for medical specialists is needed to support patients in healthy work participation.This training should focus on the importance of work as a clinical outcome [61,166,183], occupational disease [70,77,116], applying local regulations [54,57,62,68,84], and supporting patients in their personal coping with challenges regarding specific workrelated situations [34,40,50,108].

Conclusion
Medical specialists often provide some degree of CWIC.This may range from asking about the patient's occupation to extensive collaboration with the patient or other healthcare professionals to support work participation.Yet, conversations about work participation are not routinely embedded in clinical practice and are mostly initiated by the patient.Furthermore, medical guidelines are often limited in their availability or lacking useful information about what to advise patients about work.In recent years, society has increasingly expected medical specialists to provide some attention to work participation (e.g., by collaborating with occupational healthcare specialists or include RTW as treatment outcome), which is in line with recent studies that show an increasing tendency to discuss work between patients and medical specialists.Due to the expected rise in the number of people of working age with a disease, integrating work into clinical health care becomes increasingly important to sustain a healthy workforce in the future.

Table 1
Overview of the characteristics of studies included in this scoping review

Table 2
Overview categories and subcategories and which studies covered them

Discussing work-related concerns with patients
OncologyOncologists' practice (n = 6) of discussing strategies to integrate treatment with educational, employment, and social lives (on 5-point Likert scale from unlikely(1) to likely (5)): 1 (0.8), median (IQR) Tsang 2020 Orthopedics Percentage of orthopedic surgeons providing RTW advice when a patient specifically asked (n = 78): 96% Percentage of surgeons reporting whether patients in work and intending to return to work after surgery receive additional advice and support during their in-patient stay or after discharge (n = 78): 8% [82] Zegers 2020 Oncology Cancer survivors' indication that a healthcare professional within the hospital had discussed the work-related consequences of cancer and/or its treatment with them (n = 3500): 992 (32%); of these conversations, 508 (53%) were with a physician or medical specialist [96] Nature of work-related advice given to patients at 12 weeks No information reported on return to work form hysterectomy 'patient information' leaflets (n = 10) Consultant responses for Birmingham hip resurfacing procedures (BHR) (n = 13): -Advice regarding office work: 6 (46%) orthopedic surgeons advised RTW within 6 weeks -Advice regarding moving and handling (M + H) duties: 8 (62%) orthopedic surgeons advised RTW within 12 weeks -Advice regarding heavy physical work: 10 (77%) orthopedic surgeons would only occasionally advice return to heavy physical work Note: 3 orthopedic surgeons (23%) advocated RTW within other periods of time, including a return to desk work within 2.5 weeks and longer than 12 weeks if other joint problems were present Specific return to work times were stated in 4 BHR 'patient information' leaflets (n = 11).Three advised RTW within 6-8 weeks of surgery Without stipulating any limitations on the type of work other than general activities to be avoided such as squatting, twisting, or prolonged standing.One advised return to office work after 6 weeks but if work involved prolonged standing, the patient should refrain from work for 3 months [64] Clinch 2009 Obstetrics There was substantial variation in the content of women's RTW discussions with healthcare providers: -Content of RTW discussions with Prenatal Health Care Provider (n = 131) concerned: 19.5% maternal health (i.e., physical or mental); 10.6% infant's health or development; 23.6% both mother and infant's health; and 46.3% other -Content of RTW discussions with Infant's Health Care Provider concerned (n = 125): 8.4% maternal health (i.e., physical or mental); 33.6% infant's health or development; 22.7% both mother and infant's health; and 35.3% other [98] Rheumatology Advice from rheumatologists (n = 78): -8% gave organizational advice, including advice such as adjustment of tasks or work schedules -3% gave technical advice, including advice such the application of assistive devices (e.g., application of a knee table to write) -13% gave personal advice including personal adjustments to maintain work ability, which were not specific (e.g., 'do not force yourself') Receiving advice on how to maintain work ability from other medical specialists:

Interdisciplinary cooperation between medical specialists and other healthcare providers
median was 2 days, 9.0% answered until fever resolves Percentage of respondents who believed that a patient is capable of determining when to return to work (n = 182): most of the time 82.8%, sometimes 17.2%, and Start of the program: when the patient arrives for transplantation, 6%; as the patient is preparing to leave the center, 19%; at the one-year follow-up visit, 6%;and when the patient is ready to participate, 38% Sickness certification: 85% of all centers completed disability paperwork at > 1 year post-HCT for patients who are actively under their care -Criteria for considering a patient disabled include: the patient reports an inability to work, 38%; the patient has persistent or relapsed disease, 78%; the patient is still on immune suppression drugs, 38%; the patient has ongoing health complications and/or chronic graft versus host disease, 89%; and to maintain the TIP) is a specific tertiary interdisciplinary in-patient prevention measure program developed for severe cases of occupational skin disease (OSD), in which outpatient prevention measures are not successful.This program was established in 1994 as part of regular health care.In total, 1486 patients took part in TIP between 1994 and 2003 TIP consists of several components: -In-patient phase of 2-3 weeks in which dermatological and health educational measures are central.Dermatological therapy is carried out by dermatologists specialized in occupational dermatology.The health educational measures are organized interdisciplinary and run parallel -Outpatient no exposure phase of 3 weeks in which dermatological therapy is continued by the local dermatologist -Each patient will stay out of work for usually 6 weeks to allow full recovery.At the end of this period the patient returns to his workplace under further dermatological care and with the provision of optimized skin protective measures as well as optimized work organization measures.The medical course is continuously documented -In parallel, an intensified health educational intervention is carried out via group seminars and individual consultations with regard to the required, occupationspecific skin protection in each individual case (i.e., skin protective measures are tested with the support of occupational therapists in models of workplace environments; health-psychological interventions are offered; consultations with specialized job consultants of the statutory employers' liability insurances are provided regarding insurance/legal questions or to initiate changes in the work organization and work environment) Emergency medicineAcute low back pain that was the result of a work-related injury was shown to have an inverse relationship with the likelihood that an opioid was prescribed by emergency physicians.Patients (n = 162) whose injury was work related were less likely to receive an opioid prescription (p = 0.027, 95% CI)[105] Jenny 2016 Orthopedic surgery From the study protocol, progressive RTW was allowed according to patient's decision.No restriction was imposed by the physician at any follow-up time or for any work activity [106] Keegel 2007 Dermatology Advice from dermatologist in cases of workers suspected of occupational contact dermatitis (n = 44): -Percentage of dermatologists providing general advice on medical treatment and preventive measures: oral steroids/immunosuppressive agent, 54.5%; corticosteroid creams, 9.1%; corticosteroid ointment, 43.2%; topical corticosteroid not specified, 34.1%; moisturizing cream, 9.1%; moisturizer not specified, 18.2%; using gloves, 38.6%; using soap substitute/avoiding soap, 0%; antibiotics, 22.7%; and antihistamines, 0% -Percentage of dermatologists providing general advice for further diagnostics: fungal scrapings or radioallergosorbent test, 4.5% -Percentage of dermatologists providing specific work advice: avoidance/modify duties, 20.5%; change of job, 4.5% -Referring practices: treat patients independently, 2.3%; refer on initial presenta-

Table 4
Characteristics and findings of gray literature

Table 4 (
country inventories were made by the EU-OSHA.However, the excluded documents had no reference to a medical specialist within these documents 30n total,30