How to Improve Patient/employee/injured worker Expectations for Recovery from Injury
by James Talmage and Robert Snyder
The June 2025 REWARD Newsletter article, “Catch–22: Issues with How to Help Injured Workers Return to Work,” pointed out that for the group of injured workers who lags behind the usual recovery curve and who frequently has delayed or failed return to work, the most common reason is the worker’s inability to tolerate chronic pain. This prior issue then explored the published studies documenting that physicians typically lack the ability to affect chronic pain and thus to improve the return-to-work rate in this population.
The June 2025 article inspired this article—that patient expectations help to determine treatment outcomes and thus influence the outcome of return to work.
The article pointed out that many existing questionnaires composed of multiple inquiries had poor validity in identifying workers who would have delayed recovery and lower return-to-work rates. However, the simple, single question, “Do you think you’ll be able to return to work after this injury?”, had strong evidence of predictive accuracy.
This raises the question: if patient/worker expectations of recovery help determine injury outcomes, can the pre-treatment (or early in treatment) worker expectations be modified to improve return to work outcomes?
A recently published article in the Journal of the American Medical Association (JAMA) explored ways that physicians can modify patient treatment expectations to improve treatment outcomes [Laferton, 2025]. This JAMA article on communication with patients is in a journal for physicians with a target audience of physicians. It makes suggestions in four areas, and while it does not estimate the time required to implement these communication strategies, they would likely take more than the 8-15 minutes of “face-to-face” time physicians now spend with patients (due to the economic realities of modern U.S. medicine). [Teunis, 2015; Kedia 2016, Rao, 2019]
Physician practice patterns and behavior are known to be hard to change. [Forsetlund 2009, Lubarsky 2019, Wang 2020] Cunningham [2019] concluded a systematic review, stating, “Physician behavior and specifically surgeon behavior are disproportionately influenced by mentors, fellowship training, and memories of excellent or catastrophic outcomes much more so than literature and data.” (Emphasis added).
While it is unlikely readers will see physicians implement the suggestions for positive communication in this JAMA article, employers can utilize the same three steps to hopefully improve return-to-work rates in those with pessimistic expectations after injury.
Step 1
During the initial contact by the employer, human resources person, or return-to-work coordinator, implement a positive expectation when interviewing the employee while completing the required “Employer First Report of Injury after Work Injury or Illness,” or C-20. The employer (or representative) hopefully can honestly say, “From my experience of similar injuries in our employees, I can confidently say that treatment is effective, and employees with similar injuries at this company do return to work and remain at work with us.” [Set the expectation of recovery and return to work].
Step 2
After the first visit with the doctor or mid-level provider (chosen from the panel), ask open-ended questions:
How do you feel about the treatment/assessment chosen by your health care provider?”
How much do you think this treatment will help you?”
If the employee verbalizes negative thoughts about the treatment chosen, try to frame those positively: “We have seen other employees of our company get well and return to work after this treatment for similar injuries.”
A worker’s negative expectations may be communicated to the case manager (if one has been assigned), thus alerting the treatment provider. Continuing a treatment plan despite lack of improvement and despite negative expectations by the patient is rarely productive.
If the employee verbalizes significant negative thoughts about the health care provider or the treatment chosen, it may be appropriate to speak with the adjuster about a second opinion from a different provider’s office. If the negative comments are about a mid-level provider or their treatment plan, it may be prudent to get the next appointment changed from follow up with the mid-level provider to follow up with a physician.
[NOTE: By law, causation opinions are to be physician opinions and not mid-level provider opinions. A common mistake by insurer/adjusters is to pay for six office visits with a mid-level provider, but when the patient/worker fails to recover, ask the physician at office visit #7 for a causation opinion. It is unrealistic to expect a physician to opine honestly “not work related” after the insurer has paid the physician’s practice for six office visits and physical therapy. If causation is in question, the worker needs to see the physician very early in treatment.]
Step 3
Foreshadow recovery. After office visits with the health care provider or after some number of therapy sessions, ask, “Are you improving with time and treatment?” If the injured worker answers that there has been some improvement, then frame this positively. “The improvement you have noticed is evidence that your body is healing as expected and suggests you may be ready for more activity.”
The JAMA article, in addition to framing communication with positive expectations, pointed out that: “Warmth can be expressed by empathy and verbal and nonverbal signs of understanding (e.g., validating the patient’s concerns, eye contact, affirming nods).”
Conclusion
Incorporation of these ideas into interactions between employer representatives and injured workers will improve outcomes: positive expressions at initial contact, assessment of the provider’s acceptance by the injured worker, and anticipating recovery. These suggestions may help employers encourage a positive perception toward the employer, leading to a better experience and more favorable outcome for all parties when work injuries occur.
References
- Cunningham BP, Bakker CJ, Rarikh HR, et al. Physician Behavior Change: A Systematic Review. J Orthop Trauma 2019; 33: S62–S72. DOI: 10.1097/BOT.0000000000001616.
- Forsetlund_L, Bjørndal_A, Rashidian_A, Jamtvedt_G, O'Brien_MA, Wolf_FM, Davis_D, Odgaard-Jensen_J, Oxman_AD. Continuing education meetings and workshops: e.ects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003030. DOI: 10.1002/14651858.CD003030.pub2.
- Hall AM, Scurrey SR, Pike AE, et al. Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework. Implementation Science (2019) 14:49. https://doi.org/10.1186/s13012-019-0884-4.
- Kedia R, Dargan C, Hassan O, Dasa V. Pain, Functional Scores, and Radiographic Severity of Illness Influence the Perception of Time Spent With the Physician by Patients Presenting for Initial Evaluation of Knee Osteoarthritis. Ochsner Journal 2016; 16: 457–463. PMID: 27999502. PMCID: PMC5158150
- Laferton AJC, Rief W, Shedden-Mora M. JAMA Insights: Communicating Medicine – Improving Patients’ Treatment Expectations. JAMA 2025;334 (2):171-172. doi:10.1001/jama.2025.62
- Lubarsky DA, French MT, Gitlow HS, et al. Why Money Alone Can’t (Always) “Nudge” Physicians: The Role of Behavioral Economics in the Design of Physician Incentives. Anesthesiology 2019; 130:154–70. doi: 10.1097/ALN.0000000000002373.
- Rao A, Shi Z, Ray KN, et al. National Trends in Primary Care Visit Use and Practice Capabilities, 2008-2015. Ann Fam Med 2019;17:538-544. https://doi.org/10.1370/afm.2474.
- Teunis T, Thornton ER, Jayakumar P, Ring D. Time Seeing a Hand Surgeon Is Not Associated With Patient Satisfaction. Clin Orthop Relat Res (2015) 473:2362–2368. DOI 10.1007/s11999-014-4090-z.
- Wang SY, Groene O (2020) The effectiveness of behavioral economics-informed interventions on physician behavioral change: A systematic literature review. PLoS ONE 15(6): e0234149. https://doi.org/10.1371/journal.pone.0234149
About James B. Talmage, MD
Dr. Talmage is a graduate of the Ohio State University for both undergraduate school and medical school (1972). His orthopedic surgery training was in the United States Army. He is Board Certified in Orthopaedic Surgery and was board certified in Emergency Medicine 1987-2017. He retired from clinical practice in April 2016 after 36 years as a treating physician in Cookeville. He was a chapter contributor to the AMA Guides, 5th and 6th Editions, and he was Assistant Editor of the Guides Newsletter 1996 2023. He does peer review of article submissions for 3 orthopaedic journals. [The Spine Journal, Journal of Bone & Joint Surgery, JBJS-Reviews]. In 2013 he was Acting Medical Director for the State of Tennessee Division of Worker’s Compensation. In 2014 he became the Assistant Medical Director. He has taught in Physician CME courses for IAIME, AAOS, ACOEM, SEAK, and the TN BWC. Since 1992 he has given over 900 lectures to physician audiences. He was core faculty for the AAOS Workers’ Compensation Course for 24 years. Currently with the Bureau, he serves as peer review consultant to the Drug Free Workplace Program and the Medical Impairment Rating Registry. He is a member of the Medical Advisory Committee and contributes lectures to the Certified Physician “Best Practices” Course, lectures and articles to the R.E.W.A.R.D. program and articles to the AdMIRable Review. He assists Dr. Snyder with Utilization Review Appeals.
About Robert B. Snyder, MD
Dr. Snyder was appointed Medical Director for the Bureau of Workers’ Compensation in January, 2014 after 37 years of Orthopaedic private practice. A graduate of Wayne State University School of Medicine in Detroit, he completed two years of general surgery training at the University of Pittsburgh before coming to Nashville to complete a residency in Orthopaedics and Rehabilitation at Vanderbilt University. Special activities have included Associate Team Physician for Vanderbilt and Tennessee State University Athletics, Volunteer Orthopaedic Consultant at Fort Campbell during Desert Storm, Orthopaedics Overseas (an affiliate of Health Volunteers Overseas) in Peru, church related mission activities in Honduras, and the 1996 Hospital Strategic Planning Symposium in Prague, Czech Republic. He served as President of the Medical Staff at St. Thomas Hospital in Nashville from 1997 through 1999, and on the Medical Care Cost Containment Committee for Workers’ Compensation from its inception in 1992 until 2014. Dr. Snyder has presented lectures for the American Academy of Orthopaedic Surgeons, Arthroscopy Society of Peru, the American Orthopaedic Society for Sports Medicine, the National Workers Compensation and Disability Conference, the National Association of Workers Compensation Judges, and in Tennessee: the Tennessee Chiropractic Association, the Tennessee Orthopaedic Society, the Tennessee College of Occupational and Environmental Medicine, the Tennessee Pain Society, the Tennessee Neurosurgical Society, the Tennessee Medical Society, and Tennessee Attorney Memo. He has made numerous other presentations to attorneys, case managers, employers, adjusters, and insurers. He is the course director for the Bureau’s physician education program and an instructor for the Certified Physician Program and WorkComp College. His activities with the Bureau include Medical Treatment Guidelines, Utilization Review, Case Management, Fee Schedules, Certified Physician Program, rules, physician/provider communications and staff support for the Medical Advisory Committee and the Medical Payment Committee.
R.E.W.A.R.D. PROGRAM: RETURN EMPLOYEES TO WORK AND REDUCE DISABILITIES
Employees’ perceptions are critical because, more than anyone, injured workers are responsible for their own physical and economic recoveries. Their attitude and approach will define their ability to recover. Their cooperation and participation are gauges to understanding an injured employee’s attitude and beliefs. For more information, download the REWARD Toolkit.
Disclaimer: Views expressed in the REWARD Report are solely those of the authors and may not reflect the official policy or position of the Tennessee Bureau of Workers’ Compensation, the Tennessee Court of Workers’ Compensation Claims, the Tennessee Workers’ Compensation Appeals Board, or any other public, private, or nonprofit organization. Information contained in the REWARD Report is for educational purposes only.