Propagating the new work disability paradigm for disability benefits & workers' comp systems



The American College of Occupational & Environmental Medicine (ACOEM). Founded in 1916, ACOEM is the nation's largest medical society dedicated to promoting the health of workers through preventive medicine, clinical care, research, and education. The American College of Occupational and Environmental Medicine (ACOEM) represents more than 5,000 physicians and other health care professionals specializing in the field of occupational and environmental medicine (OEM).

ACOEM guidelines and guidance statements

ACOEM publishes numerous books, reports, and position statements, as you can quickly see on their web site at Due to some terminology confusion that has since been addressed, two very different publications were originally called "guidelines" - (a) the medical practice guidelines and (b) the paper on preventing needless work disability which is the foundation for The 60 Summits Project.

Perhaps the most widely-known ACOEM publication is the Occupational Medicine Practice Guidelines, which are addressed to treating clinicians and which describe specific diagnostic steps and treatments for most common work-related conditions. The Practice Guidelines are several hundred pages long, and are sold on the ACOEM website.

In contrast, the ACOEM paper on preventing needless work disability is a "Guidance Statement," which is a much shorter document addressed to all stakeholders, and which describes in general how to make a shared process work better. It is about 20 pages long, and is free on ACOEM's website.


In medicine, this means that something should not be done because it poses a serious risk to a patient, for example giving penicillin to someone with a history of anaphylaxis from previous exposure to penicillin.

Disability, disabled

The word "disability" (or "disabled") has two distinct meanings in American society today.

1. In employers' benefits programs and employment policies, in insurance laws, regulations, and policies, "having a disability" or "being disabled" refers to being absent from work or not working at full productive capacity for reasons related to a medical condition. This is the meaning used in The 60 Summits Project.

2. In equal employment and anti-discrimination programs, the Americans with Disabilities Act, and advocacy organizations, the words "disability" and "disabled" are used to describe physical or functional impairments.

For example, a person who has an impairment that affects one or more life functions is considered to have a disability under the second definition. However, people with ADA-qualifying impairments who are working at full productive capacity would NOT be considered disabled according to the first definition (or work disabled according to The 60 Summits Project), because they are at work.

Disability benefits systems

The disability benefits systems of North America include all the programs that protect workers when they become unable to work for medical reasons - especially those that provide financial support - such as sick leave, workers' compensation, short term disability (STD), long term disability (LTD), and Social Security Disability Income (SSDI) in the United States. Other closely related programs include the Family Medical Leave Act (FMLA) and the ADA (in the US) and their Canadian counterparts, though they do not pay benefits per se. The estimated total annual cost of disability benefits paid under all these systems in the US exceeds $100 billion.

Every disability benefit program usually requires a physician's signature on a letter, note, or form of some kind before benefits can be awarded or denied. Other than that one similarity, disability benefit programs and the processes for administering them are better characterized by their many differences. Each has its own complex rules and processes for eligibility determination and for administration of benefits. Experts in one system often do not know much about the others. Each of the programs has generally received significant study and attention on process improvements and benefit program design, but each one has been considered in isolation. The programs are not knit together into a coherent, coordinated whole, and the whole has not received similar attention to potential improvements.

Iatrogenic invalidism

This is a term we have coined. Iatrogenic usually refers to an unfortunate medical event that was caused by the doctor, the hospital or the healthcare system. In our usage, we broaden the meaning to include adverse outcomes caused by the failure of the stakeholders to respond appropriately to the needs of the injured or ill worker and collaborate in driving the episode towards a good outcome. Invalidism refers to a state in which people see themselves (inaccurately) as invalids, as people who "can't". And, unfortunately, once someone believes they "can't", that point of view becomes a self-fulfilling prophecy.

Medically-discretionary disability

Lost workdays and productivity due to a discretionary decision by an individual or a group. A discretionary decision is one that could go this way or that way. Most discretionary decisions are actually business or cost-benefit decisions: How much effort or expense am I willing to expend in order to obtain/deliver whatever productive capacity is available from this worker today? Examples include:

  • "There's nothing useful this person can do."
  • "We don't allow light duty."
  • "I don't have time to fuss with this stuff."
  • "We can't figure out how to provide work within these limitations."
  • "There's no way to get her to work if she can't drive."
  • "Our labor contract prohibits light duty."
Medically-related employment situations

Difficulties at work due to the inability to attend work or situations function at previous levels that are attributed to a medical condition. This includes episodes of workplace absence or withdrawal; questions about fitness for duty; performance problems, discipline, termination or other job loss due to poor attendance or inability to perform.

Medically-required disability

Lost time from work that is required for specific medical reasons due to an identifiable and unavoidable risk to the worker. Also referred to as medically-necessary disability. Absence is required when there is a contraindication to work, such as:

1. The worker requires care in a hospital, day treatment program or has a medical care appointment.

2. The worker is confined to bed or home.

Generally, this is because of (a) prostration and need for rest due to acute response to injury or trauma; or (b) concerns about contagion or immunity.

Note that absence that appears to be medically-required is often really due to circumstances such as the nature of the commute or workplace factors, and not due to the nature of the condition itself. In other words, if the circumstances were changed, the contraindication to working would disappear.

Medically-unnecessary disability

Lost workdays and productivity that are impossible to justify but hard to eliminate completely. Basically, most of this absence is due to the lack of a sense of urgency, to bureaucracy, flabby management, and poor accountability. However, a lot of workdays and productivity are also lost due to delayed, inadequate or ineffective medical care.

Needless work disability

Lost workdays and lost productivity that is not medically required. Needless work disability is either medically-discretionary or medically-unnecessary.

Occupational & environmental medicine

A medical specialty, a part of the general field of preventive medicine health problems or concerns due to workplace exposure.

Occupational physicians prevent and treat work-related injuries (usually covered by workers' compensation) as well as occupational illnesses such as asbestosis, repetitive stress and musculoskeletal disorders caused by exertion and overuse. Occupational medicine also includes worksite wellness and health promotion programs and more recently has begun to include an emphasis on work disability prevention and management as well as workforce well-being and productivity.

Stay at Work / Return to Work
(SAW / RTW) Process

A sequence of questions, answers, actions and decisions made separately by parties in different sectors of society (workers, employers, doctors) that, taken as a whole, determines whether a worker will stay at work in spite of a medical condition, and if not, determines whether, when, and how the worker will return to work during or after recovery. However, this process is often stalled or short-circuited because the focus is on certifying, corroborating, justifying or evaluating the extent of disability rather than preventing it.


All those who get involved in medically-related employment situations or who participate in or have influence over how the stay-at-work and return-to-work process functions: employers, working people, physicians and other healthcare professionals, the disability benefits and workers' compensation insurance industries, regulators, policymakers, unions, lawyers, judges, legislators.

Work disability

Absence or withdrawal from work, or working at less than full productive capacity (e.g., transitional work or "light duty") attributed to a medical condition. See also disability.

Work disability prevention

A secondary prevention technique, in which the focus is on keeping a small problem small, or as the old adage says "a stitch in time saves nine." In the particular context of work disability prevention, the technique can be summarized as "getting right back on the horse and in the saddle." The focus is on preserving or restoring normal daily routine within days or at most a few weeks in order to avert delayed recovery and the development of iatrogenic invalidism.

Work disability prevention is NOT injury prevention, NOT safety, and NOT wellness or health promotion. These are examples of primary prevention techniques which focus on avoiding problems completely.

Work disability prevention is also NOT traditional return to work programs or vocational rehabilitation. These are examples of tertiary prevention techniques, which focus on mitigating damages in situations where substantial harm has already occurred. Traditional return to work and vocational rehabilitation programs typically kick-in after several months or years of absence from work.