The results show that the information on the information exchange form was regarded to be useful. Two participating occupational physicians stated that it was useful and that it helped them to plan the reintegration to work. The orthopedic surgeons answered that the information provided through the forms could be useful for the occupational physicians. However, the form was hardly used by the participating orthopedic surgeons since only 8 patients were included. Of these patients, only 4 gave the form to their occupational physician and one patient answered that it had resulted in better communication. The fact that the form was only used for 8 patients can have several reasons. One possible reason is that the inclusion criteria for the study were too strict. However, in an additional survey among new patients visiting an orthopedic outpatient clinic we have estimated that approximately 4% of all new patients matched the inclusion criteria. This gives reason to believe that our inclusion criteria were not too strict. Other reasons can be lack of time, or the fact that the form had to be filled out before the treatment had taken place. Also, orthopedic surgeons might not see work as an important factor to take into consideration for their treatment; they treat the disorder and advice the patient on functional limitations in general.
It was decided that the form should be filled out early in the treatment trajectory since it was expected that patients would have had their complaints for a longer period already and early intervention can help a worker to return to work faster. This meant that the orthopedic surgeon filled out the form without an information request from the occupational physician, in the same way as the letter they normally send to the general practitioner. The participating orthopedic surgeons stated that the occupational physicians should take the initiative for the use of the form and both orthopedic surgeons and occupational physicians felt that it should only be used in those cases where the patient does not recover as expected. This would save time and occupational physicians will usually only ask for information when recovery does not work out as expected. Hence, the structured form may be used better at a later stage in the treatment trajectory and limited to those patients where it becomes clear that recovery will be delayed. The disadvantage of this timing may be that for some patients the orthopedic surgeon no longer is in charge of the treatment.
The fact that the patient was the carrier of the information was seen as a good and effective way to reach the colleague-physician. Since 2002 a new law has been implemented in the Netherlands, the Gatekeeper Improvement Act (Wet Verbetering Poortwachter), giving responsibility for the duration of sick leave not only to the employer and occupational physician, but also to the employee on sick leave. In this study we gave the patient the responsibility to transfer the information exchange form to the occupational physician, and thereby to transfer medical information on the disorder. In this study, only four forms were given or sent to the occupational physician. The patients not transferring the form to their occupational physician recovered before their first visit to the occupational physician was planned and, thus, the information on the form was not needed to plan the rehabilitation. We have no indication that patients would object against the transfer of medical information from the specialist to the occupational physician. We do not think it is an important barrier in most cases, since in the before mentioned Act patients have the obligation and responsibility to fully cooperate with regard to return to work. Most patients are motivated to support all actions that are necessary for that, including information transfer to the occupational physician. However, a minority of patients could be reluctant to give permission for information transfer to the occupational physician, because they are afraid this information will be given to the employer. Although this is forbidden under Dutch privacy and physician-patient legislation, this fear is sometimes present and is enhanced by the fact that the employer pays for the work of the occupational physician directly or indirectly (via an occupational health service).
In the Dutch health care system the tasks and responsibilities of curative health care and occupational health care are strictly divided. Curative health care providers advice on and give medical treatment and occupational health care providers manage work rehabilitation. An occupational physician is an expert in translating functional limitations to limitations and possibilities at work. The main goal of the information exchange form was to inform the occupational physician on the diagnosis, treatment and functional limitations from a medical point of view. Due to the fact that the occupational physician is responsible for work rehabilitation, the information exchange form was directed to convey information from the orthopedic surgeon to the occupational physician. In other health care systems clinical health care providers can have the responsibility for return to work or the decision that a patient is fit for work. In those cases the information exchange might be directed both to and from the occupational health care in order to provide all parties involved in the management of the disorder and sick leave with necessary information.
Many patients visiting an orthopedic surgeon ask for information about their limitations in daily life related to the diagnosis and prognosis. Work is part of the daily life activities of many patients. However, most orthopedic surgeons, just as general practitioners, are not trained in occupational health [17
]. They might perceive difficulties when asked for advice on the workability of a patient, without knowing the specific capabilities required to work in a specific work situation. In this study, one of the orthopedic surgeons did not want to give information on functional limitations due to fear of possible legal consequences. However, Dasinger [19
] showed that workers with a worker's compensation claim for low back injury are more likely to get off disability-benefit status when they were informed on their readiness to return to work by their treating physician. Early intervention by a treating physician can help a worker to resist the negative effects of a system that discourages early return to work [20
]. Since orthopedic surgeons treat a disorder and do not usually seem to consider work as part of this treatment, this may hamper collaboration.
The question remains whether using this form can improve information exchange. The form was only used for eight patients in this study, of which only four transferred it to their occupational physician. The form is easy to fill out for the orthopedic surgeon and provides the occupational physician with medical information, planning of treatment and information on functional disabilities. However, for orthopedic surgeons filling out the form is extra work in addition to the information on diagnosis and treatment they provide to the referring physician, usually the general practitioner. Two orthopedic surgeons suggested to also giving a copy of this information to the occupational physician. This is not common practice right now and usually does not include information on functional limitations, while the occupational physicians appreciated this information on the form.
In this study the orthopedic surgeons had to add the procedure of filling out the form to their usual work, diagnosing and treating the patient. Since the form was only applicable for a small proportion of patients and will in most cases not change the treatment given by the orthopedic surgeon, implementing it into the routine of medical specialists will be difficult. In the interviews, the suggestion was given to let the occupational physicians take the initiative for information exchange; they need in the information in some cases in order to manage an employee's rehabilitation to work. Furthermore, according to the Gatekeeper Improvement Act, the occupational health service has to give an advice on the prognosis and the possibilities for reintegration for those employees on sick leave for six weeks and who will probably not return to work on short notice. At this moment the occupational physician needs the information as provided on the form, information on diagnosis and prognosis, in order to complete the advice.
The developed information exchange form does not leave room for specific questions regarding the disorder or the patient. Whether using a form on initiative of the occupational physician is more useful than a written request for information or providing the occupational physician with a copy of the letter send to the general practitioner cannot be answered in this study. Further research is needed to answer this question.
Data triangulation was performed by means of interviewing both patients and physicians and by means of a member check: the interviewed physicians were asked whether the results as they are written down were a correct rendering of the information they provided. No medical files or other documentation was used; the data collected in the study was limited to the experience of the patients and physicians with the exchanged forms.
In this study it was decided that the orthopedic surgeon should use the information exchange form early in the treatment trajectory for all patients on sick leave with certain disorders. There was no difference between patients at risk for long term sick leave and patients who would only call sick for some days. However, when patients are on sick leave for only a few weeks, they might not visit their occupational physician. In this study that resulted in three forms not being transferred to the occupational physician. The suggestion to leave the initiative for using the form to the occupational physician might overcome this issue.