Disabling Backache in France, Switzerland, and the Netherlands: Contrasting Sociopolitical Constraints on Clinical Judgment

Abstract

A century has passed since clinicians assumed a linchpin role in the administration of programs to provide recourse and redress for persons suffering the illness of work incapacity. Medicine was asked to certify whether the illness was an injury in the absence of trauma, to ascertain whether further healing was possible, and to quantify the residual functional capacity. The response has been to force the vagaries of clinical judgment into the programmatic algorithm. No country has abandoned or redirected all three of these charges. Physicians have generally remained passive or intransigent as the society in which they function attempts to compensate for the indeterminate nature of these clinical questions. The current study compares the fashion in which the programs in Holland, Switzerland, and France have evolved in response to the clinical uncertainties. The Dutch have discarded the accident question. The Swiss emphasize the accident issue but consider the work-relatedness of the event to be irrelevant. The French have honed the traditional paradigm and have added a tier of clinical judgment within the program to monitor that without. These and other distinctions should cause all physicians to question their own convictions with regard to the three issues and, further, to question whether the basic paradigm is clinically flawed and therapeutically counterproductive.