In conversation with Barbara Hochstrasser, MD, and Prof. Dr. iur. Ueli Kieser is concerned with the meaning of burnout from a medical and a legal point of view. Furthermore, the associated consequences for the practicing physician are discussed.
From a medical and legal perspective, how do you perceive today’s discussion regarding burnout compared to five years ago; is burnout recognized as a disease or still often perceived as a “fashion construct”?
Dr. Hochstrasser: The discussion about burnout has become more objective in recent years, as the topic is increasingly placed in the context of depression and other mental disorders by experts and especially by the media. De facto, burnout is recognized as a problem by medicine and increasingly by employers. The current discussion focuses on the classification of burnout. In the official classification, burnout is still not classified as a specific mental disorder, but more correctly as a syndrome, which includes various symptom components and which can lead to secondary diseases, e.g. depression.
Prof. Kieser: From a purely insurance law perspective, burnout is still not recognized as an illness. In this respect, nothing has changed from a legal perspective in recent years.
The diagnosis of burnout is associated with a wide range of consequences for the patient in the various areas of life (work, family, finances, etc.). What are the central tasks of the attending physician in the care of burnout patients?
Dr. Hochstrasser: Although burnout does not represent a specific ICD-10 classified disease diagnosis, but is understood as a syndrome, the condition associated with it does have disease value. I.e., the affected person suffers, is restricted in his or her everyday functions and requires professionally appropriate treatment. In addition to the purely medical care of the burnout patient to regain health, an important task of the treating physician is to systemically consider the causes and consequences of burnout on the affected areas of life, such as the professional, family and financial situation. The ultimate goal of treatment is to enable the burnout patient to deal with the consequences and develop a different way of living in the various areas. The attending physician ideally assumes the role of coordinator in the context of interdisciplinary care of the patient.
The disease burnout usually has an impact on the patient’s work situation, which results in labor law issues for the patient and the employer. Does burnout generally represent a new legal problem or are the effects of burnout clearly regulated by labor law?
Prof. Kieser: Burnout does not represent a new legal problem because burnout cases have always been assigned to a medical indication, e.g. to depression or other psychological complaints. However, there is some fear among insurance companies that burnout syndrome could be the coming “big” diagnosis, which could lead to a claim for insurance benefits and thus to a risk of abuse.
What are the main requirements for insurance to cover mental health benefits, such as burnout?
Prof. Kieser: That’s easy to say: there must be a health impairment at the origin due to an illness or an accident. And the health impairment must lead to a reduction in the ability to work. The problem with burnout is that it is not accepted as such as a health limitation. I.e., the starting point for insurance benefits is already missing. This is different, for example, in the case of depression or an anxiety disorder: this is naturally considered a health impairment and is therefore recognized by the insurance companies when it comes to benefits for incapacity to work (e.g. daily allowances).
What should generally be considered when calling in sick and regulating the patient’s employment? What is the role of the attending physician?
Dr. Hochstrasser: First and foremost, the attending physician has the task of defining the resilience together with the patient, taking into account the patient’s state of health. It is desirable that the patient be accompanied by the physician before and during the discussions with the employer. Within the framework of this monitoring, the physician should make recommendations regarding the possible work performance, the type of work as well as possible sources of danger for the patient.
What problem areas exist and what advice can you give to physicians who care for burnout patients regarding cooperation with insurers?
Dr. Hochstrasser: There are basically two aspects to consider. First, the question of cost coverage by the insurer, especially for inpatient stays, must be clarified. The insurer will only cover the costs if there is a clear medical diagnosis. Since burnout does not correspond to a disease diagnosis, a psychiatric comorbidity must be present and diagnosed for the costs to be covered by the insurer. Most severe burnout cases have a psychiatric comorbidity in the form of depression, anxiety disorder, or neuroasthenia (chronic fatigue).
The second aspect concerns the preparation of insurance reports by the treating physician, e.g. in the form of cost credits or the extension of cost credits. It is crucial that, in addition to the symptomatology, the physician provides as detailed and specific a description as possible of the patient’s performance. In addition, it is recommended that direct, personal communication be sought with the responsible case managers of the health insurance companies or daily allowance insurers or IV managers.
Prof. Kieser: The important thing is that the physician should write reports and expert opinions for the attention of the insurance company as comprehensibly as possible, so that a medical layperson can understand them. The basic problem is that much of what needs to be legally evaluated is written in a language that lawyers do not understand. The physician should always be aware that a lawyer is reading the opinion or the physician’s report. Otherwise, one runs the risk that the diagnosis cannot be legally classified with corresponding effects on the case, i.e., that a cost approval can be rejected. In addition, the word “burnout” should not be used in the reports because burnout is not recognized as a disease; thus, from a medical perspective, it is always a matter of making a medical diagnosis (if available).
What should be considered from a medical and legal point of view when a burnout patient returns to work?
Dr. Hochstrasser: A patient’s return to work should not be too early, should be gradual and always depend on the patient’s resilience. The attending physician has the important task here of clearly informing and sensitizing the employer in this regard. Experience shows that the patient needs at least as much time as he was incapacitated for work to regain full capacity.
Prof. Kieser: On the part of the patient, when taking up a new job, there is often a health questionnaire to be filled out by insurance companies, which must be filled out correctly in any case – that is the most important recommendation in this context. From an insurance law perspective, the main problem is often that the new insurance company can make a reservation. Another problem may be that after starting a job, a health problem reoccurs that is related to the previous illness, so that the pension fund of the new employer may argue that the employee came with a pre-existing condition that is not covered by that pension fund.
Two professions (legal and medical) work together across the board to make decisions about the patient, even though they have little knowledge of the other profession. How can you do justice to the patient?
Prof. Kieser: The problem is that different standards are applied by doctors and lawyers, so that the medical and the legal view often diverge on important issues. Today, the laws are designed in such a way that the performance obligations are limited in many cases. A doctor treats and is convinced from a medical point of view that the treatment is right and appropriate. The insurance company takes note of the physician’s determination and determines the obligation to pay benefits, however, only on the basis of legal regulations. It would be incumbent upon the legislature to consider whether medical opinion should be weighted more heavily than legal opinion in matters of duty to perform. That’s why it’s important for doctors and lawyers to stay in conversation and learn from each other.
Which information offers and tools can you recommend to treating physicians who want to learn more about the topic of burnout and labor law?
Dr. Hochstrasser: There are numerous information platforms on the Internet for both medical professionals and patients. We recommend, for example, the platforms www.swissburnout.ch for laypersons, www.burnoutexperts.ch.
for medical professionals and www.stress-no-stress.ch on the topic of stress management. In addition, a major expert conference for professionals will be held in Bern on November 14, 2013. Information on the event can be found at www.burnoutexperts.ch.
Prof. Kieser: Unfortunately, there is currently no legal handbook available for physicians on the subject that deals with the problems and possible solutions surrounding the topic of burnout. Physicians may find helpful the legal books from the Observer www.beobachter.ch, which explain legal issues simply.
