Occupational clinicians often disagree on whether it’s appropriate to include an employee’s diagnosis in their report to the employer. Some clinicians are strongly against this in all circumstances, while others seem to think nothing of sharing highly confidential information. This article explains when not to share medical information and when it can be done judiciously and in a way that’s in the best interests of the employee.
The overriding principle OH clinicians should observe is “If in doubt, don’t share medical details.”
While you have a dual responsibility to the employee and the employer, sharing medical information is one of those aspects of your consultation and report which must be conducted with the employee’s interests first. The exceptions to this are if there’s a legal requirement to disclose information or there is a public interest in doing so. Regulatory and legal advice should be followed here where appropriate.
Gaining the employee’s consent to share medical details like diagnoses is a prerequisite – not only for the consultation to take place and for a report to be written, but additionally as part of a conversation with the employee in which you discuss the information you are planning on sharing, and why you think it best to do so. However, the employee’s agreement it is not sufficient on its own in this situation. If sharing isn’t in the employee’s interests (or the legal/public interest exceptions don’t apply), you should share as little information as possible to advise the employer. If the employee wishes the employer to know such details but you feel it best not to include them in your report, follow your instinct not to disclose. The employee can always inform the employer themselves if they so wish.
Inappropriate oversharing can cause harm in several ways including:
Stigma
Many health conditions are associated with stigma which could adversely affect the employee in the workplace. The impact of this can vary in different cultural contexts; knowledge of a diagnosis of depression may lead to constructive support in some places, yet wrongly be seen as a sign of weakness, or used to delay career progress in others. This can even be the case in different departments of the same company.
Incorrect association
A manager may think they understand the support required by a person diagnosed with a condition because they have managed another person with the same diagnosis. Because the same condition in two different people can vary vastly in nature, sharing a diagnosis without sufficient explanation of its impact on function can result in an employer tailoring their support incorrectly.
Misunderstood diagnosis
It’s very easy to mistake one condition for another. Irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) sound quite similar but are very different. It’s easy to see a diagnosis in a report, search online for it, and draw the wrong conclusions. This can lead to very confusing conversations between employee and employer and incorrectly-tailored support being offered.
As a rule of thumb, the more stigmatizing or difficult to explain the illness is, the greater the potential for adverse outcomes or misunderstanding – and the more likely it is that disclosing is not likely to be beneficial.
When sharing the diagnosis helps
Despite the disadvantages, however, there are circumstances in which sharing or confirming a diagnosis can help the employee significantly. These situations include:
When the diagnosis is obvious
Someone who twists their ankle at work and is using crutches has a medical condition which is not likely to be stigmatizing, the nature of which is likely to be known to the employer. Confirming an ankle sprain rather than a fracture gives the occupational clinician the opportunity to explain that sometimes, sprains can take longer to heal than breaks, and that recovery may be longer than expected (going on, of course, to make a clear plan). Being absolutist about medical non-disclosure here (I’ve seen this in practice, unlikely as it may seem) is not a pragmatic approach and does not help advance the case or the interests of the employee.
When the diagnosis is uncertain or unknown to the employer but misunderstanding may cause greater harm
This can be very tricky to navigate, and often presents itself in situations where employees have mental health problems. It is, in many situations, appropriate to say ‘the employee has a medical condition which results in the following functional limitations...’ However, if the employer is under the mistaken impression the employee has a particular diagnosis, it may be appropriate to correct their understanding, or at least disabuse them of the erroneous assumption they hold. Again, careful discussion with the employee is essential here.
Where the employer (and/or employee) may have an inaccurate understanding of a diagnosis
The experienced clinician has a library of anecdotes of clearing up misunderstandings from consultations with other clinicians. Understanding the circumstances in which a diagnosis or label was applied, and who was making the diagnosis, can be instructive. For example, a junior doctor in the emergency department diagnosing a ‘greenstick’ fracture in a 70-year-old (this fracture occurs in children), a GP agreeing with a patient that it sounds like they are on the autism spectrum (without onward referral), or a counsellor mentioning their patient ‘probably’ has post-traumatic stress disorder (PTSD), can cause enormous confusion down the line. Anyone in a position of clinical authority can often find their speculations are quickly interpreted as gospel, and what was intended as a suggestion to be taken lightly turns into a belief on the employee’s part that they have been diagnosed with a condition.
It is generally not the occupational clinician’s role to diagnose, and certainly not to treat. It’s also enormously important not to further muddy the water by denigrating the medical opinion you have heard second or third hand – you may not have the whole picture yourself. However, if careful history-taking reveals a particular diagnosis that seem unlikely, and that this has been communicated to the employer, it is reasonable to highlight your concerns and the remedial action you propose. As always, consent is vital, and you may feel it more appropriate to share your concerns only with the employee rather than communicating the detail to the employer. The clarity provided by communicating this to both employer and employee should not be overlooked however, and should certainly be considered.
Where the diagnosis helps the employer help the employee.
An employee with epilepsy may need specific support in the workplace, including training of colleagues in the best way to support them. Quite specific details of the nature of epileptic episodes may need to be communicated with consent in order to best protect the employee.
In other cases, the diagnosis is common enough that its communication is helpful on balance. Saying an employee had a stroke may be much more valuable than confabulating about a medical condition which causes loss of strength and coordination and muscle power on one side of the body. What’s important here is the explanation of what the functional limitation is, details of expected recovery, and clear advice on how the employer can best support the employee.
As always, careful history-taking, fully-informed consent, and deep consideration of how you are going to help the employer and employee must be brought together to produce an occupational health report that adds value for both. Sharing or not sharing a diagnosis is a judgement call and a significant responsibility for the occupational clinician. Like so much in occupational medicine, getting it right can have an enormously positive impact on people’s lives.
This article is aimed at occupational clinicians and refers to occupational health practice in England