My Obstetrician Got However Me Fired : How work notes can be I am - PowerPoint PPT Presentation

10/27/2016 I have no financial disclosures My Obstetrician Got However…… Me Fired : How work notes can be I am not a lawyer nor a Human harmful… Resources expert and how to make them better Rebecca Jackson, MD, Obstetrics, Gynecology and Reproductive Sciences Zuckerberg San Francisco General Hospital University of California, San Francisco Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences 2 Partners Familiar request? • Joan Hastings JD • Liz Morris JD • Sharon Terman JD • Julia Parish JD • Jenna Gerry JD Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences 4 1

10/27/2016 Young vs UPS Preview • Why we should care • Is it safe for women to work in pregnancy? • The minimum we need to know about leave and accommodations • How to write a work modification or leave letter to protect our patients’ jobs and pay Department of Obstetrics, Gynecology & Reproductive Sciences 6 US Working Mothers Pregnancy discrimination prevalence • In a structured interview study of 165 • 67% of first time mothers work, most work working women, 69% reported at least one full-time, over 80% work well into the 3 rd form of workplace adversity during trimester (EEOC) pregnancy • 40% of mothers are the primary • Higher prevalence in public vs. privately breadwinners for families in the US today insured women (Glynn, S.J. Center for American Progress 2012) (Cooklin, Rowe & Fisher, 2007) • Juggling work, pregnancy, motherhood is 8000 stressful. Worse is losing a job just as you EEOC are about to start/enlarge your family 6000 Pregnancy • The US lacks social supports and social 4000 Discrimination protection to buffer against stresses Charges 2000 1997 Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive 2010 Sciences Sciences 0 2

10/27/2016 Work accommodations for pregnancy It still happens. Employers…. • In a national survey of working • Fire women when they divulge pregnancy pregnant women, more than half felt • Decide what a pregnant woman should and they needed a change in their job shouldn’t do at work (“shouldn’t you be at home growing your baby?!) duties or schedule • Hold pregnant women to higher standards— • ~40% of them never requested an they are forced to “prove” themselves accommodation capable • Of those who did, at least 13% were • Tell them they can’t have time off to go to prenatal appointments denied. • Force them out on leave rather than making simple accommodations Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive EEOC cases Sciences Sciences Declercq ER, J Perinat Educ 2014 9 US lacks a paid national maternity leave policy • The Family Medical Leave Act (FMLA) guarantees unpaid job protected leave for up to 12 weeks • Restricted to: – Women who have worked for an employer for at least 1250 hours/year Today, we’re the only advanced country on Earth – Employer must have at least 50 employees that doesn’t guarantee paid sick leave or paid maternity leave to our workers. Forty-three million workers have no paid sick leave. Forty-three million. Think about that. And that forces too • Less than 50% of US workers are covered many parents to make the gut-wrenching choice by FMLA between a paycheck and a sick kid at home. So • 20% of new mothers are eligible I’ll be taking new action to help states adopt paid Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive leave laws of their own." Sciences Sciences 3

10/27/2016 Safety of working during Is it safe to work while pregnant? pregnancy • Early studies focused on concerns around workplace exposures and teratogens for the fetus • More recent evidence examines associations between certain working conditions and SAB, PTB, and other ob outcomes . – Evidence low quality: observational studies, mostly retrospective, many do not control for confounders, often assess for occupational exposure AFTER delivery (recall bias) – Work types are inconsistently defined making comparison between studies difficult and many studies include only first trimester employment • Bottom line: Use caution when interpreting—results Department of Obstetrics, Department of Obstetrics, could be due to bias/confounding especially for odds Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences ratios <2.0) 13 14 Preterm delivery and work What does ACOG say? • Being employed (vs not) doesn’t increase risk • Not much • For physically demanding work, most prospective • Guidelines for Perinatal Care (7th edition): studies show no increased risk of PTD but a few do • Multiple meta-analyses: – Physically demanding work (prolonged standing, heavy lifting, physical exertion, occupational fatigue and demanding posture): OR 1.3 (1.1-1.6) (van Beukering, 2014) – Work>40h, stand>4 hr, shift work : OR 1.1-1.2 (Palmer, 2013) – Higher quality studies had lower OR’s Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive • OR <1.5 likely due to bias and confounding Gynecology & Reproductive Sciences Sciences 15 16 4

10/27/2016 Other guidelines about work in What does UpToDate say? pregnancy? SUMMARY AND RECOMMENDATIONS — • Systematic reviews have generally concluded that standard working conditions present little hazard to maternal or child health. A woman with an uncomplicated American Medical Association Council pregnancy who is employed where there are no greater on Scientific Affairs. Effects of potential hazards than those encountered in routine daily pregnancy on work performance. life may continue to work without interruption until the JAMA 1984 ;251:1995-7. onset of labor. However, the physical demands of the woman's job should be considered on a case-by-case basis, especially in women at higher risk of preterm delivery or who have medical or obstetrical disorders that are unstable or associated with impaired placental perfusion (eg, preeclampsia, fetal growth restriction). Similarly, avoidance of possibly toxic exposures during pregnancy is prudent. Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences 17 What about lifting? • Physically demanding work is associated with low back pain, musculoskeletal disorders • Proposed guidelines for lifting published in AJOG in 2013 McDonald, AJOG, 2013 • Use an NIOSH “lifting equation” to determine the RWL=recommended weight limit, the load nearly all healthy workers can lift up to 8 hrs per day without LBP • For non-pregnancy, max RWL=51 lbs in ideal lift (2 hands, close to body, no twisting, starting lift at 28-52 inches off the floor) • As the distance between the load and the worker Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive increases (eg in pregnancy), the RWL decreases Sciences Sciences McDonald, AJOG, 2013 5

10/27/2016 Take-away on lifting…. The limits might be less than we think…. WORK NOTES • Infrequent lifting – Early pregnancy: 36 lbs 26 36 – After 20 wks: 26 lbs • Less than 1 hour of lifting per day: – Early pregnancy: 30 lbs 22 30 – After 20 wks: 22 lbs • >1 hour of lifting per day: – Early pregnancy: 18 lbs 18 13 – After 20 wks: 13 lbs Department of Obstetrics, Department of Obstetrics, Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences 21 22 When caring for or interacting with pregnant How can writing a work note be patients, how often do employment-related harmful? issues come up (such as leave, disability, work Ms. Smith, a 28 year old G2 P1 at 22 weeks gestation, asks you to write a letter to her employer to limit her lifting. She modifications)? is not having any issues related to the lifting but is worried that it may cause problems in the future. She works as a 29% A. Never 27% stocker in a large retail store and lifting is a major part of 26% her job. B. Sometimes C. Around half the time 18% You write the note as requested and at her next visit Ms. D. Most of the time Smith asks that her medical leave papers be signed because her employer told her she must go out on leave E. Nearly always because she can no longer lift. The rest of her pregnancy is uneventful and she has a cesarean delivery. She returns post-partum and informs you 0% that she was terminated from her job because her 4 months of leave was consumed before she was ready to return to Sometimes Never Most of the time Nearly always Around half the time Department of Obstetrics, Department of Obstetrics, work. Gynecology & Reproductive Gynecology & Reproductive Sciences Sciences 23 6