The form was used for only 8 patients by three orthopedic surgeons. The other 7 orthopedic surgeons did not include patients in the study and, therefore, did not use the form. Of 8 patients, 7 agreed to participate in the qualitative evaluation. These 7 patients were treated by 3 orthopedic surgeons and 6 occupational physicians. All three orthopedic surgeons and three occupational physicians agreed to be interviewed. Figure 1 is a diagram in which all participants are schematically represented. Most patients had knee disorders and one patient had non-specific low back pain.
Did the form improve information exchange?
Of the 7 patients in this evaluation, all remembered that their orthopedic surgeon mentioned or filled out the form. However, three forms did not reach the occupational physician. Two patients (1c, 2b) had not visited their occupational physician and also not mailed the form. Patient 3 said that his orthopedic surgeon had sent the form to his occupational physician, however, the occupational physician had not received the form. In all cases where the occupational physician had not received the form, the patient was recovered before a consultation with the occupational physician was planned. Four forms were given or mailed to the occupational physician; patient 2c had send it over mail, even though he did not have an appointment with his occupational physician, and the other three patients handed the form over to their occupational physician.
The form was given to two of the three interviewed occupational physicians. The occupational physician not receiving the form was the one referring his patient to another orthopedic surgeon for second opinion. His opinion on the form was ambiguous: "The form passes the role of the occupational physician with regard to the functional limitations. However, my thoughts are ambiguous since I have just said that when I am unsure about the functional limitations, that is just the information I need from the orthopedic surgeon"(OP3). The two occupational physicians who had received the form answered that it gave them enough information to plan the patient's rehabilitation to work: "It was, for me, a guide to plan the work rehabilitation relatively fast and easy"(OP1).
Patient 2a answered that he felt that the form had resulted in better communication, since the occupational physician now knew which orthopedic surgeon to contact. His occupational physician referred patient 3 to another orthopedic surgeon; in this case the occupational physician did not need information from the first orthopedic surgeon and had not received the form either. Patients 1a and 1b assumed that the form was read, but did not know whether it resulted in anything else.
None of the orthopedic surgeons remembered to be contacted by the occupational physicians for additional information. Since only a few patients per orthopedic surgeon were included, they could not answer the question whether the form improved information exchange.
Did the information exchange form provide relevant information?
The three orthopedic surgeons considered the forms to be complete and useful. They had no difficulties filling out the form, and all answered that the five minutes necessary to fill it out was a reasonable amount of time. Two of them had instructed their secretaries to inform the patients about the form and the research in order to save time during the consultation. They felt that the information exchange form asked similar information as usually asked by occupational physicians.
The forms gave the occupational physicians information on functional limitations, which helped them to help the patient return to work: "A clinician gives clinical, health related information on specific functional limitations. <...> That gives an estimation, when an orthopedic surgeon can give this information that is important information. It takes questions away" (OP2). Besides the information provided on the form, there was another reason that made it useful: "It gives you the opportunity to contact the treating specialist" (OP3).
Two occupational physicians wanted to add information to the form. One occupational physician (OP3) said that the form might be too strict; he answered that it should provide room for extra information or explanation. Another occupational physician (OP2) felt that information about a patient's medical history and how he recovered from possible earlier treatments was missing. The third occupational physician found the information on the form complete: "It is more than I would have expected. Usually, when I ask similar questions I do not receive the answers this complete. Especially not regarding the functional limitations. May be it is so easy, because all the orthopedic surgeon needs to do is to put the crosses in the right squares"(OP1).
One of the orthopedic surgeons did not want to fill out the part on functional limitations: "Once it is on paper, it is regarded as a fact. ... Also I do not know where the patient works and what his job is. To me that is part of the job of an occupational physician. My predecessor always told me: you have to be able to defend everything you write down" (OS3).
When asked whether the use of the form made orthopedic surgeons more aware of the fact that a patient also has a role as a worker, only one of them agreed: "You are more aware of the fact that the patient also has a function in life" (OS2). However, all three surgeons said that they usually asked their patients about their job. Asking questions about a patient's job does not mean that they also inform the patient on their functional limitations at work. The participating surgeons only discussed functional limitations when the patient asks for information on what he can and cannot do. Two of the surgeons preferred not to give direct information about consequences for the patient's work: "Yes, when they ask for it. In activities of daily live. Never for their work, and that is because I do not know the company and workplace"(OS1).
Ideas to further improve this information exchange
All participants, both physicians and patients, agreed with the patient being the information carrier. One orthopedic surgeon said: "There is no reason, for me, to keep the information on the forms secret for the patient. He is allowed to see all information in his medical file, including this information"(OS1). Both occupational physicians and most orthopedic surgeons felt that the patient would take better care of the forms than when it is sent with regular mail. However, one orthopedic surgeon questioned whether the forms would reach the occupational physician. He had no objections against giving the form to the patient, but would also send it separately to the occupational physician.
All interviewed physicians would not mind using the form in future, as one of the occupational physicians said: "It gives you the possibility to contact each other" (OP3). In this study the orthopedic surgeon took the initiative to inform the occupational physician. However, all orthopedic surgeons said that the occupational physician should take the initiative since it is their responsibility to manage the patient's work rehabilitation: "I think that the occupational physician should take the initiative, be more active. That is his work. Our work is to cure people. And we have nothing to do with the fact whether this man works or not"(OS1).
Another option mentioned was that the occupational physician could ask for a copy of the letter written to the general practitioner, with medical information on the diagnosis and treatment instead of using this form. "The letter to the general practitioner is a moment when you already exchange information. So if you can limit information exchange to one moment it is no extra effort" (OS2).
All orthopedic surgeons and 2 occupational physicians felt that the form should not be filled out for each patient visiting an orthopedic surgeon, but only for those patients who do not recover as expected. "In cases with chronic musculoskeletal complaints or when there is a complication in the recovery" (OP2).