If a worker was holding down two jobs, why does it become so easy to accept not working at all?
Accept that many injured workers, due to limited education and opportunity, take on jobs in which the potential for injury is quite high. These occur chiefly in the construction injury in which lifting accidents and falls occur. But they can also occur in semi-skilled manufacturing jobs in which there is also machine-related trauma.
Due to economic realities, there may be only one member of the family working, and he may have to work two jobs to provide a standard of living which permits the wife to assume a homemaker role. Even with both jobs, there is considerable and mounting debt. This system will work (barely) until disrupted by illness or injury.
However, an interesting and complicating factor arises after injury. While the injured worker may be forced to deal with pain, uncertainty, debt and fear, he also is abruptly relieved of the responsibility of managing one or more jobs each day. He may, indeed, feel shame, guilt, worry and confusion, but he is also now receiving partial financial support under an injury-management system we call “workers’ compensation.” The patient rarely verbalizes this new component to his life: relief.
He is relieved from having to perform these jobs. He is paid [seconday gain] now to stay at home, to go to doctors’ visits, and generally to not put forth effort. For the first time in many years, he is relieved of the rigors of supporting the family [seconday gain] and concurrently receives compassion, understanding, acceptance and concern from the family [additional seconday gain].
These realities are not difficult for a patient to verbalize, but he cannot do so to the family and risk depleting the tolerance they have developed for their plight.
It is at this point where pain complaints accelerate. This would sound deliberate, and, to an extent, there is a conscious dwelling on subjective complaints to justify inactivity. You note this when a patient “did not put forth consistent effort on the functional capacity exam,” or the patient limps into the office but departs with no observable sign of distress.
Although the advantages of secondary gain have a strong pull, one way to combat this entrenchment into disability is to make post-recovery plans part of treatment from the day of an injury. It is difficult to abruptly shift gears from being a patient to being a productive worker. The emphasis during early care must be one of _when_ rather than _if_ he can return to work. And there must be a focus upon what he _can do_ versus what he _can no longer do._ Just as an infection must receive attention, inactivity after injury must be aggressively addressed to obviate the drift into the pattern of inactivity and dependency.