The oil in the machine : occupational physicians' logic of holistic care

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‘The oil in the machine’

Occupational physicians’ logic of holistic care

Thesis for the Research Master Social Sciences

Graduate School of Social Sciences

August 28

th

2019, Amsterdam

Els Roding, 11256516

Elsroding@gmail.com

Supervisor: dr. Anja Hiddinga

Second reader: dr. Kristine Krause

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Acknowledgements

I would like to express great gratitude to the occupational physicians (OPs) who agreed to interviews and observations, and/or connected me to their colleagues. Thank you for sharing your thoughts, enthusiasm, worries, and frustrations. I am also grateful to the OPs who did not agree to an interview or observation. Their honesty about being too busy or worries about anonymization helped me get a sense of the tensions in the field. Many of them tried to help in other ways, for instance, by connecting me to colleagues or pointing me to websites, for which I am thankful. I appreciate the time occupational physicians took to listen to my presentation during the annual Dutch occupational medicine conference and the visits they paid to my poster. Your positive responses gave me confidence to go ahead with the argument.

I feel the thesis is the result of not only this research project, but my collection of activities at the University of Amsterdam throughout the three years I spent there. I would, therefore, like to thank my wonderful and hard-working lecturers and colleagues at the University of Amsterdam, especially the Long-Term Care and Dementia Partnership and the Eating Bodies team. They continuously supported and inspired me with interesting workshops. One workshop about ‘Caring control, controlling care,’ organized by Annekatrin Skeide was a great source of inspiration for this thesis. Special thanks to Kristine Krause for teaching me how to find joy in writing and Annemarie Mol for giving me confidence in fieldwork. Most of all, I am grateful to my supportive and patient supervisor Anja Hiddinga.

Without my friends and family, this thesis would not have been. Many thanks to my family and boyfriend for believing in me and encouraging me to keep going. Special thanks to my mother for providing inspiration about the world of healthcare. Her stories and questions from her own expertise as an occupational therapist reminded me of the importance to make the research relevant for OPs. To my friends I am very grateful for the laughs and tears we shared throughout the research process. I learned a lot from thinking through each other’s academic struggles and our dinners, walkitalkis and movie marathons provided the necessary relaxation and distraction from the work. Many thanks also to the other wonderful people in my life who I do not mention specifically here, but are a great source of support, inspiration and joy.

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Summary

Occupational physicians (OPs) working in the Netherlands are under a lot of pressure. The media regularly question their impartiality, personal stories about negative experiences with OPs are widespread, and OPs have a negative image within medicine itself. This raises questions about how OPs navigate this field of tensions. Who do they interact with in their work? What are the different expectations they face? What is OPs’ role? What do they do?

Inspired by street-level bureaucratic literature and practice theory I ethnographically studied OPs’ practices. I interviewed them about and observed them at work and found they have three main practices; illness claim assessment, verzuimbegeleiding, and prevention of illness and injury. In doing these practices, they focus on the interconnectedness of employees’ private- and work life, relationship management, and employees’ long-term ability to work. I demonstrate that there is a pattern in these practices and I call it OPs’ logic of holistic care.

In verzuimbegeleiding, however, OPs cannot always provide holistic care as it is highly structured by the UWV’s procedure (Executive Institute for Employees’ insurances; a governmental organisation that controls access to and pays out benefits). Furthermore, at the end of two years of sick leave, when WIA benefits (wet werk en inkomen naar arbeidsvermogen; law about work and income to capacity for work) are requested, the UWV checks whether procedure has been followed. However, the procedure for verzuimbegeleiding does not always concur with OPs’ broad approach to care. I conceptualise the tensions between the UWV’s procedures and OPs’ practices by contrasting the logic of holistic care with the UWV’s logic of control. The procedure’s ideal is that everyone can work as long as the circumstances are right. It is aimed at controlling access to WIA by checking if the procedure has been followed by the employer, employee, and OP.

I argue that OPs navigate the tensions arising from the discrepancies between procedure and the situations they encounter as ‘street-level bureaucrats’ (Lipsky 1980). They discretely tinker through the discrepancies they encounter, thereby constantly moving between the logic of holistic care and the logic of control. Sometimes they do not stick to the rules. At other times, they do, thereby occasionally performing practices they think are not optimal for the employee. However, the game is not fair because the UWV has more power to make and break the rules.

I draw two final conclusions. Firstly, OPs have more to offer with their logic of holistic care than the UWV’s procedure currently allows them to do and incorporating more of it would benefit both. Secondly, OPs’ holistic care approach can serve as an example for the current movement towards a more holistic approach to medicine (see, for example, Huber et al. 2016).

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Introduction: ‘The occupational physician: Friend or enemy?’

Occupational physicians (OPs) in the Netherlands are responsible for promoting, maintaining, and restoring occupational health and employees’ ability to work in the organisations and businesses they work for (de Zwart et al. 2011, 23). Their tasks include interacting with many different people with different interests, needs, and expectations, which sometimes causes tensions.

One of these tensions is between OPs’ loyalty to the employee whose health they protect and promote, and the employer1 who hires, pays, and fires the OP. OPs indicate that they sometimes experience this ‘dual obligation’ (Tamin 2015, 20) when they are pressured by employers to give advice beneficial to them, rather than putting the employee first (de Zwart et al. 2011, 87). Newspaper articles like ‘The occupational physician: Friend or enemy?’ (Tervoort 2011) and television programmes question their impartiality and accuse them of bias towards the employer (see, for example Volkskrant 2004; Smit 2015; Blijker 2011; Julen 2017; Weel 2019, Radar 2018).

In addition to the media, personal stories about bad experiences with OPs are widespread in Dutch society. Before starting this study, a friend of mine, for example, told me about a negative experience with an OP. She felt too ill to work and her doctors and physiotherapist advised her to rest. In order to request sick leave from work, she was obliged to visit an OP. To her surprise, the OP advised her to return to work immediately. He argued she was not as ill as she made it seem and that she would recover best at work. The advice upset her. Worried she would have to return to work while still ill she called her manager, who immediately took her side. They decided to ignore the OP’s advice. She would stay home to get better. Together they would evaluate how it was going and come up with a plan to return to work over time. Stories like these cause many employees to distrust OPs thereby causing tension in meetings between OPs and employees (de Zwart et al. 2011, 66).

Another tension is OPs’ negative image in the field of medicine itself. The specialisation into occupational medicine is an unpopular choice among medical students (Reijenga et al. 2015, 51). Many of them think OPs do not help people get better, are only gatekeepers for sick leave, and do not have enough time to supervise clients properly (ibid.). When I told a group of friends who study medicine about my research project with OPs they responded by saying: ‘They are all rejected

general practitioners.’ They explained occupational medicine is generally not someone’s first choice

of specialisation and argued doctors usually try and fail at other specialisations before becoming OPs. The low, stuffy, ‘not sexy’ status of occupational medicine is also apparent in the lower wages, compared to other medical specialists, causing tensions in OPs’ interaction with these specialists.

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Depending on the size and organisation of the company that the OP works for, what I call the ‘employer’ can be either the direct employer or a manager or other person in charge of the employee. For the sake of readability, I use the word ‘employer’ to refer to all of these types of people in charge of the employee.

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6 Reading about the tensions between the different obligations in OPs’ work, their negative image in the Netherlands, and their lower status in medicine, there are under-researched questions about OPs’ view on these issues. How do OPs navigate this polarised field? Who do they interact with in their work? What are the different expectations they face? What is OPs’ role? What do OPs do? Turning to the available body of academic literature and with these questions in mind, I found occupational medicine is an understudied topic in medical anthropology (Meershoek 2012, 544). Consequently, I ethnographically studied OPs in the Netherlands, interviewing them about and observing them at work.

Before I discuss these questions, what OPs do and the system in which they work in the Netherlands require further elaboration.

Occupational medicine in the Netherlands

Unlike most other medical specialists, OPs do not diagnose or provide therapy. They have an array of other tasks. These include preventing occupation-related diseases, such as shoulder injuries by advising workplaces to adjust, and the assessment of illness claims. While in most countries all doctors are allowed to assess illness claims for sick leave, in the Netherlands only occupational physicians can do so (Meershoek 2012, 546). However, to the frustration of my interlocutors, OPs spend most of their time supervising employees’ return-to-work process during sick leave.

Sick leave and the return-to-work process are structured in a procedure supervised by OPs and checked by a governmental institution called the UWV (Uitvoeringsinstituut Werknemersverzekeringen; Executive Institute for Employees’ insurances). The UWV is a governmental organisation that controls access to and pays out benefits. When an employee is sick and the illness is inhibiting their ability to work, the employer is legally obliged to pay for up to two years of sick leave. During these two years, employees have to see an OP, make efforts to get better and attempt to return to work (Hal et al. 2013, 10, see also Parsons 1951). The OP’s supervisory task in this process is called ‘verzuimbegeleiding’ (translation: leave supervision). To explain the system of sick leave and verzuimbegeleiding, I now provide an artificial example assembled from observations of and interviews about similar situations2.

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Access to observe OPs’ office hours was limited and my fieldwork was not long enough to go through the entire verzuimbegeleiding procedure with one employee on sick leave. I therefore choose to explain the verzuimbegeleiding procedure and OPs’ role in it by collecting information from observations and interviews, thereby creating an assemblage to explain the procedure with artificial people. I have been inspired by Pols (2015, 84) and Parys (2017, 36)to use this assemblage writing style.

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Bas is diagnosed with cancer. He has many doctors’ appointments and several surgeries, so he feels he cannot work during this time. Four weeks after Bas initially called in sick, his employer tells him to make an appointment with the OP, Iris. During this appointment Iris, asks how Bas is doing. They discuss Bas’ diagnosis and the treatment plan. Since Bas has so many doctors’ appointments, the recovery from the surgery, and from the initial shock of the diagnosis, it makes sense not to work at the moment, Iris argues. However, Iris also advises Bas to not lose touch with his work, “Because,” she explains, “it tends to be harder to get back to work if one has lost touch with it entirely.” He could, for instance, check his email several times a week, when he feels up for it or even go to his workplace and drink a cup of coffee with his colleagues once every two weeks. Iris and Bas decide they will meet again when Bas has recovered from the surgery and the treatment plan is clearer. Iris writes a problem analysis and sends it to both Bas and his employer. During their second meeting, Bas tells Iris that extensive further treatment is needed, since the scan showed the cancer had spread further than his doctor initially thought. It is unclear what the treatment will mean for his ability to work, so Iris asks Bas to call her two weeks after the first treatment round. During the call, Bas explains he felt bad for the first two days after the treatment, but quite alright the rest of the two weeks. They agree Bas will work for one or two hours a day, except for the weeks of treatment. Iris writes a plan on how to proceed with the return-to-work based on what she has discussed with Bas. It states how much Bas will work, which activities, and in which scenario he can increase his workload or not. She sends the plan to Bas and his employer. From then on Bas meets with his employer to discuss how to carry out the plan, for instance, how to adjust the workplace to enable him to work. Iris advises him to make regular appointments with her as well. They meet once every six to eight weeks and Iris advises him about return-to-work attempts in relation to his health, the UWV, and his manager.

Verzuimbegeleiding starts when the employee, Bas, meets the OP, Iris, in the first couple of weeks of

sick leave. Bas is legally obliged to do so and his employer is obliged to call in the service of an OP. This can be done either directly with a self-employed OP or with a commercial organisation called ‘arbodienst,’ which provides services related to occupational health. During the first meeting in the

verzuimbegeleiding the OP and the employee discuss the problem and the (in)ability to work. The OP

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8 Arboportaal n.d.). Subsequently, the employee meets his employer every six weeks to reflect on the execution of the plan. In the meantime, the employee could also meet the OP regularly and there may be meetings involving the OP and the employer and the employee, called ‘trialogues.’

After one year of sick leave Bas’ health has declined. The treatments are taking a large toll on his wellbeing, making it impossible for him to work. A trialogue with Bas, his employer and Iris is organised to evaluate Iris’ action plan. Due to Bas’ declined health they have diverted from the planning of building up his workload, so the employer proposes a new plan. Bas’ illness is not caused by his work and there is no reason to assume he will not be able to return to work in due time. They therefore decide to keep trying to reintegrate him into his own work, which, Iris explains, is called the ‘first track.’ They decide not to explore other jobs as possible places for him to reintegrate, referred to as the ‘second track.’ The treatments are effective and a month after the first year evaluation, Bas starts working a couple of hours a week. He slowly builds up his hours until his work days are back to what they were before his sick leave.

In case Bas had not returned to work completely within two years of sick leave, he could apply for government benefits, called WIA (wet werk en inkomen naar arbeidsvermogen; law about work and income to capacity for work). WIA provides partial financial compensation for the hours he would not be able to work. Bas and his employer would fill out the end evaluation of the plan of proceedings. The evaluation, the plan of proceedings and the reintegration report would be checked by an insurance doctor at the UWV. The insurance doctor checks the set of documents to judge retrospectively whether enough attempt has been made to return to work. On the basis of the evaluation, it is concluded whether the employee will receive WIA and how much. If the insurance doctor claims options to return to work have been left unexplored, the employer can be sanctioned to pay for another year of sick leave so these opportunities can still be explored.

Policy and practice

OPs’ work in Verzuimbegeleiding is, however, more complex than may seem from Bas’ case. My data show there is a tension between the UWV’s procedure for verzuimbegeleiding and OPs’ practice. OPs argue the procedure does not fit their knowledge and practices. The decision between staying on the first track and exploring the second track, for instance, is where OPs would often disagree with the procedure. When an employee has not returned to work for a significant proportion of their hours after one year of sick leave, the procedure prescribes return to work in other jobs should be

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9 explored; the second track. OPs, however, often know from experience that the employee will return to their own job eventually and a forced exploration of other job opportunities may decrease their rate of progress as it takes a toll on their health. If, however, the OP takes the risk and does not advise to explore the second track and the employee has not returned to work completely after two years, the employer will be sanctioned for not following procedure. OPs navigate this tension, constantly relating to the procedure.

Previous studies about professionals caught in between policy and practice have focussed on the pressures these professionals are under, such as ‘limited resources (time and information), in which their authority is regularly questioned, and [working] under ambiguous and changing expectations (Eikenaar et al. 2016, 768, 769). These ‘public employees who grant access to government programs and provide services within them’ (Lipsky 1980, 3) have been conceptualised as ‘street-level bureaucrats’ (ibid.). This refers to their delivery of public policy through direct interaction with citizens (paraphrased ibid.). Street-level bureaucratic literature offers a way to analyse the strategies street-level bureaucrats develop to deal with pressures. It focusses on strategies that do not conform to standardized rules and procedures (ibid., xii). Other studies have further emphasized professionals’ decision-making process is different than what standardized, prescribed procedures anticipate. The latter has also been referred to as the difference between ‘formal rationality’ and ‘practical rationality’ (Meershoek 2012, 547). Both studies show professionals working with a procedure or policy perform different practices than those prescribed and argue for a focus on and interpretation of these discrepancies.

These two frameworks allow for interesting questions about OPs. Like the professionals in these studies, OPs’ work is structured by governmental policies and procedures, which they do not always agree with (see, for example, ibid.). This raises questions about how OPs navigate tensions between the policy and their professional knowledge. What do they do? What are their practices? This study will illustrate what these frameworks would look like in practice and asks:

How do OPs navigate the tensions between policy and practice in their work?

Like studies in the two frameworks, this study focuses on practices. It describes what OPs’ do and analyses how their practices relate to the UWV’s procedure for verzuimbegeleiding. I describe and analyse three of their main practices; illness claim assessment, verzuimbegeleiding, and prevention. Unlike the frameworks above, I do not draw conclusions about the assumptions and practices of all street-level bureaucrats, policies, or professionals. Rather, inspired by Mol (2005), I identify a pattern in OPs’ approach to their practices. In comparing these practices to the UWV’s procedure, I show how OPs navigate the tensions in their work.

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Section 1: The study

In this section I discuss the design of the study. I show what theoretical work inspired this study and how the study was designed and conducted. The latter includes a discussion of ethical considerations.

1.1 Theory

Since occupational medicine is an understudied topic in social sciences, and medical anthropology specifically, I take inspiration from studies in the broader area of care and occupational health services to, first, raise questions, and second, interpret data. Several studies into occupational health services discuss how professionals in these services apply different frames (see, for example, Eikenaar et al. 2016; Dodier 1998). Eikenaar et al. (2016), for instance, study the normative aspect of reintegration services in the Netherlands, which includes a variety of professionals, and formulate five frames of references and types of supervision the professionals deem relevant. In the ‘work focused frame of reference,’ for instance, the client is seen as ‘unemployed’ (ibid., 775-777). Professionals’ main aim in this frame is to help the client return to work, regardless of the clients’ circumstances. The ‘facilitating frame of reference’ (ibid., 780), by contrast, places the client’s circumstances in the centre of attention. The client is viewed as a ‘customer,’ with the professional focussing their meetings on what the client asks for (ibid.). The professionals facilitate the client’s wishes. The diversity of frameworks raises questions about OPs’ variety of styles of working within the same standardized procedures in the Netherlands. How do they practically work with procedures? And how do they make sure to do a ‘good job’?

Eikenaar et al. (ibid.) conceptualise the reintegration professionals as ‘street-level bureaucrats’ (783). These are ‘public service workers who interact directly with citizens in the course of their jobs’ (Lipsky 1980, 3). In doing so, they are caught between standardized procedures and the situations they encounter. According to Lipsky ‘street-level bureaucrats attempt to do a good job in some way. The job, however, is in a sense impossible to do in ideal terms’ (ibid., 82), because of limited resources, the professionals’ authority being called into question, and ambiguous expectations (paraphrased Eikenaar et al. 2016, 768, 769). They have ‘substantial discretion in the execution of their work’ (Lipsky 1980, 3) and use it to cope with the pressures. In attempting to do a good job, they develop strategies, or ‘coping mechanisms’ (Eikenaar et al. 2016, 769), which are not necessarily in line with procedures (Lipsky 1980, xii). Eikenaar et al. (2016), for instance, argue the

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11 reintegration professionals’ frames of reference show the variety of coping mechanisms (783). In enacting these strategies, Lipsky (1980) argues, policy is made by the street-level bureaucrats, rather than policy-makers (13).

Street-level bureaucrats are ‘public employees who grant access to government programs and provide services within them’ (ibid., 3), such as teachers, social workers, or the police (see, for example, Maynard-Moody and Musheno 2012; Buvik 2016; Tummers et al. 2015). Buvik’s (2016) study, for example, shows how police officers make decisions deviating from the law during their work in Oslo’s nightlife. There are too many illegal things happening for the officers to handle, so they have to decide which ones to prioritise. By studying the officers’ practices, she argues the officers developed decision-making strategies. With these strategies to prioritise they do not conform to the law in practice, because they under-enforce it.

Like the police, OPs enforce regulations as gatekeepers to sick leave and they work under several pressures. As shown in the introduction, their authority is regularly questioned by the media, employers, and employees, who do not trust them to be unbiased. The UWV, furthermore, also questions their authority by developing standardized procedures in which OPs have little space to use their expertise. OPs also have little influence on regularly changing laws and procedures that impact their work greatly (de Zwart et al. 2011, 11). They are expected to go along with these changes and do what is expected of them. The questions I ask here, are, therefore; how do OPs cope with these pressures? Which strategies do they develop?

In order to answer these questions, I studied their practices; ‘…to understand street-level bureaucracy one must study the routines and subjective responses street-level bureaucrats develop in order to cope with the difficulties and ambiguities of their jobs’ (Lipsky 1980, 82). My focus on practices does not come solely from Lipsky. The discrepancies between policy and professionals’ practice have also been conceptualised as a difference between a ‘formal rationality’ and a ‘practical rationality’ (Meershoek 2012, 547). The policy has a formal rationality, meaning it assumes practices flow rationally and directly from the procedure. The professionals, however, are under different pressures, have to improvise, and be flexible in their engagement with problems. They have a practical rationality. To study the practical rationality, one has to examine the everyday practices of the professional (Meershoek 1999, 10-11). Finally, I take inspiration from practice theory (Reckwitz 2002). Its conceptualisation of a practice as ‘a routinized way in which bodies are moved, objects are handled, subjects are treated, things are described and the world is understood’ (ibid., 250) allows me to study OPs’ ideas about good occupational health care. To study ideas one has to study the practices in which they are enacted. Ideas are embedded in practice and through studying practices one can find these ideas (Law 2007, 2).

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12 To conclude, as I want to study OPs’ navigation of the tensions in their work, I study their practices, before drawing conclusions about OPs’ rationality in relation to the UWV’s procedures.

1.2 Methodology and ethics

In this study an ethnographic approach was used both as a research methodology as well as a style for this thesis as a written product of the research (Bryman 2012, 432). My ethnographic research consisted of both participant observation and interviewing. The research has an iterative nature, meaning I went through the cycle of data collection, analysis, reflections on theory, and writing, repeatedly throughout the research, adjusting the research plan and design according to what I encountered in the field (O’Reilly 2005, 3). Through constant reflection and repeatedly moving through the research cycle, I developed the study’s analysis and theory iteratively. I used an ethnographic style to write this thesis, meaning I give a detailed account of the topic of study (Bryman 2012, 432) and ‘…respect the irreducibility of human experience,’ (O’Reilly 2005, 3) by showing tensions rather than one-sided stories (Emerson et al. 1995, 173). In written ethnographies, it is often referred to as ‘thick description’ (Geertz 1973, 9, 10). In this section, I describe how I conducted this ethnographic study into OPs’ practices in the Netherlands.

Data collection

I contacted OPs through snowball sampling and by emailing and calling OPs whose contact information I found on the internet. I found OP interlocutors in the three different work constellations; self-employed, working in internal and in external arbodiensten. An internal

arbodienst is set up by and within an organisation or business, while an external arbodienst is

independent and offers their services to multiple organisations and corporations. Several OPs did not agree to an interview or observation, because they were too busy, worried about the privacy of their patients and me not having taken the Hippocratic Oath to protect it, or about their relationship with the client organisation. In total I conducted a total of 17 semi-structured interviews, using interview guides. I observed and interviewed one OP twice. The second interview was about her court case against a sanction from the UWV, which happened after the first interview. I interviewed the others once and one interview was with two OPs. Nine OPs were male and eight female. Their experience as OPs differed from months to 37 years. We usually met at their work place, such as the arbodienst, their own office space, or at a client organisation, but sometimes at their home or a cafe.

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13 In the interviews I asked them about, firstly, their work; their career track, their work activities and how they developed over the years, and what they like and dislike about it. The second topic was ‘collaboration’ to find out about the different actors in their work. I inquired into whom they work with, what they do with them, how they feel about these collaborations, what they think their role is in relation to the variety of actors, how they experience the interaction with the UWV. The third topic was tensions. I asked which problems and tensions the OP runs into, whom they ask for help, and what they feel is their responsibility in relation to the variety of actors. Finally, I asked whether we had forgotten to discuss anything and if they had any tips in regard to my research.

If the OP allowed me, the interview was followed up with an observation of his or her workday. I observed OPs’ office hours 9 times, which resulted in a total of 48 observed meetings. While the majority of these meetings were between OPs and employees on sick leave, some of them were trialogues (with the OP, the employee, the manager, and someone from the human resources department taking notes), phone calls with employees, employers, and other doctors, or social medical meetings with the OP and a manager. In these observations of office hours I focussed on the steps an OP would go through in a meeting, what the OP does, says and asks. The observations allowed me to experience the tensions that arose in the meetings and how OPs deal with them. While OPs tended to tell a coherent story about their work interviews, observing the variety of approaches they took with different employees demonstrated a depth and flexibility in their care approach that I could not have captured in interviews. I observed other settings as well, including a course day of the specialisation in occupational medicine, a conference, and I joined an OP on a work place visit. Finally, I observed two inter-collegial testing sessions, during which a group of OPs meet to discuss cases they struggle with, reflect on new policies and other problems they run into.

Positionality and ethics

Before starting the fieldwork, my plan about positionality, ethics, and informed consent in the research was approved by the departmental ethics committee.

In contacting OPs and during observations, I would introduce myself as a research master student interested in occupational medicine’s field of tensions and how OPs navigate them. I am a woman in her early twenties, which is why I think I got the role of a student wanting to learn from the OP and the OPs teaching me about it as a favour during the fieldwork interactions. When I thanked one of my interlocutors for agreeing to an interview, she, for instance, said: ‘We have to

help each other through life a bit, right?’ Many of my interlocutors would also be used to having a

medical intern shadowing them and they would sometimes compare my position to theirs. As my questions were about their work and we would usually meet at their workplace, neither of us would ask many questions about other topics than my research. We usually did not have much time before

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14 or after the interview or observation and I did not meet most of my interlocutors more than twice. I would, therefore, characterise my relationship with my interlocutors as a friendly, but distant, or professional relationship.

The distance was, perhaps, increased by my informed consent procedure. While OPs are academically educated and seemed to understand my research and what it entailed to be an interlocutor, I took great care with the informed consent procedure. I explained my research and gave OPs and other interlocutors an information letter about participating in my research. If they did not have any questions left, I asked them to sign the informed consent form. Before observations I explained they could ask me to leave the room, for instance, when the OP would think my presence was affecting the meeting negatively. It did not happen at any time throughout the research. Sometimes the OP gave me information about their history with an employee before the employee entered the office and had given informed consent. I would then not write down the information. During the conference and course day, I did not request written consent. Instead, I explained my research and my role as a researcher when introducing myself.

I tried to be as least intrusive as possible during the observations, while being open about my role and presence at the same time. I would, for instance, visibly take written notes during the observations. I tried to spatially position myself modestly though. I usually sat in between the OP and the employee or employer sitting opposite them, forming a triangle, but a bit further apart from them than they were from each other. Usually this resulted in me being more of an observer, rather than actively participating in the interaction. Sometimes an employee or manager would ask me a question or look to me for support. I would try to keep these interactions brief but be empathetic, especially when tears were flowing, which happened several times. The emotional moments in the meetings made me aware of the vulnerability of employees on sick leave and the pressure they are under. I tried to tread carefully in these moments, quietly sitting on my chair, interrupting my note-taking, looking at the employee and sometimes sharing empathetic glances with him or her.

A few times, however, I had to interfere. During one observation, the OP repeatedly explained things to me, thereby interrupting his conversation with the employee. It made me uncomfortable as it obstructed the meetings. In hindsight I should have interrupted him immediately and told him it was unnecessary. I initially did not, because I thought it would stop soon. After the first three meetings I observed that day, I asked him to desist in this practice. The informed consent procedure also interfered with OPs’ routine. Several OPs asked me if it was really necessary to do a written informed consent procedure with the employees. I emphasized the importance of doing it and tried to make it less intrusive and the OPs more comfortable by involving them in its design. I asked them individually whether they would prefer for me to introduce myself and my research or whether they would like to do so themselves and when to do so. We would also decide together

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15 where I would sit during the meetings. Like the OPs, at first, I was also nervous about obstructing their office hours. I was relieved and grew more confident after the first few meetings went well.

Collaborative research

One of my strategies to not harm informants or the field was to engage them in the research, preventing me from applying theories or frames to the field that would not fit (Glaser and Holton 2004).I invited interlocutors to co-research with me in every phase of the study.

In the research design phase, I conducted a first, explorative interview to both gain access to the field as well as engaging the field in the research design. I tested my first ideas about the research design by discussing them with the OP and asked him about possible research questions.

In the data collection phase, I used an interview style that invites the interviewee to become a praxiographic co-researcher (Mol and Heuts 2013, 128). This interview style does not focus on opinions, but asks for detailed examples of specific activities so the interlocutor develops an investigative attitude towards the practices they may take for granted (ibid.). The questions I asked thereby encouraged interlocutors to become researchers of their own practices. I, for instance, asked one of the interlocutors why there was no medical treatment bench for medical examinations in some of the OPs’ offices and we went on to discuss how he would diagnose clients based on their stories, their believability, and possibly medical files from other medical practitioners. This interview style allowed me to gather more data about OPs’ practices than I would if I had relied only my own observations, because the OP and I could reflect on the practices immediately. While some interviewees were hesitant to mention examples, resulting in more superficial interviews, but for the most part the interviews were detailed and practice-oriented. At the end of interviews, several interlocutors mentioned they had appreciated the invitation to reflect on their work and practices. The observations also showed the interlocutors had become co-researchers during the interviews. Having internalised my research questions, they would usually briefly reflect upon which tensions they experienced in the observed meeting without me asking them.

In the analysis phase, I had the chance to share my results at a practitioners’ conference for more than 500 OPs and other occupational health professionals. I gave a brief plenary presentation and a poster presentation. The professionals gave positive feedback, arguing they recognized themselves and their work in my argument. Future chances to publish results in popular medical magazines presented itself at the conference. This shows my study resonated with practitioners’ concerns.

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Analysis

I digitalised my written fieldnotes and transcribed several of my audio recorded interviews. I summarized the rest, transcribing only essential quotes. I coded these documents using a programme called Atlas.ti. The first round of coding was open, meaning that I used codes that came out of the data and grouped them with minimal assumptions (see, for example, Strauss and Corbin 1990, 12; Emerson et al. 1995, 150). Having developed a code book, I commenced on a second, more focussed round of coding in which I applied the previously formulated codes to the data consistently (see, for example, Emerson et al. 1995, 160).

In my methods and analysis, I have been inspired by the ‘iterative-inductive approach’ (O’Reilly 2005, 27). ‘Iterative implies both a spiral and a straight line, a loop and a tail’ (ibid.), meaning the researcher goes through the research cycle repeatedly, constantly reflecting on and rephrasing the research design, analysis, and theory. I analysed the data continuously throughout the research. After each observation and interview I wrote memos about my methodology and analysed the content of what I heard and observed (see, for example, Emerson et al. 1995, 155). Based on these memos I tried to constantly reflect on the research, rephrasing questions, developing interview guides, reflecting on the direction the project was taking and thinking about what kind of data I needed.This iterative way of working and constant analysis fits the explorative nature of the study.

While ‘inductive implies as open a mind as possible, allowing data to speak for themselves as far as possible’ (O’Reilly 2005, 27), I acknowledge that my mind is not a tabula rasa. My work will always be influenced by my previous experiences, discipline, and theory. I read theory before starting the fieldwork. I then did what O’Reilly (ibid.) describes as ‘proceed in a manner which is informed but open to surprises’ (26, 27). She calls this ‘sophisticated inductivism’ (ibid.).

I used coding schemes to sketch different arguments and design an outline for the thesis. I am aware of ‘ontological politics’ (Mol 1999; Law 2004, 13), meaning different arguments can be constructed by emphasizing different realities and the politics involved in choosing one and not another. I chose to juxtapose care and control, because it highlights the struggles OPs repeatedly mentioned and showed me; working with the UWV’s procedures and OPs’ negative image in society. Furthermore, the shortage of OPs in the Netherlands and its unpopularity as a choice among medical students were mentioned time and again. By making explicit the work OPs do, my aim with this argument is to help them verbalise and reflect on their position (Latimer 2000, 4-6). I hope it strengthens their approach to care and helps them fight occupational medicine’s reduction to standardized procedures.

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Section 2: Practices in the field

OPs spend most of their time on illness claim assessment, verzuimbegeleiding, and prevention. The three practices are not completely separable, for example, illness claim assessment and prevention overlap with verzuimbegeleiding. In exploration of these practices below, I show OPs have developed specific focuses and styles in fulfilling each of the tasks.

2.1 Illness claim assessment

Illness claim assessment takes place during an employee’s first visit to the OP since calling in sick. The visit takes place within six weeks after calling in sick. They discuss the employee’s complaints, possible diagnosis, and how it restricts them from work. Sometimes the OP physically examines the employee or requests information from the doctors who treat the employee. Procedure requires the OP to then determine whether the problem is medical or non-medical. Only when the problems are medical, employees can take sick leave and the verzuimbegeleiding starts. Thomas, a self-employed OP, for instance, describes a situation in which he determined an employee’s problem as non-medical.

‘Last week, a woman visited me. Her child was ill. At first, her employer gave her care leave, but then she had to take unpaid leave and she decided to call in sick.’ By talking in a high voice, Thomas pretends to be the employee he is talking about: ‘Because I cannot think about work at the moment and I only want to be a mother right now.’ Yes, so I explained: ‘Yes, you are not sick. You are not ill. I understand you want to just be a mother for your sick child at the moment, but, as a doctor, I cannot say that you are too sick to work. Do you understand? There has to be another solution.’ So this is the part where people really struggle, yes, for their money, really. Because this lady knows how it works, but does not want to take unpaid leave. But yeah, should you let an employer pay for the sick child? It is also a bit of a moral discussion, but the law is not meant for me as an occupational physician to support this. Obviously, I understand the situation and if the lady goes to work, it may not go so well. And maybe, eventually, she may fall ill because of it, right?!’

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18 Thomas sees the complexity of the employee’s situation. While he argues it is her daughter’s illness, not hers, he understands the employee may fall ill in the future because of the straining situation with her daughter. He also understands the financial pressure the employee is under and the advantages of paid sick leave in this regard, but argues it is not his job to support a request to let the employer pay for the employee’s sick child. Procedure is impeding him from supporting the lady’s request.

Thomas’ example shows categorizing problems as medical or non-medical is not always straightforward. The UWV’s distinction between medical and non-medical problems assumes an objective distinction can be made, like Kleinman’s (1981) distinction between disease and illness in which disease supposedly can be objectively determined and illness is a subjective experience (also see: Moser 2009; Mol 2002; Mol and Pols 1996). OPs, however, appear to work in a grey area between medical and non-medical problems (Meershoek 2012). They deal with it differently. The following meeting between Marianne (OP in internal arbodienst) and Natalie (employee) shows an illness claim assessment, similar in situation to Thomas’, can have different results. Marianne and Natalie are well acquainted from previous meetings and the atmosphere in the meeting is informal and friendly. It is their first meeting in this period of sick leave.

In the middle of explaining my research project to Natalie as part of the informed consent procedure she signs the form and starts to cry.3

Natalie: ‘I find it really hard that I am here.’ Tears run down her cheeks. Marianne hands her a box of tissues and places it on the desk in between them. ‘My child is sick. She has a severe food allergy. She was hospitalised again. It was very bad this time. She is back home now, but it was a long hospitalisation. She can eat very few types of food. Currently she can only eat the stuff she ate before this allergic reaction. The stuff that did not give her an allergic reaction. It gives me a lot of anxiety. I notice it in my body. My stomach and neck. I went to my general practitioner to ask for something to release muscle tension, Valium or something. I have gone back to work, but I cannot work full days. The problems with my daughter are not over yet.’

Marianne: ‘That’s horrible.’ Natalie: ‘Yes, fuck.’

(…)

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Marianne: ‘And when was she released from the hospital? And when have you started work again?’

Natalie: ‘Monday and Thursday.’

Marianne: ‘And what does your manager say?’

Natalie: ‘He thinks it is a complicated situation. He does not know whether he can call me in sick partially, for a certain percentage, instead of fully, so I said I would discuss it with you.’

Marianne: ‘He is right a little bit, since it is not your illness, but your daughter’s.’ Natalie interrupts: ‘No, but I do feel it!’

Marianne continues: ‘So I see why he is not sure whether it is sick leave. Yes.’ (…)

Marianne: ‘It is important to take time for yourself. It’s not a bad idea to think about taking sleeping pills to be able to sleep better. (…) What would you like to do with work currently?’

Natalie: ‘I would like it to be like it is now.’

Marianne: ‘It is totally appropriate that you work a little less in this situation. It is a healthy response to what happened. It is also important to decide with your manager on when you want return to work fully. Also, if you notice a change and you start to avoid situations and you start internalising everything that happens, you should get help for yourself. (…) I think you are handling the situation very well. Perhaps you can work for a couple of hours and then maybe go for a swim? It is good to use your body and relax your muscles a little bit.’

(…)

Marianne: ‘Well, you have my blessing and I propose we agree on you going back to work fully in January. Then your manager will be reassured too.’

Natalie: ‘Yes, yes.’

After Natalie leaves the office Marianne explains Natalie is generally easily stressed and she puts a lot of pressure on herself. She argues some of the things she wants to do for her daughter show she is not ill and can still work. While she experiences headaches, tense muscles and an inability to sleep, she is not really ill.

Marianne argues Natalie’s daughter’s illness, combined with her personality trait to get stressed easily, is causing Natalie to have several complaints. After listening to Natalie’s story and asking about how it affects her life and work, Marianne, like Thomas, argues Natalie’s problem is not medical. It is not Natalie’s illness, but her daughter’s. However, instead of dismissing her complaints

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20 Marianne advises Natalie to consider taking sleeping pills and to go swimming to release muscle tension. Furthermore, she argues it is totally ‘appropriate’ to work fewer hours at the moment, as long as she agrees on an end-date for the partial leave with her manager and sticks to it.

I interpret Marianne’s behaviour as a form of allowing. She takes Natalie complaints seriously and allows her to place them in a medical frame and take sick leave. While the UWV would not allow this sick leave if they knew about it, Marianne knows she can allow it as long as they agree on an end date for the leave. She knows the UWV will not know about it as long as the sick leave does not last longer than two years. By allowing Natalie’s short period of sick leave, Marianne attempts to prevent Natalie from falling seriously ill.

To conclude, in their illness claim assessment OPs are gatekeepers for sick leave and

verzuimbegeleiding (Meershoek 2012, 557). Their decision to frame employees’ problems as medical

or not is, however, not always straightforward. They use their discretion (Lipsky 1980, 13) to navigate the grey area of medical and non-medical problems, and take into account what is happening in employees’ lives outside of work. They emphasize the interconnectedness of work- and private life, but draw different conclusions within their discretionary space. OPs’ perception of the complexity in employees’ lives does not fit the illness claim assessment procedure’s requirement to reduce employees’ problems to a binary classification as medical or not-medical. I will elaborate on this in section three, relating it to the UWV and Lipsky’s (ibid.) ‘street-level bureaucrats’ framework.

2.2 Verzuimbegeleiding

When an OP frames an employee’s problems as medical in their illness claim assessment, they start the verzuimbegeleiding. As explained in the introduction, verzuimbegeleiding is the OPs’ supervisory task during an employee’s sick leave. It lasts up to two years, during which they carry out several formal steps required by the UWV. These are writing a problem analysis, writing a plan for the leave and the return to work, and evaluating the plan with the employer and employee. Throughout the process they usually meet, email, or call the employee and employer several times to guide, advise, and inform them. The following example shows Luuk, a self-employed OP, doing all three of these activities for Marie. They discuss how her return to work is progressing and Marie explains she feels pressured by her employer to return faster than she can handle. Furthermore, she is considering looking for a different job, as her current job in a children’s day-care is too loud and hectic for her. Luuk asks whether she ever discusses these thoughts with anyone.

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Luuk: Do you ever talk about it with anyone?

Marie: Well, with my son, but not so deeply or about whether this kind of job still suits me. It is not possible to prevent getting over stimulated in this kind of work. Luuk: The oversensitivity to stimuli may reduce over time, but I cannot guarantee it. So be honest to yourself. Your employer is asking advice on how to build up your work. I will write (Luuk reads out loud what he wrote down in the report during the consultation), more adjusted work. I understand your employer plans for you to do your regular activities, but your health is the main objective here. Can you do something with that?

Marie: Yes, I will think about whether this still fits my needs and about possible alternatives.

Luuk: How come?

Marie: I am taking the business into account too much.

Luuk: You may find it hard to disappoint people. And who do you forget? (Luuk implies Marie forgets stand up for herself. Marie starts to cry.) It is not a bad characteristic, but you should not always employ it.

Marie: … Yes…

Luuk: Not always, especially in a business relationship. Pay close attention now, this is important. You are going to work for 37 hours for this much money. It is not part of that agreement that you do not take yourself into account. It is good when you are strong and your employer does not have to worry about you. When is your next meeting with your employer?

Marie: … The first day after my holiday, I was promised a day off, but now she has planned me to work that day. From the perspective of your employer it makes sense, but well.

Luuk: You should take responsibility for your business. You do not have to change completely, but a couple of minutes per year would help you greatly. (Luuk implies it would help Marie greatly if she would stand up for herself a bit more.)

Marie: Yes.

Luuk: (Reads out loud what he advises the employer.) Does this feel like something you can hold on to?

Marie: Yes.

Luuk: I do not want to patronize you, but you should make sure you stand up for yourself more to your employer.

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22 Luuk informs Marie about what she can expect in terms of recovery of her sensitivity to stimuli and what characterizes a healthy business relationship. His supervision takes shape in his advice on how Marie can do her part of the business relationship to be able to return to work.

In doing so, Luuk has a specific focus on relationships. First, he asks Marie whether she ever talks about her work-related issues with anyone. He thereby takes into account her wider network, outside of work and how it can be managed to help solve problems. Secondly, he advises her on how to manage her relationship with her employer. He argues she should speak up for herself so the employer does not overpower her, thereby putting her in positions that make her ill.

Another self-employed OP, Thomas, argues relationship management is a large part of OPs’ job:

‘I think only a small part of our profession is medical. For the most part it is relationships; seeing who has which interests, which interactions are going on and how one can start interactions. (…) I think our job, if you look at it in a very black-and-white manner, is mostly relationship management.’

Thomas explains occupational medicine is largely about assessing different interests, exploring interactions, and bringing about interactions. He calls it relationship management.

While OPs, like Luuk, do relationship management by advising employees and employers how to manage their relationships, they also manage relationships themselves. In the next interview excerpt Lucia, a self-employed OP, explains how she would manage the relationship between the employer and the employee.

“You are in a tough position and I see that, because you have an employee who can and dares to say very little about what made him or her ill and you have an OP who is not allowed to say anything of the sort either. So you cannot understand and you cannot do anything. Because in this case it is not about work. If it was about work, I would talk to you about it, but it is not about work so you cannot do anything, but you are burdened with the problem. You have the burden. You are standing there, having to pay the person while he or she is far away and you don’t know exactly what will happen and I cannot say much about it either. That is incredibly tough. But it is what it is for the moment. It is a part of being an employer that you have to deal with right now. The only thing I can tell you is: Ask your questions. I don’t know if I can always answer them, but I will include you in the process whenever I can.’ And I tell employees the same. I tell them: ‘`Yes, they

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are being unkind or they do not listen or they do not pay attention and barely reach out.’ And then I say: ‘Yes, that may not feel good and may not be nice, but make no mistake about what is happening on their side. You are home. You have been for eight weeks now. They have to, firstly, work harder to solve the problem and think about whether they have to replace you. They don’t hear from you. They don’t see you. They know you are seriously ill, because you told them and I did so too. They want to believe you, but they cannot work with this information. So yes, they are powerless. So the best thing for them to do is carry on and you are less a part of it, because you are not there. You are elsewhere. That is,’ I often say, ‘the reason why we try to get people to return to work as soon as possible. So that is what we; you and me, can do now. It should, however, actually be possible. But you should imagine they are powerless and I can tell you it is a very unpleasant feeling. So I get it.’

Lucia explains how she tries to help both the employer and the employee understand each other’s position and expressing empathy for their situation. She therefore manages their relationship with each other and with her.

Both types of relationship management are combined in a special type of meeting between the OP, employee on sick leave, and employer. OPs usually prepare these trialogues with the employee beforehand. They, for instance, inform them they do not need to share any medical information and they plan how the employee will position themselves in relation to the employer in the meeting. The next excerpt is from observation fieldnotes of a trialogue between Gertjan (OP working in internal arbodienst), Birgit (employee), Hanneke (employer). A woman working at HR was also present, taking notes to write a report about the meeting. Gertjan did not prepare the meeting with Birgit beforehand due to holidays.

Once everyone has arrived, Gertjan opens the meeting by introducing everyone and summarising Birgit and Hanneke’s history throughout Birgit’s sick leave. Gertjan says he will interrupt in case Birgit gives too much medical information to her manager, because she is not legally obliged to do so. Birgit starts to explain how she is doing. It is going much better than when she called in sick. She is being supervised by a coach. Hanneke complements the story by saying Birgit works all of her hours, but on a different level than she would normally. Gertjan compliments Birgit on how well she puts her situation into words. She reflects well on it and her limitations. Hanneke and Birgit briefly discuss Birgit’s capacity to

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work, focussing on the type of tasks she is capable of carrying out. Gertjan asks Birgit to tell about the near future and her plans. Birgit says she will continue to be supervised by the coach, about which she seems content. Also, she tells about her desire to have children and explains she has fertility problems. She will try conceiving artificially in the coming months. Since this can take an emotional toll, it may knock her out of balance every now and then. Gertjan asks whether she will have to take any medication for the artificial conception and Birgit replies she will only have to inject herself with hormones once a month. Gertjan asks whether anyone in the meeting has any questions left. The manager asks whether Birgit is now 90% capable of working. Gertjan replies yes, but explains it is irrelevant in the first year of sick leave. No one has any questions left and the meeting ends.

In this verzuimbegeleiding Gertjan provides advice, he informs, and he supports. He, for instance, advises Birgit not to give medical information to Hanneke if she does not want to. Gertjan informs Hanneke about the sick leave procedure and that the 90% work capacity is irrelevant in the first year of sick leave. He provides support in the form of relationship management. Not only does he organise the trialogue to prevent miscommunication between Hanneke and Birgit and himself and possible negative consequences for their relationship. He supports Birgit in managing her relationship with Hanneke by reminding her to tell Hanneke about her plans for the future. They had discussed these plans and he knew it would be important for Hanneke to know. He thereby supports their relationship management as well as managing the relationship between Hanneke and Birgit. In discussing the meeting with me after everyone has left Gertjan says Birgit and Hanneke’s relationship had had some rough patches in the past, but it seemed to be going quite well now. He says the meeting went well, showing he paid close attention to managing their relationship.

To conclude, OPs are required to advise, inform, and support the employee and employer during verzuimbegeleiding and they have a specific focus on relationships in doing so. They do

verzuimbegeleiding by both managing the employee’s and employer’s relationships directly as well

as advising them on how to manage theirs. In the latter, they include work relationships as well as non-work relationships, such as Marie discussing her thoughts about changing jobs with her so. They, therefore, focus on the interconnectedness of work- and private life, like in illness claim assessment. This raises questions as to whether OPs do more than what the UWV’s procedure for

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2.3 Preventing illness and injury

OPs spend most of their time on assessing illness claims and verzuimbegeleiding. Frustrated, some call themselves ‘verzuimboeren,’ which translates as ‘sick leave-farmers’. It refers to having to do

verzuimbegeleiding repeatedly. It is an expression of their frustration of doing symptom treatment,

instead of preventing the problems that are making people request sick leave. During interviews, many expressed their wish to do more preventative work, to deal with the root of the problem of sick leave. A conference organised by the Dutch Ministry of Social Affairs and Employment sent a hopeful message that the procedures and laws shaping OPs’ work would increasingly focus on prevention in the future.

One of the most straightforward ways in which OPs currently perform preventative activities is in workplace visits. During these visits, which they can do at any time, they pay attention to risks to the employees’ health. These can be both social risks, like bullying, or physical risks such as low desks which cause back injury or dangerous machines. While most OPs have no time to do these visits, I observed Renate, a self-employed OP, on one of hers. As it was a factory with large machines, she paid close attention to possible dangers to cause injury.

Before entering the factory we put on hairnets and protective, long jackets. We walked through very noisy, large spaces and in one production hall the radio was on loudly. I could often not hear what Renate and employees were discussing, but I could see what they pointed at and demonstrated and sometimes Renate would explain to me afterwards.

We first entered a space with a lot of metal machinery. Renate pointed at a machine and told me she had inspected it before. One of the employees had explained it had nearly caused several accidents. Employees would almost hit their head on a piece of metal that was sticking out. Renate showed me the metal sticking out, concluding nothing had changed. The machine was still a health risk to the employees. (…)

Later on we meet one of the employees on partial sick leave, Nabil, whom we saw earlier that day during a meeting with Renate. He shows us heavy rolls of product and demonstrates how he has to lift them and carry them around. Renate explains carrying heavy things above shoulder height can damage one’s shoulders and back. She says there is a machine to carry these rolls. Nabil replies he uses the machine, but he still has to lift the roll onto the machine and from the machine to

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another one. Renate advises him to do so with a colleague. Nabil does not seem convinced, arguing colleagues are not always around or busy doing something else.

During the workplace visit, Renate tries to detect health hazards, such as metal sticking out of the machine. Furthermore, she creates awareness of risks by explaining about the risks of carrying things above shoulder height. Finally, when telling Nabil to lift the rolls with a colleague and a machine, she advises how to work safely and adjust the workplace to make it safe.

While workplace visits are a very obvious form of preventative care, OPs also do preventative work during other activities, such as verzuimbegeleiding. Before Renate’s workplace visit, she met Nabil to discuss his return to work. Nabil is on partial sick leave due to a shoulder injury. He wants to increase his work hours.

Renate: Why do you want to increase your hours? Nabil: I feel like the leave is taking too long.

Renate: So are you going to recover faster when you increase your work hours now? Nabil: No.

Renate: So why do you want to increase your hours? Do you want to show others in the work place that you are trying? (Renate seems to think Nabil wants to increase his hours prematurely. She seems to try to force him to say why he wants to do so to make him see it is a wrong reason for increasing. Her tone is forceful, strict.)

Nabil: Yes.

Renate: Obviously, you are allowed to do so! But only do so when your joint actually feels better than before. If it starts to ache again, you have to go back to working four hours a day.

Nabil: The new schedule starts on Monday, shall I start working five hours from then on? Renate: Yes, but do you understand what I said?

Nabil: Yes.

Renate: So what happens when the joint starts to ache again? Nabil: I go back to working four hours a day.

Renate tries to prevent Nabil from increasing his hours too early, thereby not giving his shoulder enough time to heal. She wants to prevent the injury from getting worse and advises him to reduce

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27 his hours again if it does. In doing so she takes into account future scenarios.4 She thinks about Nabil’s long-term ability to work.

In OPs’ prevention efforts in work-related health they focus on the long-term ability to work. Lucia, a self-employed OP, explains this:

‘I don’t want someone to simply return to work. I want someone to return to work and be able to stay for a longer time. If the work or his way of working was bothering him, I want him to learn how not to let it happen again. That is what I want.’

Lucia argues an employee on sick leave simply returning to work under her verzuimbegeleiding is not enough. She aims her supervision at a long-term return to work in which future relapses into illness due to the work situation are prevented. Similarly, Thomas explains his supervision is aimed at long-term return to work.

‘I try to work toward sustainable recovery with people and not like ‘Yeah, you are better tomorrow, so then you return to work.’ Because people nearly always get well again, but it is about whether they stay well. So I tell people: ‘I hope I see you a couple of times now and never again after, because that means we did something right.’ When someone visits me, returns to work, and falls ill again, I think he is not growing or reaching any solution. It does not work for the employee, nor for the employer.’

Thomas’ explains with his aim at sustainable recovery of health and return to work he attempts to prevent employees from falling ill and taking leave repetitively. He helps them learn something about how to prevent falling ill again in the long-term.

To conclude, OPs work to prevent work-related injury and illness by doing workplace visits and in their verzuimbegeleiding. In doing so, they anticipate future scenarios and think about the long-term ability to work. While the verzuimbegeleiding procedure requires only two years of sick leave supervision, OPs think about scenarios in the more distant future. They support employees in restoring health and preventing future relapses and injuries for them to be able to continue to work.

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The oil in the machine : occupational physicians' logic of holistic care