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What can you do when experts disagree? One doctor says the worker has a real injury, another says the pain is psychosomatic and yet another says the worker is faking. Whom do you believe? More to the point, how do you decide whom to believe?
This is a problem in the case of chronic musculoskeletal problems, where different experts have different explanations for what is going on. They can't even agree on a name.
There are two main reasons for this. The first is that these problems present challenges for those who make diagnoses. They aren't as obvious as a broken arm. Therefore, there are quite a number of possible explanations that could be entertained at first glance. The second reason for the diversity of explanations is that there are strong social interests involved -- vested interests if you like -- which means that workers, doctors, employers and others have something to gain by preferring one explanation over another. This doesn't necessarily mean that anyone is consciously biased, simply that there are benefits to be had by sincerely believing certain points of view.
When divergent explanations for a phenomenon exist -- chronic musculoskeletal problems in this case -- it is common to hear the cry, "Give me the facts!" Surely it must be possible to dispassionately look at the evidence and decide which explanation is best. Unfortunately it's not that easy. "The facts" are never unambiguous, even in fields like physics and molecular biology. Different scientists may disagree about what counts as a fact. There may be disagreement about the methods used to investigate the phenomenon or the way findings are interpreted. When scientists agree, it's not because the evidence is unambiguous and overwhelming; instead, they say that the evidence is unambiguous and overwhelming because they agree! At least this is the perspective adopted by some sociologists of science, who argue that scientific consensus is a social process involving persuasion, negotiation and resolution of conflict (Albury 1983; Barnes 1974; Feyerabend 1975; Latour and Woolgar 1979). One of the factors in this social process is the influence of interest groups.
To delve into the controversies over chronic musculoskeletal problems, we start by listing the main explanations and outlining some of the main areas of dispute. Then we look at a range of different interest groups, from people with these disorders to government, and comment on how they tend to line up. Finally, in the light of this survey of interests and knowledge, we suggest a few simple procedures for assessing conflicting claims.
We list here six common explanations for chronic musculoskeletal problems (Bammer and Martin 1988, 1992; Meekosha and Jakubowicz 1986). Supporters of each explanation typically cite certain evidence in its favour, but each explanation has difficulty with some evidence that doesn't fit. The latter we list under the category "anomalies."
Explanation: the body suffers a real injury, typically affecting muscles, nerves and/or tendons, due to rapid repetitive movements, less frequent but more forceful movements, static load or some combination of these
Preferred name: chronic musculoskeletal injuries, repetition strain injuries, occupational overuse disorders, cervicobrachial disorders, cumulative trauma disorders
Evidence cited in support: reproducibility of symptoms; link with characteristic activities; aggravation by continuing the activities; growing body of patho-physiological evidence
Pain and disability: real and work-related
Anomalies: objective signs may not be present; symptoms may vary in location or seriousness; problems may not go away with rest or other treatment
Typical advocates: workers with problems; sympathisers
Beneficiaries if this explanation is accepted: workers
Typical responses: rest; avoidance of activities causing pain; biomechanical and organisational modification of the workplace
Reference: Quintner (1989)
Explanation: workers are faking pain and disability to avoid work or obtain compensation
Preferred names: malingering, faking, goldbricking
Evidence cited in support: observations or indications of workers freely doing things they say are impossible or highly painful; unwillingness to return to modified work
Pain and disability: not present
Anomalies: objective signs in some cases; prevalence in the most committed workers; similar problems related to recreational activities such as sports
Typical advocates: sceptical employers, co-workers, insurers
Beneficiaries if this explanation is accepted: insurers, employers
Typical responses: disbelief; loss of pay; refusal to provide compensation; dismissal
Reference: Scarf and Wilcox (1984)
Explanation: workers unconsciously develop symptoms in order to obtain compensation, either monetary or psychological (increased attention and concern), often after recovering from a real injury
Preferred name: compensation neurosis
Evidence cited in support: lack of objective signs; variability of symptoms; recovery after financial payout received
Pain and disability: experienced as real but not linked to organic injury
Anomalies: objective signs in some cases; similar problems related to recreational activities such as sports; lack of recovery after financial payout received; loss of pay and sympathy after reporting problems; lack of objective signs for psychosomatic origin; lack of effectiveness of therapy
Typical advocates: sceptical employers and insurers
Beneficiaries if this explanation is accepted: insurers, employers
Typical responses: disbelief; counselling or therapy*; refusal to provide compensation
(* although counselling or therapy should be the response, in our experience the assessment which leads to this diagnosis is medico-legal and hence treatment is rarely offered.)
Reference: Rush (1984)
Explanation: workers develop psychosomatic symptoms in order to escape (convert) psychological problems; no injury is involved
Preferred name: conversion disorder
Evidence cited in support: lack of objective signs; variability of symptoms; pre-existing or concurrent psychological problems
Pain and disability: experienced as real but not linked to organic injury
Anomalies: objective signs in some cases; similar problems related to recreational activities such as sports; lack of objective signs for psychosomatic origin
Typical advocates: sceptical employers and insurers
Beneficiaries if this explanation is accepted: insurers; employers
Typical responses: disbelief; counselling or therapy*; refusal to provide compensation
Reference: Lucire (1986)
Explanation: normal pain and discomfort from physical work is interpreted as injury
Preferred name: normal fatigue
Evidence cited in support: lack of objective signs; variability of symptoms; recovery after rest
Pain and disability: real but not due to underlying injury
Anomalies: lack of recovery after rest
Typical advocates: sceptical employers, insurers
Beneficiaries if this explanation is accepted: insurers; employers
Typical responses: rest; ergonomic changes at work
Reference: Hadler (1986)
Explanation: workers with normal pain are encouraged by doctors and others to become patients with pain; a widespread belief in the hazards of certain activities becomes a self-fulfilling prophecy
Preferred names: social iatrogenesis; pain-patient model
Evidence cited in support: lack of objective signs; variability of symptoms; "epidemics" of cases at particular times and places with no connection to objective conditions of work
Pain and disability: real but not due to underlying injury
Anomalies: objective signs in some cases; similar problems related to recreational activities such as sports; lack of objective signs for psychosomatic origin
Typical advocates: sceptical employers, insurers
Beneficiaries if this explanation is accepted: insurers, employers
Typical responses: change in social attitudes to normal pain
References: Bell (1989), Spillane and Deves (1987)
Our table inevitably simplifies the information about and the case
for and against each explanation. More detailed accounts and
arguments are readily available. The table shows a close similarity
between explanations 3 and 4, each of which offers a psychological
explanation for problems, and between 5 and 6, which complement each
other. Beyond this, it should be obvious that it is quite possible
for different explanations each to be correct, but only to apply in
certain circumstances. For example, proponents of explanation 5
usually accept that some relatively well-defined disorders such as
carpal tunnel syndrome are real, attributing less specific problems
to normal fatigue. And proponents of explanation 1 accept that a
small percentage of people do fake symptoms. Finally, our assessments
of what are the typical advocates and the usual beneficiaries are
accurate at most in a rough sense. Some of the complexity of the
debate will be indicated below.
Some of the main areas of debate are indicated by the evidence and anomalies listed for the six explanations. In many cases, one explanation's supportive evidence is another explanation's anomaly, and vice versa. Nothing surprising in this! What would be surprising would be for a single explanation to explain everything. In that case there would be no controversy. Some of the main areas under dispute are as follows.
Critics of explanation 1, organic injury, often point out that while workers have symptoms -- they tell of pain and disability -- many exhibit no objective signs of injury. But lack of signs is not a definitive objection. Other physical problems, such as migraine headaches, are widely accepted as real and organic even when there are no signs. Intriguingly, there is a double standard here. What are the objective signs for compensation neurosis or any of the other explanations?
Many critics of the organic injury explanation say that there is no evidence of underlying pathology. Some say permanent injury of muscles through overuse is impossible. But one explanation for lack of evidence of pathology is simply that medical science has not yet developed the methods or insight to explain what is happening. In addition, there is now growing evidence for possible underlying pathology.
Critics of the organic injury explanation often say that symptoms do not make clinical sense. Again, this may simply mean that clinical science has not yet come up with an explanation, but that one is possible. Critics sometimes also dismiss plausible explanations. For example, some critics cite development of pain in the "other arm" -- the one not originally injured -- as a symptom which does not make clinical sense. But it is possible that this pain developed because the "other arm" was overused through avoiding use of the injured arm.
Critics of the organic injury explanation say that when an injury does not respond to rest, some other explanation is needed. This is hardly a definitive argument, especially considering that there is little evidence that any of the treatments recommended for compensation neurosis and the like are successful.
There have been great surges in reported cases of chronic musculoskeletal problems at certain times and places. For example, the number of reported cases of "repetition strain injury" in Australia skyrocketed in the 1980s. The idea of an "epidemic" suggests contagion rather than work-induced injury. Those who say that most cases are due to organic injury argue that injuries have been occurring in workplaces around the world for decades, but only occasionally are the circumstances favourable so that workers feel they can report them. When employers are able to dismiss injured employees easily, workers are hardly likely to make complaints. Critics argue that media reporting on a burgeoning problem of injuries encourages workers with normal fatigue to imagine that they are injured, makes malingering more likely and suggests potential physical symptoms to those with psychological problems. The disappearance of an epidemic is also cited as evidence for a non-organic basis for the disorders, but as we have shown elsewhere, this is not necessarily the case.
In each one of these areas of contention there are arguments for and against each explanation, arguments that in many cases can be backed up with studies and by the testimony of experts. Going deeper into the issue may not resolve it, since the divergent viewpoints influence the selection and interpretation of evidence at every level. Most crucially, which experts should you believe?
The stakes are high. Is the injury real, faked or psychological? Is recovery more likely through rest, exercise, therapy, or scepticism? Is is worse to make a mistake by disbelieving someone who actually has a real injury or to believe someone who is faking? What is the impact of a diagnosis on other workers? What measures should be taken in the workplace to prevent further problems? The answers to these questions can affect the health and livelihood of workers, the economic viability of enterprises and the sorts of tasks and technologies that are introduced.
Science does not provide a final answer to any of these questions. And because the stakes are high, there is strong incentives to pursue certain types of explanations. A diagnosis of organic injury validates a worker's suffering but can be costly to an employer or insurance company. A diagnosis of conversion disorder tells workers the problems lie in life outside of work and reduces immediate costs to employers and insurance companies. It should not be surprising that different groups prefer different explanations.
There is no conspiracy here and probably little cynicism. It is safe to presume that proponents of different explanations sincerely believe their stands. It just happens that there is a convergence between interests and preferred explanations.
For example, a psychiatrist may know a lot about psychosomatic disorders. Some psychiatrists may see patients who seem not to have organic injuries, so a psychosomatic explanation seems plausible. Once this explanation is tentatively adopted, the psychiatrist is attuned to look for supporting evidence and examples and to find holes in other explanations. Then an insurance company asks the psychiatrist to testify on its behalf. The company asks this particular psychiatrist, who is the one with an explanation to suit the company's judgement that the sudden upsurge of cases must be something besides real injuries. The psychiatrist testifies in court and, by being an open advocate, develops an even greater committment to the psychosomatic explanation. (It would be embarrassing to back down at this stage.) The greater visibility of the psychiatrist leads to more referrals, more invitations to give testimony, and so forth.
The same sort of process can apply to proponents of any explanation. No malice or dishonesty need be involved. People of good will can legitimately line up in different camps. This process can continue as long as there is enough ambiguity to allow different explanations to seem plausible and/or enough power and money to encourage advocacy of particular explanations. The important thing to note is that interest groups, such as insurance companies, can have an influence on the way people line up, even though all concerned believe they are being fair and objective.
Is there some way to be fair and objective, not just in intent but in reality? We think not, because there is no universal standard, no ultimate facts, to which to appeal -- at least not in a controversial area like chronic musculoskeletal problems. Every one of us is influenced by commitments, beliefs, social location, personal experiences, friendships, aspirations and the like. We can carefully examine and assess our beliefs and commitments but there is no way to make them totally free of social influences -- nor perhaps would we want to.
Nevertheless, just because perfect objectivity is not possible does not mean that all explanations are equally valid. Far from it. It is certainly worthwhile examining evidence and listening to arguments in order to make the best judgement possible in the circumstances and in accordance with one's own values. It is also important -- and this is our main point -- to take into account potential vested interests when assessing evidence and arguments.
With this context, we now list some of the main interest groups involved in the controversy over chronic musculoskeletal problems. In each case we suggest the sorts of explanations they are likely to prefer, always noting that there are always some people who diverge from any pattern.
Workers who suffer pain and disability are likely to believe that it is real -- it feels real, after all -- and to prefer the explanation of organic injury. Nevertheless, some find that other explanations seem to 'fit' better -- they may see a relationship with problems outside work or may be convinced that they are suffering from normal fatigue consequent on an increase in a normal workload.
The responses of co-workers to workers claiming to have chronic musculoskeletal injuries can vary enormously. Some, especially those who have experienced similar problems, believe that the injuries are real. Others, especially those who have never experienced any problems, may blame the others for trying to get out of work. The attitudes of workers are likely to be influenced by attitudes of employers, trade unions and doctors and by stories in the media.
In principle, trade unions might be expected to stand up for workers claiming that they have been injured at work, but this often does not happen. Trade union officials can be torn in different directions: by the claims, beliefs and disbeliefs of workers, by doctors and by their own negotiating relationship with employers. When trade unions take a strong stand about the significance of workers' claims, this can have a powerful legitimating effect.
In the short term, employers have an interest in denying the existence of disputable claims and in saying that problems are not work-related. This is especially the case when injured workers can be dismissed and easily replaced. Therefore, employers are likely to favour explanations of malingering, psychological origin, normal fatigue and social iatrogenesis.
On the other hand, if the number of workers affected is large or if it is difficult to replace them, or if those affected are workers with whom employers have a highly valued personal relationship, then the problem may be taken more seriously. Measures may be taken to prevent injuries, such as introducing "ergonomic" furniture and equipment, changing work organisation, and alerting workers to hazards. Employers may also introduce measures to rehabilitate and support those already affected. If such measures reduce problems, then the employer comes out ahead in the long run, whatever the explanation.
When a large number of new claims of injury appears, insurance companies are likely to investigate with a sceptical eye, especially when plausible alternative explanations are possible. By contesting the organic injury explanation, insurance companies resist an entire class of claims. On the other hand, if the organic injury explanation becomes widely accepted, then it is easier for insurance companies to pass on costs to companies via higher premiums.
Governments often line up with employers. In some cases they are the employers themselves and in other cases they have strong interests in promoting investment and employment locally. On the other hand, governments are subject to pressure-group politics. If popular pressure increases, governments may take action. It's important to remember that governments are not unified. Different government officials and employees -- politicians, policy advisers, health workers -- may have different views and agendas.
Doctors can be pulled in different directions. They are influenced by their patients, by their relationship with employers, by their training and attitudes, by other doctors, and so on. Most doctors are likely to support the dominant explanation -- the medical orthodoxy -- at any given time. Usually that has been that chronic musculoskeletal problems are not common and not a particular problem. But sometimes claims of injury become more visible and the organic injury explanation becomes the standard one, as in Australia in the 1980s. In any case, it is always possible for a minority of doctors to take individual stands. Medical researchers have an interest in promoting their particular perspectives. Doctors in workers health centres are more likely to take the complaints of workers seriously. Those who work for or receive many referrals from employers are likely to be more sceptical of the organic injury explanation.
Because doctors have a great deal of credibility in our society, they are often sought out to defend particular positions. A doctor who is willing to take a stand against the current orthodoxy may be taken up by other interest groups, as in the case of the psychiatrist mentioned earlier.
When a considerable number of people join campaigns for a certain sort of change in society, this can be called a social movement. There are many types of social movements, including the feminist movement, the environmental movement, evangelical religions, and promoters of computerisation. A key function of a social movement is to move an issue onto the social agenda, in other words to make it seem of significance to many people, whether they support or oppose change. In short, a social movement turns something into a "social problem" (Mauss 1975)
For most of the time and in most places, chronic musculoskeletal problems have not been on the social agenda. Sometimes, when the social circumstances are right, social action leads to these problems becoming more visible and taken more seriously. Beginning in the late 1970s, a few doctors at workers' health centres in Australia began to publicise the pain and disability they perceived among manual workers from repetitive movements and static load. The term RSI (repetitive strain injuries) was adopted by some doctors who wrote about the problem. Several groups took up the issue: women's health groups, trade unions and workers themselves. Then the media became interested and this triggered a massive increase in visibility and activity around RSI. The issue went from being a silent occurrence perceived only by isolated individuals to a social problem recognised by most of the population. The groups pushing RSI into visibility were, for the most part, not formally coordinated. But their efforts pushed in the same direction and they can be called a social movement. In this case, the social movement led to recognition of a social problem (Bammer 1990; Bammer and Martin 1992).
Obviously, this movement favoured the organic injury explanation. Previously, the other explanations were seldom necessary, since so few individuals tried to obtain official recognition for their injuries. The explicit formulation of the alternative explanations occurred in response to the movement's success.
In summary, the perspectives of every group and individual are influenced by their interests -- influenced, but not determined. The point is that if you are listening to what someone says, it makes sense to think about whose interests are being served by their viewpoint.
Given the complexity of the issue and the influence of competing interests, how should one proceed in trying to make a decision? There is no magical solution that avoids all the difficulties. We offer here some pragmatic guidelines.
Don't rely on a few authorities. Ask to hear the arguments and see the evidence.
For example, suppose you hear or read about the organic injury explanation. Are any anomalies acknowledged? If so, how are they explained? Are any alternative explanations mentioned? If not, why not? Look for material on other explanations.
That means giving more scrutiny to claims made by those with a vested interest. "More scrutiny" means an extra dose of scepticism, not automatic rejection. After all, just because someone has a vested interest doesn't necessarily mean they're wrong.
For example, suppose the normal fatigue explanation is being presented by a medical researcher. Ask who employs the researcher, who provides research grants and who pays for trips to courts to give testimony. If there seems to be a vested interest involved, give the claims of this researcher extra scrutiny, and listen to what critics say about the researcher's findings.
including methods of treatment and strategies for prevention. Who benefits?
If the influences on you are likely to sway you in a particular direction, you can make a special effort to hear the other side. This is a challenge, to say the least!
We started out by asking the question, "What should you do when experts disagree?" The answer is that you have to make your own decision. There is no ultimate expert whom you can trust. In making your own decision, it's valuable to seek out a range of opinions, perspectives and evidence, and the examine them with a sceptical eye, with extra scepticism when vested interests are involved.
Listening to all sides and being sceptical doesn't mean having no opinion. It is quite compatible with taking a stand and arguing strongly for a particular viewpoint. The more people who genuinely decide for themselves, without kowtowing to conventional opinion or whoever is doling out money, the healthier the debate and ultimately -- we hope -- the healthier workers will be.
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