Curbside Consultation

Caring for Patients with Job Insecurity Who Are Experiencing Chronic Work-Related Pain


Am Fam Physician. 2016 Jul 15;94(2):145-152.

Case Scenario

A 45-year-old woman presented to my practice's free health clinic with spinal pain that had been radiating down her left arm and leg for four months. She is a refugee from Cuba and lives in a crowded apartment with her adult son, her brother, her husband, and her husband's parents. Upon arriving in the United States two years ago, the family was provided with temporary Medicaid assistance for seven months, but is now entirely uninsured.

The patient's situation is complicated by job insecurity; she and her son are the only two family members who have found steady work. For the past six months, she has been employed at an automotive plant as an assembly line worker, which involves long hours of repetitive heavy lifting. She says the pain is worse while she is at work, and she feels that there is nothing she can do about it. I suspect this labor is the cause of her back pain, but I know she cannot quit her job. Given her limited options, how should I approach pain management for this patient?


In addition to providing direct medical care, the physician can help this patient by obtaining an occupational history, formulating hypotheses about the cause of the pain and potential interventions, and establishing a therapeutic relationship. The physician should also provide a complete musculoskeletal examination to evaluate symptoms and rule out sensory or motor impairment; a depression screening; and assurances that the patient will not be abandoned and that her care will continue.


The concern that work-related biomechanical stressors have caused or contributed to the patient's back pain may provide an opportunity for positive intervention. Although repetitive motion, heavy lifting, and awkward postures present clear ergonomic hazards, workplace modifications to reduce these hazards can be straightforward, affordable, and provide a tangible return on investment, particularly if other workers have been injured, which is likely. To the extent that the physician or others in the practice who provide social assistance or patient advocacy may be able to help this patient negotiate worksite modifications, she may be able to continue to work. Both the Occupational Safety and Health Administration (OSHA) and its sister agency, the Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health, provide user-friendly guidelines for reducing ergonomic hazards (Table 1). Large manufacturers may have in-house capabilities for addressing these hazards. Smaller companies are also eligible for free assessment and guidance through the small business consultation programs that OSHA funds in each state. Whether the patient is willing to raise these options with her supervisor or have the physician raise them will depend in part on her fear of losing her job, as well as the severity of her condition.

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Table 1.

Occupational Health Resources for Workers and Physicians


Government resources

NIOSH ergonomic guidelines for manual material handling

Information for employers to identify and reduce causes of musculoskeletal disorders

NIOSH health hazard evaluations request program

Free consultation program for employers; may be requested by three or more workers; best for exploring new or unusual issues

OSHA clinicians website

An overview of occupational health, workers' compensation, and ethical considerations

OSHA on-site consultation program

Listing of state contacts for free consultation program aimed at small- and medium-sized businesses

OSHA safety and health topics: ergonomics

Provides specific approaches to identifying and reducing causes of musculoskeletal disorders

OSHA workers website

Information focused on workers' rights

Nongovernment resources

Association of Occupational and Environmental Clinics

Lists of clinicians and clinics for referral or advice; outreach materials

Interfaith Worker Justice

Peer-support organization of immigrant workers focused on workers' rights

Migrant Clinicians Network

Supports clinicians with information and serves as a force for health justice for the mobile poor

NIOSH = National Institute for Occupational Safety and Health; OSHA = Occupational Safety and Health Administration.

Table 1.

Occupational Health Resources for Workers and Physicians


Government resources

NIOSH ergonomic guidelines for manual material handling

Information for employers to identify and reduce causes of musculoskeletal disorders


Address correspondence to Rosemary Sokas, MD, MS, MOccH, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

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6. U.S. Social Security Administration. Understanding Supplemental Security Income SSI eligibility requirements. Accessed August 28, 2015.

7. U.S. Department of Health and Human Services. What are Federally Qualified Health Centers? Accessed August 28, 2015.

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This series is coordinated by Caroline Wellbery, MD, Associate Deputy Editor.

A collection of Curbside Consultation published in AFP is available at

Please send scenarios to Caroline Wellbery, MD, at Materials are edited to retain confidentiality.



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