Difficult working conditions, retirement, and reform in France: what are the roles of the medical social worker and primary care physician?
Article Type: Letter to the editor
Authors: Descatha, Alexis
Duval, Sarah
Sabbath, Erika
Vuotto, Ghislaine
Pub Date: 02/01/2012
Publication: Name: Health and Social Work Publisher: Oxford University Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Sociology and social work Copyright: COPYRIGHT 2012 Oxford University Press ISSN: 0360-7283
Issue: Date: Feb, 2012 Source Volume: 37 Source Issue: 1
Accession Number: 306241025
Full Text: Although the French retirement system previously allowed retirement at the age of 60 for most citizens (or even at the age of 55 for certain civil servants), the retirement age in France is currently being raised in a context of economic constraints, aging of the population, and financial difficulties of retirement funds. In view of the inequalities of physical working conditions, a debate is currently being held in France about a more egalitarian approach to retirement age that considers difficult working conditions as a weighting factor for determination of retirement age.

In recent changes to the law on retirement, workers subjected to difficult working conditions can retire before the legal age, which has been extended. French legislators planned to grant the fight to early retirement with full pension to workers justifying a level of disability greater than or equal to 20% giving rise to compensation for occupational disease or a work injury, or greater than or equal to 10% but provided the worker can justify that this disability is due to exposure to difficult working conditions. (Work Ministry Retirement Law, 2010a, 2010b)

The legislator has, therefore, stated implicitly that difficult working conditions are determined by the presence of a recognized and resultant occupational disease. Although difficult working conditions are ultimately related to the probability of harmful effects, there are many types of exposure to high--risk situations that, although considered arduous, do not have any immediate effect on health at the time of retirement and therefore do not justify early retirement. Primary care physicians (general practitioners, occupational health physicians) and social workers, however, are often faced with medicosocial requests about work-related premature wear and tear on the body.

Apart from the specific interest on this subject in France, we believe that certain elements of the discussion, especially in relation to individual cases, are encountered by social workers in all countries and all health systems, whether protectionist or liberal. The purpose of this letter is to provide a basis for discussion on the ways in which social workers and primary care physicians can collaborate to improve individuals' medical and socioeconomic prognoses and also contribute to discussion of these reforms. This brief report of two cases of multidisciplinary management between a primary care physician, an occupational health and social medicine specialist, and a social worker illustrates the stakes involved in any modification of the retirement system.

A 61-year-old journalist was referred to us by his occupational health physician for an opinion concerning his capacity to continue working. A clinical interview did not reveal any particular somatic complaints. This man had a history of gastrointestinal disease, which was effectively treated but had forced him to work part-time for several months and suspend any foreign reporting missions. He described loss of motivation but with no obvious depression, anhedonia, or features of an anxiety disorder. The physical examination was normal. At first impression, this patient appeared physically able to work in that he did not present any incompatibility with or medical contraindication to continuation of his job. Psychologically, he did not present any signs of depression. The possibility of burnout syndrome could have been considered, but there were no clinical signs of it at the time of examination. This man could be considered to present progressive fatigue related to his physically and psychologically demanding job. He described recent deterioration of his working conditions related to budget restrictions and lack of recognition of his work. Siegrist, Wege, Pfihlhofer, and Wahrendoff (2009) very clearly described this effort--reward imbalance, which, in this case, consisted of physical and psychological effort but no documented effect on health. Nevertheless, a career as a journalist covering various armed conflicts and wars for more than 20 years can be considered arduous. This example demonstrates that difficult working conditions are related to both demands and mechanisms of resistance, support, and reward. A joint consultation with our social worker defined the best solution for this patient's retirement.

A 58-year-old man was referred to us by his general practitioner for bilateral carpal tunnel syndrome. He had seen our department four years earlier for ruptured rotator cuff tendinitis. This chef in a traditional restaurant had more than 40 years of occupational exposure to biomechanical constraints involving the shoulders. At the time of his earlier visit, he was treated surgically, with an optimal functional result allowing a return to work, officially with lighter duties, and the injury was accepted as work related. At the present visit, he informed us that the lighter work prescribed by his occupational health physician was not applied in practice because of a conflict with his employers. On clinical examination, he presented carpal tunnel syndrome, confirmed by electroneuromyography, and an altered general state, with probable associated depression. In this context, and in view of his occupational exposure, his bilateral carpal tunnel syndrome was, with the help of our social worker, declared and accepted as an occupational disease. In view of his pain and altered general state, we recommended sick leave to allow surgery under the best possible conditions. This man will be able to benefit from early retirement on the basis of his long career. The law on difficult working conditions takes into account disabilities related to work accidents and occupational diseases, and this man will therefore not be concerned by prolongation of retirement fund contributions in view of his permanent partial disability. Nevertheless, we personally believe that, in view of these physical exposures, which can be considered important health risk factors in terms of the cumulative dose, this man should have been able to retire prior to deterioration of his health (rupture of the rotator cuff, carpal tunnel syndrome).

Primary care physicians--both occupational health physicians and general practitioners--and social workers will increasingly be faced with these types of social problems. Primary care physicians and social workers obviously have a social and preventive role in relation to disability, morbidity, and mortality and, therefore, a role in evaluation of difficult working conditions. No reliable and validated tool is currently available to evaluate difficult working conditions. The creation of a difficult working conditions observatory has been proposed to assess the nature of difficult working conditions in the public and private sectors, particularly those with an impact on life expectancy (Work Ministry Retirement Law, 2011). At the community level, a scientific approach can be adopted to validate strategies on the basis of job-exposure matrices, questionnaires, and expert opinions while integrating the essential dialogue and negotiation between social partners, company representatives, and the state. The proposed legislation in France appears to be insufficient, because it only takes into account the effects of difficult working conditions on health and not these conditions per se and will largely depend on ongoing negotiations with social partners, both globally and by sector.

Primary care physicians and social workers must also be involved with this process, because their everyday practice, already largely influenced by this type of problem, will be directly affected by variable retirement-age regulations. Primary care physicians and social workers, either experts in individual health or experts in working conditions, play, however, a relatively minor role in these discussions at present. We believe that they could be more actively involved by providing their opinion in the form of a brief report for each worker for the working conditions observatory. In practice, although difficult working conditions is not inherently a medical concept, and although this discussion essentially concerns social issues in terms of quality and quantity of work, primary care physicians and social workers have an essential role to play in elaboration of the bill, contributing their expertise to conversations involving individual health and working conditions. Given discussion of raising the U.S. retirement age to increase the solvency of the Social Security system and reduce the federal deficit, it seems prudent to consider potential resulting scenarios under which the role of the U.S. medical social worker might be changed. Particularly if such legislation were to include a variable retirement age based on lifetime working conditions, similar to that proposed in France, social workers--as both patient advocates and liaisons between patients and the health-care system--could play a considerable role in such decisions.

In conclusion, physical constraints and difficult working conditions are elements of public health requiring further evaluation that focuses on the health effects of working conditions and the role of the medical and social expertise provided by a collaborative unit of physicians and social workers at the individual level and at the community level. This model, which we are trying to preserve in France in view of France's social history, is also probably cost effective for society as a whole.


Siegrist, J., Wege, N., Puhlhofer, F., & Wahrendorf, M. (2009). A short genetic measure of work stress in the era of globalization: Effort--reward imbalance. International Archives of Occupational and Environmental Health, 82, 1005-1013.

Work Ministry Retirement Law. (2010a). Retrieved from http://www.retraites2010.fr/le-projet-de-loi/ mettreenplace-un-dispositifde-prevention-et- decompensation-de-la-penibilite

Work Ministry Retirement Law. (2010b). Retrieved from http://www.gouvemement.fr/gouvemement/ reforme-des-retraites-la-loi-est-promulguee

Work Ministry Retirement Law. (2011). Retrieved from http://www.legifrance.gouv.fr/ affichTexte.do;jsessionid=35421COAE96AOCF576C16D4CC883AD49. tpdjo09v_l?cidTexte=JORFTEXT000023022127&categorieLien=id

Alexis Descatha, Sarah Duval, Erika Sabbath and

Ghislaine Vuotto

Garches, France
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