My name is Steve Frangos. It's my pleasure to moderate this panel. With this talk, we actually went through some evolution because we had initial ideas about focusing on U.S. and non-U.S., we decided to focus on U.S. By a show of hands, who here is practicing occupational medicine outside of the U.S.? Okay, so there's a couple. So if you want to come, I'm very interested, we may get to this in the Q&A, but I'm very interested to talk about what you're doing outside the U.S. because I'm trying to coordinate a global accommodation procedure, and we'll talk some about process here also, but as you know, outside the U.S., I mean, there's as many laws as there are countries about how disabilities are managed, so we're not going to focus on that today. With this topic, I think all the experts are probably in the room. Who here, by show of hands, has dealt with ADAA issues, tried to accommodate disabled workers to get them back to work? Okay, good. So some of this will resonate with you, and if you have other perspectives based on your experience, we're certainly interested to get into that as we have our discussion at the end of the prepared remarks. The other thing is that what I decided to do in the handout was give you very detailed bios on the speakers, and in the handout, there are also three slides that specifically address definitions in the ADAA and procedures around accommodations that we use in the U.S., so we can talk more about that, but you have that information also in your handouts, okay? So speakers today, in addition to myself, Dr. Kevin Trangle is here, and he is going to be providing additional, I would say, background and nuance around ADAA issues from the standpoint of litigation, and he also has a case that he's going to present for discussion, and then also Dr. Richard Venroot is up on our panel also, and he has a case discussion also. I won't go, I should, I do need to just mention around conflict of interest, and we do not have any disclosures to make there. So today, educationally, we're going to talk about this alphabet soup of litigation. I'm going to bring up Dr. Trangle in just a minute, and we want to present and discuss practical applications of the Americans with Disability Act and amendments, and also reasonable accommodation, and we'll do that in the context of a couple complex disability cases, and again, you all may have interesting cases. We hope also that there's time to share one or two of those as well, okay? And this is a quick agenda, and while I bring up Dr. Trangle's slides, you can just see we're going to, the plan is really for the three of us to function as a panel, not only to discuss the cases that we're going to present, but to also address your questions as well. All right, I need to switch decks here. It'll take me just a minute. Can you hear me? Am I live? Can all of you hear me? Yes? Thank you. So I'm Kevin Trangle. I'm an occupational doctor. Now you can hear me. I'm going to use this, actually, the topic of ADA to talk about actually litigation support. So I've done, and I do, a fair amount of litigation in terms of high-end litigation support and testimony. I've probably testified between depositions and live trials 150 times through the years. I think it's important to know how I got there and what I did to, you know? And you can just advance it right here. Okay, great. And what I did to get to this position. But then I'm going to talk about the tools that we use. Many of them are applicable for ADA considerations, but not all of them. But I want to just sort of give you an overview of the litigation I do and the kinds of tools I use, et cetera. So my background, I've run clinics, I've owned clinics, I've sold clinics, I've been a hospital medical director, I've been corporate medical director for several corporations. Currently I'm the corporate medical director for a company called TE Connectivity, which is about 90,000 people in about 150 plants around the world. So I know it from the corporate perspective. But I've also gotten involved in the plaintiff side. I do both sides, plaintiff and defense. And I found that's not a problem as long as you are professional and you're ethical and you follow the science. So what I'm going to share with you is really from a litigation perspective, which will do a large part with the ADA, but not exclusively. It is an alphabet soup for sure. You probably know, as opposed to most of the doctors I talk to, what all these things mean. IMEs you know, UCR you may not know, use your customary review for bills. It's usually used in the defense side. It's not typically used in the plaintiff side. Medical record reviews you're aware of. The ADAA we're going to talk about. Fitness for duty is a big part of what you need to do in the ADA also. And we have both what we call life care plans and a lesser product called the future care needs. It's also about the needs of your client as well as the monies they want to spend and how to structure a practice that takes into account everything. You have to do functional capacity evaluations, that's an ADA tool, as well as physical demand analysis where you go out to the workplace and you figure out what the job entails economically. And vocational assessment, that's a very important part when somebody is involved in litigation over an issue that deals with their ability to work. So my background, you saw already. I think it's in the handout, so I'm not going to go over it. I could talk about myself for hours, but I'm not going to do that. So we're going to talk about medical legal consulting in general. These are things that I do do and that if you have a medical legal consulting part of your practice, it's probably things that you will do. So independent medical examinations, you all know what that is. Record reviews are important. I do a lot more record reviews than I actually do IMEs. The court accepts record reviews in most cases and it doesn't become an issue really. However, in some cases you do need to see the individual because you need to, if it's something that you need to assess the individual, where they stand and their abilities and their functional status, you probably need to see them. If it's an environmental exposure and it's a cancer, you don't necessarily need to see them. So at times they do fly around the country to do examinations. You have to be able to give expert testimony and we'll talk more about that later. If you want to have an IME practice, as part of it will progress on to litigation, if you don't testify and you don't know how to testify, you probably won't be chosen to do that. So having those testifying skills are important. And complex disability is really up the occupational doctor's retinue because it's really you deal with all sorts of things in order to look at fitness for duty, including exposure. And we'll talk about life care planning. We'll talk about the UCR and vocational assessment. So all these things we're going to talk about and they're necessary if you want to be an expert witness and if you want to be involved in the litigation part of what you do. Part of it, obviously communication is probably the most important part of being an expert witness. You need to be, you have to have the credentials, but once you have to have the credentials, it's really how personable you are, how persuasive you are, and how you come across the jurors and to the other people. I think you guys are experienced enough to realize it's not always the facts. It's not always truth and justice in the American way or the international way. It has to do with really how you present. It's persuasion. And in the legal system, that's probably the most important part. You have to have a biography, a curriculum vitae, and when you deal with lawyers or even any kind of organization that wants your involvement, you have to have an engagement letter, which we'll talk about. It's for your protection. You have to have a fee schedule. The court mandates that. We'll talk about Rule 26 and Rule 702 in a second. Anything in federal court, you have to be able to produce these kinds of documents and you have to meet what's called the Daubert Standard, which we'll talk about again. It's basically presenting scientifically valid, voodoo theory medicine. So you have to have a biography. I use a two-page biography. When you get to Pose, you probably have, many of you have biographies that dwarf mine. You may have 30, 40, 50 pages in publications. That's okay, but when you talk to the attorneys initially, you want to have something more succinct. And then you have an engagement letter, which is important and many people don't do this in my experience. Engagement letter lays out the parameters of who's responsible for what. It lays out the billing needs that people have to do. And probably what I found through the years, the most important part of it is the Dukas-Teckum subpoena issues. So a Dukas-Teckum subpoena, and this is usually when you're on the defense side, is usually produced by the plaintiff. And the purpose of that is to make it so onerous for you to comply with the requirements of the subpoena that you're going to drop out of being an expert witness. They would want your tax returns, every case you've ever done, your billing cycle, your billing history, every job you've had. They sometimes will ask for all your people that work for you and their history. They sometimes will ask for your entire medical file on a whole variety of things. It can be really overreaching. In fact, I've actually retained an attorney to represent me in these Dukas-Teckum subpoena requests so we can narrow it down to what's reasonable. And I also make the client pay. Because often, if you really get into the Dukas-Teckum argument in that arena, you'll end up spending more money than you'll ever get on the case. So you definitely need to have an engagement letter that spells all these things out. Is it moving? Nope. All right. Where's our IT specialist here? Oh, there we go. All right. So you have to have a fee schedule. We talked about that. You will always be asked in court, what is your fee schedule? My suggestion is you have the same fee schedule for your plaintiff or defense side. It doesn't look good if you have alternating fee schedules. On the other hand, you can have it broad enough that you can make variations on what you charge people. For example, if you're doing an IME and you have to have it videotaped, which sometimes is done, when you're doing a videotaped IME, it's a performance. It's not just doing the physical exam and doing the history. You're talking to the audience. You're talking to the jurors. It takes a lot longer because you're really educating. It's really part of your testimony. So you have to have provisions for things like that, for example. So this is what's called Rule 26. This is, if you want to actually testify, you need to all keep track of this. For five years prior to your current engagement, you need to have listed all the depositions, all the trial testimony, anything that appeared in court or is court ready. And you have to have a list with the case caption, the date you did it, and basically who requested it to be done. Without that list, you will not be allowed to testify, which means you will not get the cases to do the IMEs. So you really need to have what's called a Rule 26 list of your previous engagements that goes back five years. Very important. I've seen people thrown out of this business just because they didn't keep the list or they couldn't recreate the list. If you can recreate it now going back, you're fine. Or if you haven't done it, you're fine too. If you just haven't done it before, that's fine too. You see all those little details, which I won't go over because we have limited time. They will ask you those questions about each of the cases in terms of how much you got paid, who paid you, et cetera. The other issue is there's different kinds of witnesses. If you're an expert witness, you have to have it based on scientific data. You have to be able to go in front of the court and say that my opinion is based upon medical articles, science. It's based upon community standards, ACOM guidelines, the Society of Neurology and their TBI protocols. But it's based on something that's accepted by either the scientific academic community or it's accepted by the practicing community. It has organizational prestige. And if you don't do that, it will get thrown out. And I've seen it thrown out. You don't want to be thrown out. It's not necessarily the kiss of death, but it's not a good thing. The Daubert Challenge, it's called the Daubert Challenge because of this particular case. Once you've established a practice, you really want to make sure that your opinion is argued in a scientific manner. If you are thrown out, or at least part of it is thrown out in terms of testimony, you can recover, but it's more difficult. It's like settling in a malpractice suit and you're listed in the National Malpractice Registry. Not a good thing, even though you're not guilty and you're not culpable. It's something you want to try to avoid. So we do independent medical. This is the last thing. When you get started in a case, for example, they may hire you as an expert witness. You may come down and say, which I do, not infrequently, and say, look, you don't have a case. I can't support this case. You then become a consulting witness and you won't be disclosed. They may not file a case. They may find somebody else, but you become one of those. And occasionally you become a fact witness. If you're treating somebody and they need some information, they'll call you as a fact witness. And they'll sometimes will try to convert you at no cost from a fact witness to an expert witness. So when you see that happening, make sure that you tell them you're going to be able to say the facts, but you're not going to offer expert opinions unless they want to hire you as that. I see that a lot too. In terms of medical record reviews, at this point in time, majority of the cases I get are medical record reviews as opposed to independent medical exams. And I think that's been the trend, at least in my experience, for the last five years. And there's really nothing wrong with doing medical record reviews. You don't need to be a licensed in every state in order to do an IME. Very few states will make you be licensed to do an IME. And most of the time it's not regarded as a practice of medicine. It's quite rare that it is. If you want to be licensed in every state, like I think Dr. Peterson was yesterday, I mean, the guy, he's licensed in what, 45 states? He probably pays a good $1,200 a year for each of the states. It's a big investment. You don't need to do that. You know, I happen to be licensed in seven states where I've spent considerable time, but I ain't going to that level. There is a reciprocal agreement where you can actually sign up and get on to 32 states almost immediately, but you have to pay the fees every year. All right. Now, life care planning is part of what you do when we do litigation. Now, life care planning is not really an ADA tool. Life care planning is for somebody that has an injury. What life care planning is, it's a document that you're trying to monetize what's happening in the case. It's, in other words, somebody has an injury and you're going forth and you're trying to figure out what it's going to cost to take care of this person. The court ignores all insurances, all your VA benefits, all your private pay, and it just looks at what it would cost, and that's what they use as a barometer. It's basically a very comprehensive plan. We'll show you. There's a number of buckets you put things in, everything from OT, PT, operations, medications, pharmaceuticals, prosthetic devices, durable medical equipment, et cetera, et cetera. You have to cover all the bases. Then you have to, for each of the things you do, you also have to put in how long this person will need these interventions, how frequently they need it, what intensity, and you have to justify it. And then you have to assign a cost to it, and then you have to geographically adjust it for they happen to live for that particular cost. And it sounds daunting. It's not daunting. It just takes time and money to do. It's not actually conceptually very difficult. I do actually both plaintiff and defense life care plans. For example, when I'm hired, let's say, by Toyota or BMW, which I was recently, we had a couple of paraplegic accidents where the life care plans came in very high, I think $4 or $5 million. And they wanted somebody to give another opinion. So in those kinds of cases, we go box by box, bucket by bucket, look at what they purported to be able to need, how frequently, if it was necessary or not. And then typically, we bring in other experts. Like if it's a musculoskeletal, I may bring in a physiatrist, a neurologist, and we get their opinions on. So when you bring in these people in, you produce a document. It's expensive, but it's pretty much validated in science. You can actually, anybody here can be a life care planner. Even though it sounds very highfalutin to become a certified life care planner, what it actually is is a 120-hour course. If you have a bachelor's degree in a 120-hour course, you can become a certified life care planner. Some physicians I know are not certified life care planners because their education is so much more than that. You have undergraduate degrees, medical degrees. You have, in this group, MHAs, MBAs, MPHs. You have the economics. You have the background. In the life care planning, what you learn in the course, which I've reviewed the course, is not anything you don't probably know already. If you want to take the course for 120 hours, you can say you're a certified life care planner and get into the business. It gives you an overview. And if you're not a doctor and you're a life care planner, you can't really make opinions that have medical import. You need to bring a doctor involved. So there's a limit to what they can do. And life care planning is used not only for injury care. It's used in all these different areas, everything where there's any medical issues that are involved. I've been contacted in divorce proceedings and structural settlements, all these particular things that will use life care planning. OK, it's a process. These are some of the buckets. I'm going to skip over this. We have recommendations that cover all these different things. This is a typical one of the buckets in terms of orthopedic care, how often, how much, who recommends it, and what database did you use to get the numbers. These are the three big databases people use. We're not going to spend time on this. And then you geographically assess it. And then you put together a whole life care plan. You end up with a total amount of money. For example, I had an individual that was in the railroad and fell, cut off a leg, and cut off an arm. And the question was, what is the future care cost? In that particular case, just the prosthetic cost alone with all the new technology, it was about $5.5 million. Then you add in the other cost. It was another $5 million. And all of it's justifiable. It's right out of the records. It's right off the shelf. It's adjusted. So future care needs, as you can see, to put together a life care plan is expensive. It takes time, and it takes people and resources. Future care needs is basically doing the same thing, what they're going to need, but you don't have to assign necessarily dollar values to it. You assign frequency, duration, and how long they'll need it, but not dollar signs. Vocational assessment is something you use in the ADA, because if you have somebody that's denied employment, or is not accommodated, or can't come back for medical reasons, the question is, what can they do, and how much money will that future career activity produce? So you need to do a vocational rehab analysis. It's part of, and there's many things that go into it. You have to be certified. There's people that call vocational rehab specialists. They're certified. They basically look at an individual's, there's a couple of things they look at, and it's really their transferable skills, their job market labor analysis, or education, and their work experience. You put that together, you can figure out, for example, if a trained conductor or engineer was making, their total packages can be easily $250,000 a year. When you look at their pension benefits, their overtime, you look at their entire system of compensation, and now they can only make $60,000 a year. So that's a big deal, and that's how they calculate the value of these ADA cases. Function capacity evaluation, I'm not going to go into it. You all know what that is, but it's a tool that you can use to measure what somebody can and cannot do, to make it more objective. If you decide somebody cannot do this job, and cannot be accommodated, you really want to do, usually, often, a functional capacity evaluation to verify. Functional capacity evaluations will allow you to basically objectify, as long as it's a good FCE, on what somebody can and cannot do. It has coefficients of variation. It has verifiable, to verify, for example, checking heart rate, and checking the consistency of movement in certain directions, consistency of lifting weights, consistency of grip strength. There's several consistency measures. So if you have a good one, it really helps you on either side, whatever you're doing. And if you have a bad one, you need to know how to critique an FCE from either side, to say that it doesn't have validity. I've seen FCEs that are just made up out of the air. There's really no validity to it. So there is, actually, standards, and there's guidelines for FCEs. Physical demand analysis is actually, there's different ways to do it. I was involved in a company that was actually the largest transformer company in the world, called Howard Industries in Mississippi. And we were doing job descriptions and functional physical demand analysis. In the ADA setting, you want to go out and figure out what the job is. So what the PDA is, you go out and you look at the job, and you can use a variety of different devices to simulate the job in the workshop, too. This happens to be BTE, which is one of the companies that does this. But you can actually go out and you measure how much they bend, they lift, the force involved, the vectors, et cetera. And you can get a job description that's ergonomically will hold up in court. I've been involved in litigation with this company to support their services. And I don't think they've ever lost an ADA case having invalid equipment. So you want to make it as scientific as possible. We're not going to actually get into this. Usually customary and reasonable. This is a tool that's used usually on the defense side. In other words, somebody has an injury, and they have x amount of bills. Let's say it's a half a million dollar bill. When you apply the usual customary reasonable standard, and there's a way to do that, usually it's about half or even 30% of what the actual bill charges are. The bill charges, if you have no insurance contractual arrangements, you don't have Medicaid, you don't have workers' comp, then you get charged the full boat. The people that are hardworking that have no insurance, they're the people that get really screwed by the system. And the UCR helps justify what's a reasonable charge. OK, there's a way to do it. I'm not going to go into it. And then I think we'll move to the case, OK? Because I don't want to take up everybody's time. This is a typical ADA case. Or do you want to do your slides first? Do you have both slides here of yours? Or do you want me to get them? I have them. I guess I don't have them. Sure, Richard, you can talk. I'm taking a break. Good job. For Dr. Krankel, for me, it's a very interesting case. I mean, the cases are far more pinpointed, but in the context of everything else that you provided, it's very interesting. Because individuals may be returning to work after litigating a case. They may not be able to be accommodated and then will litigate the case at that point. So it's interesting supporting background information. OK, so we're going to go with our second case first. And Dr. Vindred, who's the medical director at Freeport-McMoran, is going to speak. And then you can just advance it right here if you want to the second one. All right, afternoon. I told Dr. Frangis they should probably put those captions underneath here so y'all can understand me. I have a very thick accent. Are there any other Southerners in here? So help your neighbors to translate. So I'm Richard Vindred. I'm an emergency medicine physician. So don't run me out of here, who is becoming an occupational medicine doctor like probably all of y'all out here. I've come through the humanitarian, military, austere international medicine route. And I've been at this large mining company for about four years. Freeport's the largest copper miner in the world. We're one of the biggest gold miners in the world. And we also have extensible and gas. And so we do deal with a lot of these issues. And so we do deal with a good bit of ADA issues, as you might imagine. But it's not as straightforward as you would think as a shovel in the ground and bringing up metal or dirt. We are an extractive industry. So it's a lot of safety sensitive positions, a lot of dangerous positions. We do have an oil and gas facet. It's very minimal. But we are pretty extractive, as you might imagine. But we also have large corporate offices. We have trucking. We have shipping. We have railroads. We even have our own airlines. We also have multiple factories. We have about more than 70,000 workers, contractors, dependents, and about probably 40 operations all over the world. We even have three operations that we own the whole town. And so I'm an office of one. And I oversee all of our medical assets. And in some of those towns that we operate, where they're true company towns, one is so complex, we have 430 healthcare workers there alone with a 60-bed hospital in the middle of the jungle of Indonesia, where we actually have a cath lab and two CT scanners, if you can imagine that. But I do work closely with lawyers and HR to try to work on these issues. And so hopefully I may give, this is a case that I want to talk about. So this is a mining company. This is not Freeport. I'm not gonna name the mining company. But this is a lawsuit that would be consistent with probably a lot of them that you all have seen if you're in the extractive industry. A long-time employee had substantial injuries at work, couldn't meet the physical demands of a job, of his job as a mining technician. Company went, provided some accommodations for this individual. They put him in another department where his physical demands could indeed, he could meet the physical demands. He worked there for a good while longer in that new department where he had, could do his duties, and then had another, an operation that was related to the previous injury. That operation unfortunately led to short-term disability and the inability to return to work for a while. Once he came back to work, obviously, as you can see, he now had, again, had some substantial issues that would not even allow him to do that job after the transfer back to his initial job. He wanted to go back to work in the mining technician job that he had after this initial event. And what I mean is the first transfer from a long time before. And there were only openings in the department that he had previously now come from. So he was, soon after, there was no work for him at that point. There was no way to accommodate him in the section where they had positions open. So he, of course, was, he filed a lawsuit. Claims said that he should have, they should have reopened the position that was from that initial transfer at the initial injury since he had, they had done this for him before. They needed to establish three truths. Legally, he's disabled, which all y'all would agree that he is, he does have issues that needed accommodations. The employer was indeed aware of this and he was qualified. Of course, qualified means that he can indeed do this job with either no accommodation or with accommodation. But he needs to provide those essential functions. Obviously, we agree that the first two were blatant, but he could not do the job that was for this open position. Therefore, it was found that they were not really, it was not required. I mean, that would have been a, what would have been a hardship, I guess, is what you would probably call it, to create a position. And therefore, the company does not have a duty under the ADA to create a new position to accommodate this employee's restrictions. It doesn't require them to reassign other employees, which they would have had to do. They would have had to move folks from that initial transferred position into another position to create a job for him. So anyway, hopefully this was, it's an interesting case. As I said, it's a real case. You could find it on Google or something, but again, it's not my company. But I think, anyway, it paints a picture of some of the complexities of this issue. Very good, thank you. I'm gonna bring up Kevin back up, but I wanna, you know, this case that Richard shared makes me think, and these are in your notes, so I wasn't sure if we would even talk about them, but what I wanna do is highlight something that all of you should know. And this last bullet here is the point that I really wanna make. You know, and in your case, Richard, you know, the issue of, you know, what is a reasonable accommodation is central to that discussion. You know, can you get the person back? And it really has to be an interactive process between the employee, the manager, HR, legal. We, with recent cases I've had, we're actually going back to the personal physician for some clarification of the health issues. Of course, the personal physician is the biggest advocate for the patient. So ultimately, what their determination is regarding their fitness for work is really not, I mean, we would take it into consideration, but it was really more to focus on what the accommodations might look like, what the treatment might look like. Is there a change that's needed in the work environment? And as you know, we can make administrative and equipment and personal protective equipment accommodations, so we've actually used the personal physician's opinion for that. But this is, it's a complex process, as you know, and it's interactive, and there is, to highlight this point from Richard also, you know, companies are not required to create jobs, and certainly, and I've seen this happen in discussion, where do we want to return somebody to work who can't do all the essential job functions, and then hire a second person to work alongside them, or drive him around the field because the individual isn't able to drive, and again, that's not, it doesn't meet this test of what's reasonable. So I'm gonna find, I'll find yours here quick, Kevin. Kevin has a case to share with us, and let me get to it. Yeah, yeah, so you've got two slides here. That's it. You can turn me on now, so to speak. I would just emphasize, I do a lot of litigation, both on defense and plaintiff, and if you don't have the interactive part of it, you're gonna lose on either side. I mean, that's an essential part of it. You have to get these discussions ongoing. I've seen judges give summary judgments if you don't, so you do need to have interactive process, and I also agree with you that even when I'm advocating on behalf of somebody that wants to return to work, that feels they were denied appropriate return to work rights, I don't rely upon the family doctor. Yeah, you take into consideration, but they're the advocate. This is a simple case. This is a railroad engineer that had a hearing impairment, and he had a hearing impairment for years. He's working for, I think, 20 years on the job. He had a hearing aid, but he also had special muffs that were designed to both dampen and to amplify the noise, depending on the ambient hearing or the ambient environment of noise. And some people will get feedback with that kind of configuration. He didn't. He did it for 20 years, never had an accident, never had an ear miss, never had a problem. And the company decided to change their hearing program and went to only two standard ear muffs. That was it. And neither of them were this particular ear muff. So he actually was fired at that point in time because he could not accommodate, he could not qualify to pass FRI regs because of the new standard. So how do I get to the next slide? Hang on. There it is. So basically, that's what happened. Long story short. At the end of the day, I had an audiologist, went in, we verified everything I said was just true. We had him tested with and without the hearing muffs. We made sure he could pass FRI regulations, et cetera. And then we actually subpoenaed the noise, the symmetry area readings where this guy worked. We paired up where he actually worked for the last 20 years, particularly focused on the last five years, and where the noise levels in the ambient area were tested. And it turns out that the locomotives were made so quiet that where he worked, at least, he didn't even need a hearing protection. So needless to say, when that went to the jurors, there was a fairly heavy judgment on behalf of the employee just because of the economic loss of wage, which we talked about. But also there was a punitive damage that was several million dollars. So that's that particular case. I'm showing you both sides. Very good. Thank you, Dr. Engel. So that's what we've prepared for today. What I want to ... Steve, I don't see a mic in the middle there. Is it supposed to be this one that I have? I think it's yours. Okay. Well, I'm just going to talk then. No, I want to bring the mic down. If you have insights into the cases we've presented, that would be good. If you have a specific issue that you've been confronted with around accommodation, and if nobody has any questions, then we can talk a little bit about global accommodation processes. But let's stay focused in here in the U.S. first. Thank you. Hi, this is Rebecca Guest from New York. That was really interesting. Thank you all very much. My question has to do with requests, or something that I've anecdotally noticed, which is an increase in requests for medical accommodations to work from home. This has increased a lot since individuals who are working fully remotely during the pandemic have been brought into the workplace, or brought back hybrid, or fully on site. And what we're sort of seeing, and again, this is anecdotal, is that initially these requests for accommodation to work fully from home were easier to accommodate because there were fewer of them. But as they're increasing, as more people are being required to return to work, it's becoming more of a hardship on the departments, because they actually need certain, they need a critical, the departments where I work need a critical mass of people on site. Not everyone, but some people actually have to be physically present. So I just wanted to know if you have any observations about this trend of requests for accommodations to work fully remotely, or any projections about that, and how they could be handled. Sure. Do you want to start, Kevin? Sure. I have had those requests. And basically, it's a procedural policy decision on the company, what they need, in terms of if they can work at home or not. Unless there's a medical reason, and they're actually usually far and few between, there's no need to accommodate them to work at home, unless you can justify medically why they need to work at home. So just because they want to work at home, and they want accommodation, unless there's a medical reason for that, it's really up to the company to decide the configuration of who works where. And I, sorry, and I would add, as you were talking, I put this slide up, and you know, this, the issue around whether it's an ADA protected disability, you know, that's, I mean, this is the language, and this is in your notes around, you know, the ADA, that's, protected disabilities under ADA are very different from personal requests and company policies that would allow individuals to work from home. Some of our managers, you know, during COVID and right after COVID, dealt with issues around people wanting to work from home, and for many of them, the response was, you know, are the people, the workers on our ships, on our offshore platforms, remotely working in the Cameroon or in Nigeria, I mean, they've never worked from home. You can't do those jobs from your living room, right? So I know that the issues are still out there, that companies are wrestling with that, and with HR policies related to that, but to Kevin's point, it's not related to a specific, you know, medical condition or disability in general. Yes? Great stuff, thank you. Thank you. Dr. Joe Mignone, Melbourne, Florida. We all know that the earlier an injured worker gets back to work, it's better for everybody. I'm curious, for when the company wants to accommodate a return to work, but the employee's normal position is not open, there's nothing that he's trained for that he could do, is there an issue with an employer bringing them back to any open position, even if it's well below their skill set, provided they're providing comparable pay and benefits? Yeah, and I... You're going to have to translate. We couldn't hear him. Go ahead. We couldn't hear you. Yeah, I'm sorry. Can you restate at least part of that? I think the issue is bringing somebody back to a job that wasn't their job before. Correct. I mean, bring the rocket scientist back to a janitorial job or an administrative job, comparable pay and benefits, but they're at work doing something while they're recovering. How do you approach that, Richard? We totally agree, and I work very closely with HR and the sites to try to find ways to get... Because I totally... I do realize that a lot of these people are very valuable, and at some point they will potentially be able to do the jobs that they previously did. But we try our dangdest to get them back in some position, to the point that we... Again, creating a position, we're not forced to do it. We sometimes can do it to retain that talent. We do recognize, though, that if it's creating a position that's going to be a big expense or is it going to make sense, we won't do it. We definitely do things like that. And there's something... We've talked to attorneys before this talk, but we purposely didn't put any on the panel. I don't know if there's any in the audience, but I'll at least say this. I agree with the premise that getting the workers back to work is better than not doing that, especially those that are valued resources. I have seen it done differently for individuals based on their skill set and which ones we're trying to get back kind of as a business necessity or a business priority. And in some of those cases, Dr. Trangle spoke a little bit about functional capacity evaluations, and I have seen work hardening authorized for individuals and at company expense to pay for beefed up physical therapy and either work hardening or work conditioning to get people back to work. But those cases are rare, and I think they're... I mean, it certainly wouldn't be for every class of worker or every skill set. Well, I've seen the same thing, people that do go through work hardening, et cetera. There is a flip side to this. The flip side is what if you have somebody that has an injury and they want to be accommodated but not maybe the way that you want to or can accommodate them, so instead they're claiming to be never able to work again and they want a big future payout for lost economic wages. In those circumstances, you can assign them a job. You can do a PDA. You can do a functional capacity evaluation on the individual, and you can say, Look, you can do this job. It's a comparable job. We're willing to accommodate you, and if you don't want to, that's your choice. So that's part of the litigation process. Okay. Thank you. Harry, one more. Like an example, we've had folks that have had injurious seizure issues where they've injured themselves, fallen from a height, ended up having seizures, deemed to have a seizure disorder by a neurologist. We are pretty confident that person hopefully will not have another seizure. Therefore, we've gone and found a safety-aware position where he's able to work with somebody else. It was not previously there, but we recognize that that person could indeed contribute with hopes that after his seizure, the time frame for the seizure being a concern, hopefully will have waned and we can return him back to the workforce. Yeah, and part of that, I think that's a great example, and part of that absolutely depends on the job because it would be hard to do that with somebody that works as a field specialist by themselves or in an offshore platform and, you know, you're not going to get a lot of support from HR or legal to create a huge system around an individual to get them back. Go ahead, please. So in the case where you have a worker who can't do his current job, but you have an open job he's qualified for, it's a lateral transfer into another trade and union rules forbid that. That's not an uncommon setting in some industries where they can't leave their trade. They can't jump the line, so to speak. Right. I mean, I'll make a comment. I haven't had that personally happen to a case that I was dealing with, but on this slide at the bottom, I would add union representatives or union stewards to this team that's looking at what's a reasonable accommodation because I think you would have to do that. No, I've dealt with that in the past, and usually the union rules trump everything else, and they're not allowed to do that, and I've seen very rarely where the union will allow them to cross lines. There's a bigger picture they don't want to have sullied. So in that case, the company has an undue burden, and they're not liable for the ADA inability to place them in that job, or are they still liable in a sort of double jeopardy? You have to individualize it. It's a good question, but you have to individualize it because it's not always crystal clear. Wow. Okay, I don't see any hands. I will show one other slide, I guess, just as a wrap-up, and this is in your notes also. You know, the occupational health provider has to be in the middle of this discussion, right, because we understand what the essential job functions are. We may have been involved in developing the functional requirements of the job, and I've dealt with more of these recently with candidates that are trying to apply for a job and be disabled, but it could be a candidate or it could be the employee. And I think that what's fundamental in the discussion of accommodation, and I think that this absolutely has to be discussed, and this absolutely needs to be communicated to the individuals, are issues related to confidentiality and worker safety essential functions and business needs. I know that some individuals that are, they don't have to be long-time employees, but they're currently workers, they may be reluctant to raise their hand and say, you know, I have a problem, I have a disability, I need somebody to evaluate my fitness for work and my ability to do my job. So they need to know that at least the initial discussion, this used to happen to me all the time when I was dealing with expats and expatriate family members going on international assignments. They really wanted to go on the international assignment, and it was really difficult for, I was with Chevron at the time, it was really difficult for us to go through the selection process, identify the people that we want, examine them, evaluate them, oh my gosh, there's a disability issue, or there's a special medical need for their wife or kids. I mean, it was actually often the dependents that were more of an issue, and then at that point, you know, we'd have to cancel the assignment and go back to square one. So you really need to be seen as a resource for your employees. You want to have at least an initial discussion that's confidential, I've done that now recently with some cases and told the individual, you know, well, I'm not embarrassed, I have to go back, I will share this. I had individuals years ago that were early diagnosed with MS or HIV and AIDS, and it's not limited to those medical conditions, but these workers, one worker with AIDS, actually I was the only one that knew he had AIDS in the company, and he was missing work, he was late for work, he couldn't complete his assignments. He came to see me one day and he said, you know, I'm getting suspended. And I said, no, you're not. But we have to tell your supervisor that you have a medical condition that we're managing, but that you need special consideration, we need to talk about what's a reasonable accommodation to try to manage the expectations of your work and your ability to do the job. So occupational medicine can do that without involving HR and management and the business and all these things, and we really should do that. And when an individual comes to light that has a protected disability, you know, then ADA provides those protections and then we need to manage that as a team within the business. So any closing comments? I'll stick around if any of you have questions about IME practice or litigation. I'll be here, I'll be happy to answer your questions. Okay. Well, very good. Thank you for coming. Thank you very much.

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