In two articles appearing in this journal issue, the researchers challenge lay-public notions of persons with rheumatoid arthritis (RA) (1, 2). Mancuso and colleagues demonstrate that there are few differences between patients with RA and healthy controls on a range of workplace issues and especially negative workplace experiences (1). In a well-designed longitudinal study, the authors demonstrate that persons with RA confront the same workplace conditions as healthy workers. Varekamp and colleagues use qualitative techniques to allow lay-public notions of working with arthritis to emerge from both employees with arthritis and the health professionals that treat these individuals (2). Surprisingly, there was much common ground between the 2 groups concerning what is needed for persons with arthritis to continue working. The challenge, manifested in the Varekamp et al study, is how to frame or conceptualize the problem both to enable research and to ensure that the knowledge generated from the research is translated into practice.

Mancuso and colleagues use a stressful life events model to guide their work. This model, grounded in a rich intellectual research tradition, may not be the most relevant for labor market issues. The challenge has always been how to translate stress research into sound secondary prevention activities. Drawing on a strength of qualitative work, Varekamp and colleagues allow the theoretical issues to emerge from the participants. Their call for a multilevel, patient-centered approach to treatment and prevention is equally difficult to translate into practice in work settings due to the often competing agendas of the various individuals involved (managers, supervisors, insurers, health professionals, person with RA) and the broader organizational and societal context. Neither study helps achieve secondary prevention activities from the research.

It is critical to consider the employer and the organizational context in which the person with RA works, from both a research perspective as well as a practice perspective. Organizational policies and practices (OPPs) have been shown to predict successful work role functioning in patients undergoing carpal tunnel release surgery (3). These policies and practices capture the broad culture of the organization, specifically safety climate, disability management policies and practices, and ergonomic policies and practices. Williams et al have shown how OPPs vary across organizations (4). Many of the themes and subthemes identified by Varekamp et al fit into the OPPs perspective (5). These themes and subthemes are not characteristics of the employee, but the organization the employee works in. Similarly, the health professionals also identified these same OPPs. Certainly, Varekamp and colleagues could reframe their findings, locating the employee within the organization and having health professionals work with the employer and the employee to manage RA more effectively.

Why care about OPPs? The employer plays a key role in the management of work disability. Therefore, the employer, by establishing policies and standard practices, can influence a range of important processes. Best practices or other forms of knowledge dissemination of benchmark companies are useful approaches for disseminating knowledge to employers, but first we would need to collect the data. We wonder whether many of the employers identified by Mancuso et al have effective OPPs and whether this is why no differences were observed between patients and controls. Bringing the organization back into work research expands our conceptualization of work and offers new prevention strategies beyond the patient.

A great challenge is how to motivate employers to attend to the issues of work disability and the employability of persons with RA. Employers are motivated by market concerns, thus productivity is always an easy entry into businesses. Recently, a number of researchers have offered tools for measuring health and productivity (6). A key component of these measures is an assessment of presenteeism, which is the ability of the employee to meet the demands of the job given a specific state of health (7). This class of new work role functioning measures provides an indirect link between health and productivity. For example, if a person scores 80 on a scale of 0 to 100, then 20% of the time that person is unable to meet the demands of the job because of health. Recently, Allaire et al have shown that adults with RA have work role functioning scores of ∼80% (8). Work role functioning measures should be substituted for traditional functional status measures that are designed to capture clinically meaningful changes but often are not sensitive enough to capture economically meaningful changes in productive activities. Imagine if Mancuso et al had demonstrated no differences in work role functioning for patients with RA compared with controls!

It is important not only to demonstrate the productive time of persons with RA, but to show what predicts productive time. In our work, OPPs have been shown to predict successful work role functioning (3). We have hypothesized that 2 mechanisms through which OPPs operate are job accommodation and improved self efficacy. Elaborating a fuller multilevel model that considers the role of the organization, health professionals, and insurers—all key persons in creating healthy labor markets for individuals with RA—remains a continued challenge for arthritis researchers.

As we sit in Houston, Texas amid the Hurricane Katrina recovery, we would be remiss if we did not comment on social inequalities and the broader societal context. The research of Mancuso and colleagues focuses on highly educated female professionals who had access to health care, and almost one-third of the sample could afford not to work. We wonder whether their social status and the social context of their lives may differ from persons with RA who are unemployed or experiencing employment insecurity. As multilevel models are elaborated, inequalities must be redressed by attending to the needs of all persons with RA and not only those easily accessible through health plans or physician offices.


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