Dr. Hadler's trenchant comment [1] points out that the conventional nature of the workers' compensation process in the United States may be partially responsible for promoting and prolonging a claimant's musculoskeletal symptoms and disability and he proposes a "no-fault" compensation scheme.

However, workers' compensation cases are just as difficult in Quebec, despite a large and generous social safety net that includes universal medical coverage, a workers compensation scheme, and social welfare benefits for disabling personal medical illness. Despite this essentially no-fault system, I have seen voluminous compensation files for musculoskeletal complaints extending over many years. These files contain opinions from different treating physicians and multiple experts, as well as adjudication hearings and appeals. This strongly suggests that the compensation problem is not due to a system that rewards fault-finding alone.

In Dr. Hadler's more detailed analysis of musculoskeletal compensation problems, published elsewhere [2, 3], he describes a situation wherein symptoms, without any significant organic pathophysiologic abnormalities, are claimed to be the result of either single or multiple injuries. Often, physicians face the predicament of a lack of valid diagnostic criteria, modalities of treatment, or an objective means to quantify disability. The claimant's predicament derives from confusion about conflicting medical diagnoses, impatience with the lack of response to "treatment," and fear of having to repeatedly validate one's "injury" to the compensation system.

Part of the solution is implied in Dr. Hadler's analysis. The predicament arises largely from a physician's inability to diagnose, treat, or evaluate musculoskeletal disability, in the absence of significant organic pathophysiologic abnormalities. A means must be devised to identify particular individuals early and efficiently. Once identified, these persons should be promptly extricated from the compensation process, which for them is likely to be long and damaging.