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September 24, 2001.
This Week's Topic: The
Pre-Surgical Patient
Question: “I sat in the office
with a back injured worker while the nurse explained to him what surgery was
indicated and how it was to be performed. The patient had no questions, and I
feel he understood, but I gather you feel that I needed more information?”
Dr. Adams Replies: “Patients are
often silent because they are overwhelmed by the fear of the impending
procedure, do not know how to structure a meaningful and clarifying question and
chose to believe that surgery offers them a guarantee of complete resolution of
pain.
Among the data that you need to have
secured are:
a.
Does this patient have any past
surgical experience
b.
Has any of the patient’s family
or friends had spinal injuries and/or procedures
c.
What would the patient perceive
as “successful surgery”
d.
What alternate career plans has
the patient considered
e.
How heavily are financial
burdens weighing on patient and family
f.
How has the patient’s role as a
spouse and/or parent been altered
g.
How has the family’s perceptions
and treatment of the patient changed as a result of injury and limitations
h.
How compliant has the patient
been with a fixed schedule of pain medication
i.
How compliant has the patient been
with diagnostic and conservative measures up to this point
In effect, a silent patient,
about to undergo spinal surgery is not necessarily a patient who understands the
procure, is prepared for its aftermath and/or who will comply with post-surgical
rehabilitation.
Monday, September 17,
2001.
This Week's Topic: The Red Flag
Age Group
Question: “In your opinion is
there a critical age group or demographic description which typifies the more
problematic patient? By that I mean, which age-group patients are least likely
to return to work independent of injury?””
Dr. Adams Replies: “In my
clinical experience there are actually two age groups which present problems of
rehabilitation.
The first group is the comparatively
young (e.g. ages 30-40) males in manual labor positions who often have (or came
from) families with one or more disabled family members *and* who themselves
have no alternate skills for non-labor intensive occupations. Within a year of
injury, these individuals acclimate to a sedentary lifestyle of watching
television, gaining weight and inactivity aside from doctor visits and physical
therapy visits. Dependency upon medication arises. These individuals can be
readily identified and assisted if referred soon after injury.
The second group is comprised of two
subgroups, but they share in common their age ranges. This group is the age
range of ~48-60 years of age. The first of these subgroups are those who are
working to offset boredom and have no financial need to be in the workforce.
Their motivation to confront their injury-related problems in order to return to
productivity is very low. Vigorous efforts to mobilize them will ultimately
fail, and such patients need to be early identified so that care is more
targeted to a decision they have already made.
The other subgroup of these middle aged
individuals is comprised of those who have had a long, productive and effortful
career. In effect, they are simply tired. They feel they have made their
contribution to their family and the workforce. While they obviously would
prefer not to have been injured, the injury provides the secondary gain of early
“retirement” and justification for seeking social security benefits which they
have funded for decades. Once again, early identification of these patients
enables assisting them in realizing that this is the decision that they are
making and how best for them to communicate this to their families.”
Monday, September 10,
2001.
This Week's Topic: PTSD Common
After Work Injury?
Question: "We are seeing more and
more claims for posttraumatic stress disorder after work-related injury,
especially (but not always) after an auto accident. Why are these cases more
common?”
Dr. Adams Replies: “Actually,
valid cases of PTSD are not common. A study [Schnyder, U. et al. (2001)
Incidence of prediction of prevalence of posttraumatic stress disorder in
severely injured accident victims. Amer. J. Psych. 158, 4, 594-599.]
remind us that symptoms of PTSD cannot be diagnosed until symptoms have lasted
for at least one month.
Thus, when there is a claim of PTSD
immediately following an accident, it is not clinically valid, and it may be a
transient adjustment response.
In the aforementioned study, 4.7% met the
criteria for PTSD after one month, and one year later 1.9% met the criteria for
PTSD.
Of the few that developed PTSD, it was
found more common in those who had few friends or relatives, and it was more
common in women.
Higher reported PTSD may be from
misdiagnosis in which the label is attached to those who have several symptoms
but did not, in fact, meet criteria for actual diagnosis as define in the
DSM-IV-TR.
This, once again, points to the
importance of obtaining valid diagnostic examination when PTSD is suspected.
Monday, September 3,
2001.
This Week's Topic: Open
Psychological Benefits?
Question: "When we settle a case,
we would prefer not to provide open-psychological benefits for the next year. We
feel this would increase our costs and exposure as an employer. How much
open-psychological is optimal and fair for both sides?”
Dr. Adams Replies: “I would prefer
to believe that there are not “sides” doing battle but that you are providing
mandated care in an attempt to provide as much relief to the employee as
possible.
With that said, even though 3-6 months of
open psychological care is common, I am still tempted to say that “it does not
matter how much open psychological is provided at settlement.” In reality, the
vast majority of those who put closure on their work-injury, do not, in fact,
continue psychological care after that closure.
Most of us have seen patients who express
profound appreciation for psychological care provided at some point during the
course of their injury. They feel it helped them navigate through all that they
confronted.
These well intentioned patients also may
state with great certainty that they wish to remain in care long after benefits
have been exhausted, “even if I pay out of pocket.” However, soon after closure
occurs, they cease to schedule return appointments.
This is not surprising: During the course
of injury related treatment, they have exposed and discussed many conflicts and
aspects of their lives which they would prefer now to set aside.
The offering of open-psychological is
more of a symbolic support for that which they have had to deal, but it is
consistently found that remarkably few make use of this care-after-closure.
Monday, August 27,
2001.
This Week's Topic: The Angry or
Enraged Patient
Question: Many of the injured
workers that present in our occupational medicine center appear more angered
than depressed; resentful and difficult to treat. It is hard to fathom where
this anger comes from, and/or what to do about it. What is your take on this?
Dr. Adams Replies: "First, anger
can be a predominately male defense against expressing the true feelings of fear
and futility. Anger is an effective means of burying “what am I going to do now”
since responsibilities continue even when productivity is temporarily halted.
Secondly, there are often valid reasons
for being angry. The employer may not have had adequate safety precautions. The
patient may have been required to perform tasks for which he is not skilled. The
patient may have been required to complete tasks which are beyond his/her (or
anyone’s) physical capacity.
Additionally, after injury, it is not
uncommon to hear that the employer asked the patient not to report the injury
and have it treated under general medical insurance. There are instances in
which the employer neither calls an ambulance nor assists the patient in getting
to the ER. Of even greater concern are those cases in which the patient is told
to continue to work even though clearly in need of medical attention.
The quality of care can be problematic.
There may be long distances driven in order to secure care, followed by hours in
waiting rooms, brief visits and no significant feedback.
Thus, we may see numerous and justifiable
reasons for injured worker anger. The problem is that this is rarely addressed.
The patient is x-rayed, medicated, sent to P.T., and everyone notes that he/she
is angry if not enraged.
Whenever a patient is felt to be angry,
the most effective action is to insure that someone spends time with the patient
to determine the source of the anger and potential resolution?”
Monday, August 20,
2001.
This Week's Topic: Are They Truly
Depressed?
Question: "I am not certain how
you know someone is depressed. Do you just ask them, and if they say they are,
they you are certain that this is a valid problem?”
Dr. Adams Replies: Actually, most
depressed patients will say that “something is wrong” but will also state “but I
do not think I am depressed.” They will go on to describe changes in appetite,
significant weight changes, forgetfulness, irritability, problems with
concentration, decreased libido, pessimism, self-doubt, early morning awakening,
agitation, loss of interest in their hobbies, desire to be alone, impatience,
low frustration tolerance and numerous other symptoms that, when combined,
indicate clinical depression.
However, if a person has a need to be
seen as depressed for some ulterior motive, they can learn to parrot those
symptoms on demand. This is where formal, standardized psychodiagnostic
assessment is critical. There are checks within these instruments of the
validity of complaints made by the individual.
Although it is possible to suspect that
an individual is depressed based upon a clinical interview, the psychodiagnostic
tests are need to confirm this as a diagnosis.
There are patients who measure as
depressed but less depressed than they are focused upon bodily complaints. That
is, the diagnostic instruments indicate significantly less depression than the
physical concerns would suggest. Something is keeping the patients from being
more depressed than we would expect. In those cases, the existence of secondary
gain may be in operation, and the patient may be found rewarded for his/her
complaints through additional attention, affection and relief of
responsibilities.
Thus, you are correct, we cannot solely
rely upon a patient’s statement that they are depressed. We need to look for
specific symptoms and use standardized instruments to determine the severity and
validity of those complaints.
Monday, August 13, 2001
This Weeks Topic:
Is Psychotherapy Effective/Appropriate
Question: "Are there times when
psychotherapy to do with an injured workers’ pain and depression is not
effective or even appropriate?”
Dr. Adams Replies: Candidacy for
psychotherapy is a critical factor to have measured. While psychotherapy can be
a powerful means of dealing with painful aftermath of injury and a very
effective means of dealing with anxiety and depression, it may not be
appropriate for specific patients.
Patients who come from a family or
cultural background in which psychological complaints are considered weaknesses
has been discussed before, but there is a larger group of patients in which
talking about emotions and inner thoughts is strongly discouraged. These
patients believe that they are to deal with such concerns privately; they are
not to share them with others.
When such patients, in desperation, enter
psychotherapy, two negative outcomes may emerge:
a. They
may become so threatened by what they find themselves thinking, feeling and
verbalizing that they withdraw from treatment completely or
b. They
may become pathologically dependent upon their psychologist since this is the
first person to whom they have told their most private concerns.
Thus, not infrequently, we find a patient
who has complaints that warrant psychotherapy, but if you examine closely
enough, you find that such care may evoke even greater problems for the patient.
While it is important to know
that the patient’s symptoms indicate care, it more important to know the
potential adverse effects if such care is delivered.
Monday, August 6, 2001
This Week's Topic:
The Inability to Understand
Question: "I
understand what you were saying about the intelligence level of many injured
workers…perhaps they cannot give informed consent because they do not understand
medical terminology. But my office provides them with written material and
routinely asks if they have graduated from high school. Should this not be
sufficient to insure a patient understands the planned surgery?”
Dr. Adams Replies:
Unfortunately, it is not. It is quite common to see patients who have a high
school diploma, or say they do, and yet be unable to understand spoken and/or
written information.
Many patients will say that
they have a high school education because they quit school in the 9th
grade and later obtained a GED. Or they indeed completed the 12th
grade but were almost 20 years of age and had repeated two or more grades while
in school.
And even with a high school
diploma, even earned by age 18, there are numerous patients that simply have
reading limitations.
In my own practice, I screen
for reading, spelling and mathematical capacity. There are individuals with
greater than high school education that cannot incorporate data that is intended
to be at an 8th grade level.
Not only their ability to
receive new data is of concern but also their ability to communicate a complete
history needs to be considered.
These cognitive limitations,
whether in receptive capacity, expressive capacity or learning disability, may
be major hurdles to adequately communicating with a patient and preparing that
patient for surgery and its aftermath.
Monday, July 30, 2001
.
This Week's Topic:
The Capacity to Understand
Question: "I am an
orthopedic surgeon in a large group practice. Many of us in this practice
believe that the intelligence of the patient is a big factor in determining
surgical outcome. Do you believe that to be true and do you routinely assess
intelligence of pre-surgical patients?”
Dr. Adams Replies: I
recommend, and routinely assess the intellectual functioning of injured workers.
There are two problematic groups for which intelligence plays a major role:
a.
Those injured workers of significantly subaverage intelligence not only
may fail to understand their condition, treatment options and risk/benefit of
surgery, but they may also lack the capacity to formulate questions to obtain
the data they need. Post-surgically, they may complain about pain but be unable
to have their fears/concerns assuaged by the explanations provided them and/or
fail to understand their post-surgical treatment regimen (medication, physical
therapies and objective limitations).
b.
Those injured workers of significantly above average intelligence may
find the
del
ays inherent in their care, the awaiting for approval of treatment,
and the lack of extensive patient education to be frustrating if not
threatening.
For those in the former
group, it may take repeated and simplified information and instructions to
maximize quality of care and compliance for the patient.
For those of above average
intelligence, the workers’ compensation system, with its checks and balances,
may feel demeaning or insulting. These patients may feel that their capacity to
understand is dismissed and their intelligence impugned by a system that
encourages passivity and dependency.
If you do not formally
measure the capacity of the patient to understand the condition and treatment
options, there is no established frame of reference with which to communicate on
a level acceptable to the patient. Differences in intelligence levels can be as
disruptive to communication as differences in spoken language.
Monday, July 23, 2001
This Week's Topic: A
Fallacy in Case Management
Question: "One thing
is indisputable: after injury, most injured workers have severe financial
problems, and if they could, they would return to work.”
Dr. Adams Replies:
This may be inaccurate. While many, if not most, have severe financial problems
that threaten their security, there are numerous cases in which the individual
does not
wis
h to return to work:
a.
The family has begun to compensate for the financial difference, and,
with social security benefits, it may not be mandatory that the patient again
works.
b.
The patient may have formed a new relationship that promises financial
security, and re-employment is no longer required.
c.
Choosing between poverty level existence or working long hours in pain,
some will make a choice to avoid the pain.
d.
Many injured workers have performed manual labor since age 16 or before,
having had little time with their family, and this may be the first opportunity
for some semblance of a family life.
e.
They reside in a community (or family) in which disability is not
uncommon, and they receive considerable support and encouragement in a decision
not to return to the workforce
f.
The hurdles of finding something within their restrictions is greater
than the hurdle of trying to cope with minimal income
One of the critical case
management factors is having the patient evaluation to determine whether a
patient truly wishes or plans to return to any form of work, not merely that
he/she financially needs to do so or is physically capable of doing so.
Monday, July 15, 2001
This Week's Topic:
Unmotivated, Worthless…or Helpless?
Question: "We have a
post-surgical patient who has shown good physical recovery, actually has minimal
PPD, is at MMI, and…he does nothing and this does not look like it is going to
change. Are some people just unmotivated, inappreciative and basically
worthless?"
Dr. Adams replies:
Likely there are quite a few inappreciative and/or unmotivated patients, but I
wonder if you have considered “conditioned helplessness.”
“Conditioned Helplessness”
can be at the core of many patient management problems. The patient is doted
upon by a well-meaning spouse and becomes increasing dependent and decreasingly
motivated.
The patient is told not to
attempt to find employment and to “just wait,” and this formerly hard working
individual now spends days inactive, overeating, and failing to look at future
employment options.
The patient’s “conditioned
helplessness” is exacerbated by receiving financial compensations for weeks,
months…years in the absence of a work demands, work schedules and competing in
the workforce.
The patient was not able to
determine the schedule or order of care; this is done by his doctors, and he has
become conditioned to be passive, dependent, indecisive…helpless.
“Conditioned Helplessness”
may be at the core of most cases of situational depression (depression arising
from specific negative life events). In that case, the patient feels that it is
futile to even try; so “why bother?”
While the concepts of
lacking motivation and appreciation can be considered, first determine if the
psychological climate of the patient’s post-injury life has created and
maintained a state of “conditioned helplessness.” If conditioned helplessness
has developed, the family and others involved in the rehabilitation process can
be shown how their behavior is impeding the patient’s mobilization. It is a
solvable problem once diagnosed.
Monday, July 8, 2001
This Week's Topic:
The Disruptive Husband & the Interfering Wife
Question: "As a case
manager, I have a great deal of difficulty with the husband or wife of an
injured worker. Can you tell me how and why these problems present themselves
and the solutions?"
Dr. Adams replies:
This is consistent, important and needs to be addressed. It is an excellent
question and observation. This also is the topic of the next Newsletter
(September, 2001), but let me try to summarize here:
a.
The spouse resents that the full burden of the household now falls upon
them
b.
The spouse blames the physician(s), nurse case manager and adjustor for
the burden that is now upon them
c.
The patient permits the spouse to assume responsibility for everything
from filling out a history form, to tracking medication, to interfacing with the
insurer and providers
d.
The spouse is often blamed by the patient for the burden now facing the
household
e.
The spouse assumes full financial burden, yet the patient may
concurrently demand that the spouse not work and transport the patient to all
visits.
f.
While assuming full burden, the spouse is provided no physical affection
nor verbal appreciation
Often the couple/family has
lived an emotionally and financially precarious life with past conflict and
unresolved problems. At the time of injury, the uninjured spouse consciously or
subconsciously takes this opportunity to attack both the injured patient and
those attempting to provide care and rehabilitation.
As with all such
psychosocial factors, it is important to identify the existence of these spousal
burdens, demands and conflicts. Often the patient will willingly, of not
gratefully, discuss the relationship problems. Equally as often, the spouse, who
seems so offensive, will be relieved to ventilate that which is bothering them.
However, with that said,
both patient and spouse need to be reminded that it is the injured worker who is
the patient, and the spouse can elect to be a facilitator of rehabilitation or
an obstruction to recovery.
Monday, July 2, 2001
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This Week's Topic:
Injury and Diabetes – Unlikely?
Question: "I have an
injured worker who is convinced that his diabetes is cause by his injury. That
is absurd is it not?"
Dr. Adams replies:
How much do you know about his life other than the injury? What is his daily
routine, his sleep schedule, his exercise regimen and his diet? As surprising as
this sounds, these are all psychophysiologic issues of great importance.
Let’s set aside someone who
has sustained a pancreatic injury at work and cannot produce insulin and look at
the more difficult cases to understand/fathom.
If you do not have a
psychological exam on this patient, and he/she is depressed, sleep will likely
be disturbed. It has been shown (go to
http://www.psychological.com/question_of_the_week.htm ) that
America
ns are getting less sleep. With less sleep comes the production of
substantially less insulin. If the
ind
ividual is depressed, they may well be getting less than the
mandatory 7+ hours of sleep.
If the
ind
ividual is in chronic pain, he/she may be getting less than the
mandatory hours of sleep, and/or if he/she has marital, financial or family
pressures, he/she may be obtaining less than optimal hours of sleep. Once again,
all of this has been associated with onset of Type 2 Diabetes.
Furth
er, if you do not have a psychological exam, you do not know if the
patient is exercising, sedentary, his/her dietary intake and other
complicating/contributing risk factors.
Since this sleep-diabetes link has been established,
we simply need to know more about the post-injury lifestyle and its health
implications. These are not issues typically investigated in depth, but they
need to be.
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