This Week's Topic: “Hooked”  

Question: “These pain centers pump out medication like crazy…and I believe a lot of these people are addicted…is there a way to tell?”  

Dr. Adams Replies: Yes, there are several behavioral signs which raise a red flag that you should do some further investigation:

This Week's Topic: “Warning Signs” 

Question: “I understand why, and to some degree how, an individual can lie about their disability. Are there warning signs when this is occurring.” 

Dr. Adams Replies: There are behaviors that create a high index of suspicion:

a. The patient has been employed briefly and has a history of brief employments

b. The patient has past disability claims or suits and/or has friends and family with such events in their lives

c. The patient is noncompliant with treatment, diagnostic studies and especially with referrals for 2nd and 3rd opinions

d. The patient places someone else in the path of communication such as their spouse

e. The patient expresses more anger than motivation

f. The patient expresses groundless distrust in response to clear attempts of others to mobilize him/her

g. When a patient attempts to "hide-out" from a psychological exam, they are displaying a fear and avoidance of revealing their goals and motivation.

This Week's Topic: “How Much Is Too Much” 

Question: “We have a real messy case, and we have had many like it…someone sent this claimant to a pain center…now the patient is not sleeping, complaining of sexual problems…says he is depressed…and they are wanting sleep studies, Viagra, antidepressants and psychotherapy…something is wrong here…any help appreciated.” 

Dr. Adams Replies: This is very typical. Pain centers use numerous medications with a wide variety of side effects. These medications are often added to those which are prescribed by the orthopedist, the neurologist etc. 

The side effect profiles of these agents include potential for sleep disruption, sexual dysfunction and can promote changes in mood.  

What you will be told is that the medications cannot be halted because of the patient’s pain. 

However, in reality, the medications can be stopped for a brief period of time to determine what if any impact this has upon these newly emerging symptoms. Alternatively, if it can be established when the symptoms first arose, often you can link that to which medication was started during that timeframe. 

Interestingly, and importantly, regardless of what you are told regarding the necessity of the medication and the patients “need” for them, patients will often tell me that they hate the side effects, cannot tolerate being sedated all day, loathe the impact upon sleep and sexual functioning but are too intimidated to stop taking the medication.

This Week's Topic: “Psychological Preparation” 

Question: “How do we most effectively make a referral to insure patient compliance?”? 

Dr. Adams Replies:  If you are seeking a psychological exam on a chronic pain patient, explain to the patient and his/her primary provider that you need to determine if there are any psychological factors that complicate the patient’s coping with pain. 

If you are seeking a psychological exam to determine problems with patient motivation and compliance, you explain to the patient that you need to determine if there are issues that are complicating the rehabilitation process. 

If the concern is for occult depression (problems with mood that are being displayed as irritability and/or withdrawal), then you let the patient and authorized treating physician(s) know that you feel that there may be complications to the injury that no one has diagnosed and addressed. 

If you feel that there is some form of conscious symptom amplification occurring, you tell the patient that you need a fuller understanding of their needs and goals. 

This Week's Topic: “The Questions” 

Question: “I am an adjustor and appreciate what you said last week. I think these doctors need to do their job and get these people back to work. I am doing my job of paying the bills. Is that not your point? 

Dr. Adams Replies:  Not entirely.  

You complain that unmotivated patients and divisive attorneys make your work unpleasant. Yet, you passively approach each case in a similarly ineffective fashion: you authorize care and await resolution. 

There is a psychological reason why a patient chooses not to recover.  

You expect the surgeon to tell you what that is and how to handle it. 

However, this is not a surgical determination, and the surgeon expects you to find someone else to determine the reason the patient is not mobilizing. 

Both you and the surgeon are asking for the same information, and both of you expect the other to provide it.  

These issues are psychological (the science of behavior) and not surgical. 

But you postpone a psychological exam because you often do not know how to ask the simple question: “I am referring this patient because I need to know why he/she is not recovering as expected.”   

And, if the psychological referral is made, you expect the surgeon to make it. 

The way I see it, the surgeon should provide the clinical care and note that the patient is not appropriately/predictably responding.  

You, in turn, then need to authorize a one-time psychological evaluation to determine which the patient is not responding. 

This Week's Topic:   “Claims Adjustors Do Not Have Clue”

Question:  “I am an orthopedic surgeon and am backing away from taking workers’ compensation cases. The patients are inappreciative, manipulative and frankly dishonest…but just as annoying are the claims adjustors who demand that I tell them why this patient will not return to work…I have no idea, this is not my role, and these claims adjustors do not have a clue as to my role and their responsibility. Care to comment?

Dr. Adams Replies:   I would like to point out that claims adjustors and nurse case managers share your frustration.  But you need to consider the following: 

Claims adjustors and nurse case managers are hired to manage the following:

- A worker is injured, needs medical and financial benefits, and may need assistance/coordination with the employer to return to work.  

Claims adjustors and nurse case mangers are NOT specifically trained to recognize or manage the following:

- A worker is injured, appropriately treated and compensated, and, for reasons unclear, does not recover or declines to return to work and/or develops new symptoms 

Your responsibility is not only to provide clinical care, whether conservative or invasive, but also to explain why a patient does not recover. 

This Week's Topic:  Hiding Out

Question:  I understand the concept of secondary gain...this means that the injured worker gets a lot of attention and money and this influences his symptoms...but even with all this attention, why would someone cling to apparently miserable symptoms?

Dr. Adams Replies:   Many of them are simply "hiding out." An injury can be a very effective excuse for all of the failures of life, and the lack of creativity to find new options for the future.

Most of us wonder `what would we do if we lost our job' or had a disability that prevented us from doing our current job.

What would most people do?  Most would seek a new path in life whether with or without new education. We would find something to do...some way of surviving because ultimately we must all take care of ourselves and our families.

When you pay someone not to work, you complicate the situation, you reduce some (and in some cases all) of the urgency. You allow the person to hide from their own lackings:

• low motivation

• low education

• low creativity

Many people need fear as a motivator, fear of survival. For others, there is the fear of having no work identity...no answer to the question "what do you do (for a living)?"

An injury (and often an illness) can become a means of hiding out from our responsibilities for our own future and the wellbeing of the family.

It is imperative to determine whether or not this is occurring. Is the injured worker using the symptoms from the injury as a means of hiding from the greater fear...the future and potential failure.

Once we know from what the injured worker is hiding, we are better equipped to direct him/her toward a functional future rather than chasing down physical complaints which appear to have little or no basis.

This Week's Topic: The Common Misconception

Question: Like most case managers, I usually recognize when a patient is depressed, but you seem to believe this is one of the less common reasons for referrals. Can you explain to me what you believe to be examples of your “psychological overlay.”

Dr. Adams Replies:  Most people know now how to recognize depression and how to refer when they see it. That is rarely an issue nowadays. 

However, increasingly case managers are aware that there is a psychological overlay in which these injured workers exist.  

Permit me to outline a recent case of an injured worker who had no apparent psychological complaints and certainly no desire for treatment: 

1. He was left fatherless by the death in an auto accident of his alcoholic father, setting the biological pattern for him to fear addiction and be vulnerable to it. He is prescribed Vicodin upon which he is now reliant.

2. He was raised in poverty by a mother who complicated their plight by repeatedly being impregnated by men whom she never married, bringing children into the world that she could not afford to support.

3. He was forced to work in the fields by age 12, forced out of school by 17 to support the family.

4. His mother then immediately married and did not need his support

5. He married a woman of his mother’s age (who had children older than he) when he was 19

6. He lived for many years in a rental home rather than suffer the anxiety of relocating

7. Before he was middle age, his wife had reached retirement age.

8. After his injury, his employer delayed his securing care for many hours while they scrambled with paperwork, finding a relief worker, etc

9. Treatment was directed toward a minor injury while the significant part of his injury was minimized

10. His wife wanted him out of the home, back at work, yet interfered with his care

11. Several doctors whom he saw were more invested in providing care within their specialty area than in providing care targeted toward his needs

12. The transitional duty work offered was, in many ways, more difficult for him than his full duty work

13. His authorized treating physician communicated more directly with the employer than with the patient

14. Wife, physician and case manager have despaired of him. 

This is a dependent, anxious and avoidant individual who needs no psychological care and has no psychological limitations. 

This Week's Topic: Direct Advice

Question: Do you ever directly advise a patient what they should do about their injury?

Dr. Adams Replies:  Yes, I provide them with ten simple truths and cautions that others may never have told them:

1. Do not use an injury to hide from greater problems in your life

2. Do not let an injury solve problems that you need to address yourself

3. Do not tell yourself you are depressed when you are actually angry and frustrated

4. It is your body, make certain you understand how it works

5. Do not think of your injury as a competition in which you prove someone else to be “wrong”

6. Do not use your injury as a weapon against the family

7. Be certain you fully understand the goal of any treatment to which you submit yourself

8. Be certain you understand that treatment may never restore you to where you were prior to injury

9. The opinions of others may be interesting but not necessarily accurate

This Week's Topic: Single Most Important 

Question: “In your opinion, what is the single most important psychological factor that determines the patient’s probability of recovery?” 

Dr. Adams Replies:  Intelligence.  The injured worker must be capable of receiving and understanding patient education. He must understand what damages have occurred and what can…and cannot…be done to assist him.  

When treating injured workers, most of us proceed as though the patient has at least a basic fund of knowledge that permits him to understand the nature of his orthopedic or neurological injury.  

When you sit down with a patient, and/or when a patient insists on copies of his records, we make the assumption that the patient reads, the listens to, researches, and develops an understanding of, his condition.  

However, quite often the patient does not even have a cursory understanding of the nature of the injury, cause of the pain, benefits of care, limits of current medical knowledge, and a functional appreciation of the true nature of limitations.  

Further complications arise when these individuals rely upon others who cannot provide them with objective data. Friends and family comprise the latter group, and they can often complicate recovery by offering. 

This Week's Topic: Can of Worms - Revisited 

Question: We have new claims adjustors. As nurses, we try to get them to make psychological referrals to find out why these claimants are not getting better, not getting back to work, but they will not even order a psych. exam., afraid that it would open them up to all sorts of additional costs? 

Dr. Adams Replies: What costs are we talking about?  If the claimant is not working, continuing to access health care, charging you for medication, doctor visits, repeat MRIs, course-after-course of physical therapy, pain management…look at your current expenditures as nonproductive…and what are you saving?  

It sounds like the big concern is that a psychological exam is guaranteed to indicate the need for psychological care and that such care will go on endlessly. In reality, less than 5% of those psychologically examined would ever consider being in psychological care (social embarrassment) and of those few, most will terminate care very rapidly. For those who do seek and continue in care, you set a strict limit as to number of visits. 

A psychological exam does not reveal any problem for which you are not already paying. You may be paying for pain that does not exist, for limitations that are exaggerated, for lack of ambition, lack of motivation, fear of failure, few occupational skills and options. And you are paying for these because they are presented to you as physical complaints.  

Underlying problems govern all cases. The patient does not want to reveal or address these issues.  So they direct attention at physical complaints. 

In turn, you try to “solve” their psychological problems by meeting their physical needs; then become discouraged when that is not effective.  

This Week's Topic:  Additional Law Suits and Future Goals?

Question: Do you see individuals who are engaged in law suits associated with their workers’ compensation claim, and has it been your experience that they are less or more likely to mobilize?

Dr. Adams Replies: I often see patients who are involved in product (and other) liability law suits associated with their work-related injury. This may be a suit because of equipment failure or lack of equipment safeguards as well as other reasons for suit. 

These patients appear to recover to a certain point, and while it appears that they are now ready to look at career/employment options, they suddenly stop progressing. 

Some will candidly say that they are able to be productive but have been advised that this will diminish their potential amount from their suit. 

Others will state that they really have no future plans and are relying upon this potential financial outcome to determine the course of their lives. 

Thus, while they may not seek employment, they may engage in activities suggesting the capacity for employment. They may also begin looking at expensive items like homes and vehicles which they believe they may soon be able to afford.  

This Week's Topic: Saving Money?

Question: When you talk about making psychological care “brief” is this because you are trying to save the insurance companies money?

Dr. Adams Replies:  Psychological care is not expensive, and when compared to its shortening the time of disability, it is actually money saving.  

The reason for keeping psychological care brief is two fold:

a.    The longer it continues, the more dependent a patient can become upon this emotional support.

b.    The longer it continues, the more likely an inexperience clinician is to delve into aspects of the patient life that are not remotely related to the injury. 

Psychological care should, therefore, not only be brief (eg. 8-10 visits is often ideal) but also spaced (Eg. Every 2-3 weeks), but also specifically targeted to injury-only concerns as we discussed last week. 

The most functional way to obtain that is to insist upon a treatment plan, regular and thorough progress notes, and call the psychologist monthly to determine if the patient is progressing toward closure.