Monday, March 15, 2004

(WEEKLY CASE MANAGEMENT UPDATE #278)

This Week's Topic: “Baseline or the Basement”

Question: “When we have an injured patient with pre-existing problems, they never seem to recover from their injury… (and)…I think this concept of “exacerbation of pre-existing problems” is itself a problem. How much responsibility should we assume?” from PsychIME.com

Dr. Adams replies: “Let’s take a brief example. A young adult male strains his back at work. There are no remarkable physical findings. He complains of pain and is irritable. Both of these are depressive symptoms. Is he depressed because of his injury? Is he in pain because of his injury?

The problem actually is relatively simple to solve.

First let’s look at the situation. Dependent upon the study, between one-fifth and (as much as) two-thirds of injured workers’ had one or more diagnosable psychological problems prior to injury.

These include not only mood and anxiety disorders but substance abuse and personality disorders.

That was their “baseline” when they were injured. This baseline often involves dysfunctional marriages, extreme financial pressures, social inadequacies, conflicts with authority, etc.

The worker is injured and drops below this baseline.

The goal of injury treatment must be to return them as close as possible to their specific baseline which may be far below what we would consider “normal.”

We must establish this individual baseline as soon after injury as possible. If we do not, then we assume responsibility for pain and mood complaints that actually arise from problems unrelated (and perhaps not even exacerbated by) injury.

Monday, March 8, 2004

(WEEKLY CASE MANAGEMENT UPDATE #277)

This Week's Topic: “Injury as Vengeance”

Question: “You recently saw a patient for me who had a legitimate injury from which he has recovered. He continues to complain despite completely negative findings. He feels “suspicious” to me, yet you say he does not have a conversion disorder or any disorder but is seeking revenge. Please explain.” from PsychIME.com

Dr. Adams replies: “There is no doubt that some injured workers are mistreated. They do not receive approval for diagnostic studies, treatment is intentionally delayed, procedures are cancelled, prescriptions are not filled and financial compensation is not sent.

The patient, in a dependent position, grows resentful and also feels powerless.

After months of enduring these frustration, the patient (most often male) feels that the only alternative is “to get them like they have been getting me.” That is, simply refuse to recover, refuse to consistently comply and refuse to settle.

This passive-aggression, the patient erroneously feels, will balance the scales and make others suffer as he feels he has.

The patients often see the “system” as simply his employer, his insurer, his adjustor and his primary physician. The patient can only appreciate his own plight and does not see (nor particularly care) about administrative and clerical problems.

Often educating the patient as to why delays occur is effective. Equally as often, however, is an acceptance that passive-aggression has become the patient’s sole recourse. In that instance, all that can be done is base clinical and administrative decisions solely on objective findings.

Often the most important finding is “what are the patient’s grievances that occurred after injury” rather than the seeking of obscure reasons for continued complaints.

Monday, March 1, 2004

(WEEKLY CASE MANAGEMENT UPDATE #276)

This Week's Topic: “Self-Examination”

Question: “As you know, I am a _____, and I wondered if there is a way I could reliably determine if I am depressed.” from PsychIME.com

Dr. Adams replies: “Print this out, read each time, circle the one response to each item that best describes you for the past seven days:”

SLEEP
I. Falling asleep

0 I never take longer than 30 minutes to fall asleep
1 I take at least 30 minutes to fall asleep, less than half the time
2 I take at least 30 minutes to fall asleep, more than half the time
3 I take more than 60 minutes to fall asleep, more than half the time

II. Sleep During the Night

0 I do not wake up at night
1 I have a restless, light sleep with a few brief awakenings each night
2 I wake up at least once a night, but I go back to sleep easily
3 I awaken more than once a night and stay awake for 20 minutes or more, more than half the time

III. Waking Up too Early

0 Most of the time, I awaken no more than 30 minutes before I need to get up
1 More than half the time, I awaken more than 30 minutes before I need to get up
2 I almost always awaken at least one hour or so before I need to, but I go back to sleep eventually
3 I awaken at least one hour before I need to, and can’t go back to sleep

IV. Sleeping too much

0 I sleep no longer than 7-8 hours per night, without napping during the day
1 I sleep no longer than 10 hours in a 24-hour period including naps
2 I sleep no longer than 12 hours in a 24 hour period including naps
3 I sleep longer than 12 hours in a 24-hour period including naps

A. Enter the highest score on any one (1) of the four SLEEP items above: _____

MOOD

V. Feeling Sad

0 I do not feel sad
1 I feel sad less than half the time
2 I feel sad more than half the time
3 I feel sad nearly all the time
B. Enter your score on the mood item (V) above: _________

APPETITE/WEIGHT

VI. Decreased Appetite

0 There is no change in my usual appetite
1 I eat somewhat less often or lesser amounts of food than usual
2 I eat much less than usual and only with personal effort
3 I rarely eat within a 24-hour period, and only with extreme personal effort or when others persuade me to eat.

VII. Increased Appetite

0 There is no change in my usual appetite
1 I feel a need to eat more frequently than usual
2 I regularly eat more often and/or greater amounts of food than usual 3 I feel driven to overeat both at mealtime and between meals

VIII. Decreased Weight Within the Last Two Weeks

0 I have not had a change in my weight
1 I feel as if I’ve had a slight weight loss
2 I have lost 2 pounds or more
3 I have lost five pounds or more

IX. Increased Weight With the Last Two Weeks

0 I have not had a change in my weight
1 I feel as if I’ve had a slight weight gain
2 I have gained 2 pounds or more
3 I have gained 5 pounds or more

C. Enter the highest score on any 1 (one) of the 4 appetite/weight change items (VI - IX) above: ________

X. Concentration/Decision Making:

0 There is no change in my usual capacity to concentrate or make decisions
1 I occasionally feel indecisive or find that my attention wanders
2 Most of the time I struggle to focus my attention or make decisions
3 I cannot concentrate well enough to read or cannot make even minor decisions

D. Enter your score on the Concentration/Decision Making item (X)
above: ________

XI. View of Myself:

0 I see myself as equally worthwhile and deserving as other people
1 I am more self-blaming than usual
2 I largely believe that I cause problems for others
3 I think almost constantly about major and minor defects in myself

E. Enter your score on the View of Myself item (XI)
above: _________

XII. Thoughts of Death or Suicide:

0 I do not think about death or suicide
1 I feel that life is empty or wonder if it’s worth living
2 I think of suicide or death several times a week for several minutes
3 I think of suicide or death several times a day in some detail or I have made specific plans for suicide or have actually tried to take my life

F. Enter your score on the Thoughts of Death or Suicide item (XII)
above: _______

XIII. General Interest:

0 There is no change from usual in how interested I am in other people or activities
1 I notice that I am less interested in people or activities
2 I find I have interest in only one or two of my formerly pursued activities
3 I have virtually no interest in formerly pursued activities

G. Enter your score on the General Interest item (XIII)
above: ______

XIV. Energy Level:

0 There is no change in my usual level of energy
1 I get tired more easily than usual
2 I have to make a big effort to start or finish my usual daily activities (for example shopping, cooking, homework or going to work)
3 I have I really cannot carry out most of my usual daily activities because I just don’t have the energy

H. Enter your score on the Energy Level item (XIV)
above: _________

PSYCHOMOTOR

XV. Feeling Slowed Down:

0 I think, speak, and move at my usual rate of speed
1 I find that my thinking is slowed down or my voice sounds dull or flat
2 It takes me several seconds to respond to most questions and I’m sure my thinking is slowed
3 I am often unable to respond to questions without extreme effort

XVI. Feeling Restless:

0 I do not feel restless
1 I’m often fidgety, wringing my hands, or need to shift how I am sitting
2 I have impulses to move about and am quite restless
3 At times, I am unable to stay seated and need to pace around

I. Enter your highest score on either of the psychomotor items (15 & 16) above: _____

Enter the sum of A+B+C+D+E+F+G+H+I = ____ This is your total score (range 0-27)

Go to the bottom of the page at http://www.psychological.com/self-exam.htm

Monday, February 23, 2004

(CASE MANAGEMENT UPDATE #275)

This Week's Topic: “Referral Annoyances”

Question: “As you know, I am a nurse case manager. I accompany many injured patients to their medical visits. The method by which referrals made by the primary treating physician is, at best, inconsistent if not downright annoying. Is there a “psychology” to this referral process?” from PsychIME.com

Dr. Adams replies: “In the ideal world, the primary treating physician is a member of the employer’s panel.

That ideal panel would consist solely of the most competent clinicians in the community.

The primary treating physician would refer to the most competent board certified specialists and subspecialists based upon the implications of the patient’s symptoms, diagnostic studies and consequent needs.

However, as you suggest, the referral process may be greatly, and perhaps unnecessarily, compromised.

Clinicians may refer based upon factors other than competence, the most common of which is friendship, to others within the same office, or to show appreciation to someone who has referred to them.

The clinician may delay or avoid a referral because the employer or insurer would be displeased. In many cases, the primary treating physician is fearful of disapproval from the insurer or employer (and retaliation in the form of receiving less/no cases from them).

(I reviewed medical records on a case recently in which the surgeon said "this patient needs a psychological evaluation...I am not making that referral and not saying it needs to be made...but the patients problems are psychological...but it is not a referral I am making at this time....)

Perhaps the most alarming situation in the workers’ compensation system is that referrals are made, blocked, redirected, encouraged or coerced by those without any health care training. In those cases, you have non-doctors making decisions about medical necessity and appropriateness. This occurs in situations where the interfering party is trying to cost-contain or trying to case build. These non-clinicians want to govern the data that appears in the chart by hand selecting clinicians over whom they feel they have control.

The solution is both simple and direct:
a. build effective panels of the best credentialed, most thorough, and consistently objective clinicians.
b. Provide those clinicians with access to the most competent subspecialists available.
c. Do not abandon a provider if an occasional case does not go the direction you would have preferred, and verbally reward the doctors for excellence in patient care and most of all,
d. respect their competence to chose the best providers to whom to refer rather than allowing the referrals to originate from non-clinicians.