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 Atlanta Medical
Psychology The clinical
practice of Dr. David B. Adams is located in The Medical Quarters in
the northside of Atlanta at the junction of Scottish Rite, Northside
and Saint Joseph's Hospitals. Dr. Adams consults to occupational
medicine, surgeons, nurse case managers, insurers and employers
regarding the psychological impact of work-related injury and the
role of psychological factors in short- and long-term
disability.
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| CASE MANAGEMENT UPDATES | |
CASE MANAGEMENT UPDATES:
April - June, 2004 |
Tuesday, June 29, 2004
(WEEKLY CASE MANAGEMENT UPDATE #293)
This Week's Topic: “PMP not psych”
Question: “I have a case with which I have some concerns.
Is there a way to obtain those data but not get involved in
“mental disorders”; “psych” can have very negative connotations
to our clients.”
Dr. Adams replies: Absolutely. The bottom line is you
don't need a psychological exam for someone not claiming
depression, anxiety, posttraumatic stress disorder, etc.
What you do need is information, and what you want to order is a
Pain Management Profile (PMP). A PMP will not introduce the
dreaded "psych", or provide DSM-IV diagnoses, or recommend
psychological care. What it will do is inform.
After 20 years of seeing injured workers, I see very little
change in case management. Although adjustors and nurses
recognize the need for early psychological intervention, their
hands are tied by the employer's fear that a psych eval will
escalate the cost of their claim. Conversely, claimant attorneys
know that the vital information to be obtained could, in some
cases, diminish the value of their settlement.
95% of the information obtained in a psych eval on a three year
old claim is present before the injury occurs or soon
thereafter. These data, which I have discussed on many
occasions, has been influencing the course of the patient's
response to care.
If the information had been known early on, by the treating
physician, adjustor and nurse, the course of treatment would
have been more targeted. Redundant procedures and changes of
provider could have been avoided, and narcotic pain management
could have proceeded on a more informed basis.
The way to obtain this crucial data - who will recover, who
needs to settle, who does not understand their injury, who is
angry, etc., is to take it out of the psych arena. It is not a
psychological evaluation.
A Pain Management Profile is a diagnostic tool to be ordered in
much the same way as an MRI or EMG study. It does not diagnose a
psychological disorder, nor does it recommend psychological
care, much as an MRI does not recommend surgery. It merely
provides the data you need for effective case management. It
cannot open the proverbial "can of worms", but it will let you
know the worms are there.
Tuesday, June 22, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #292)
This Week's Topic:
“Any Chance of PTSD?”
Question: “We are
seeing a rash of claims for Posttraumatic Stress Disorder after
neck, back and even knee and shoulder injuries. Aren’t these
most likely to be bogus? What should we expect?”
Dr. Adams Replies:
You are going to have to expect PTSD to be very common in
orthopedic injury especially those involved in MVAs and falls.
“About
half of patients who have an orthopedic traumatic injury go on
to develop posttraumatic stress disorder (PTSD), according to a
report in the June, 2004, issue of The Journal of Bone and Joint
Surgery.
"If you take care of orthopedic trauma patients, you're going to
encounter PTSD," Dr. Adam J. Starr from University of Texas
Southwestern Medical Center, Dallas, Texas told Reuters Health.
Contrary to the researchers' expectations, the risk of PTSD
seemed to increase with more elapsed time since the injury.
The prevalence of PTSD was higher among patients injured in
motor vehicle-pedestrian collision (65%) or in motor-vehicle
collision (57%) than among patients injured in a fall (43%), the
results indicate.
The best individual predictor of PTSD was a positive response to
the item, "The emotional problems caused by the injury have been
more difficult than the physical problems," the researchers
note, though even this response was only a fair predictor of the
presence of PTSD.
"We know from research in other disciplines that PTSD has a
profound negative impact on outcome," Dr. Starr said. "We think
(although we haven't proven) that treatment can lessen symptoms
of PTSD which arises after civilian trauma."
"Now that we've found that PTSD is common after orthopedic
trauma, the question is, can we do anything to lessen the
symptoms or lessen the prevalence of the illness? "We plan to
compare the rate of PTSD, depression, and anxiety among
orthopedic trauma patients who get cognitive behavioral therapy
(CBT) to a similar group who get our current standard of care,
which is no psychological treatment."
J Bone Joint Surg
2004;86:1115-1121.
Tuesday, June 15, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #291)
This Week's Topic:
“Delay? Now It’s Catastrophic”
Question: “This
is an increasing problem for us…in the midst of finding
alternate work…and mounting data that the worker can perform
transitional work…he(she) applies for *catastrophic* status, and
everything comes to an end. This meets no one’s needs. To me,
the obvious problem is that someone is misdirecting the
claimant. How do you see these cases?”
Dr. Adams Replies:
“Sorry, but I see the problem as partially your own. I would
imagine that within the first 60-90 days following injury,
notations in the patient’s chart suggest problems with the
case. The patient’s symptoms did not match the doctor’s
findings.
We operate under the
assumption that all adult Americans want to work. Clearly, not
all of them do, so we must determine the reasons why some elect
not to work, and measure not only their intellectual capacity,
but their willingness to do so.
The old annoying cliches
of "Strike while the iron is hot"; "Don’t put off until tomorrow
what you can do today" exist for a reason.
If you can determine
within the first 60 days what a patient's intentions are
regarding RTW, you can direct care and rehabilitation efforts in
the right direction.
You must find out this
information before the patient is misinformed or misdirected,
and the term "catastrophic status" in placed into their
vocabulary. That term becomes a replacement for motivation.
While there are injuries
that clearly warrant catastrophic status, the vast majority do
not. Why allow management of patient care to be hampered or
controlled by a term when what is needed is medical case
management and resolution? With in-depth analysis and
information, your action could be more targeted and effective.
From the standpoint of
assisting a return to productivity, all efforts are halted by
the declaration of catastrophic status. You must get proactive
in your case management and seek earlier consultation.
Tuesday, June 8, 2004
(WEEKLY CASE MANAGEMENT UPDATE #290)
This Week's Topic: “Case In Point”
Allow me to describe an excellent case in point from this week:
This is a 31 year old male who sustained a neck injury when
falling from a hyster.
The MRI did not confirm his symptoms. The adjuster should have
requested an immediate psychological consult before the case
worsened. This was the second week on injury.
The adjuster did not request a psychological consult. The
surgeon several months later recommended a psychological
consult, and the adjuster refused.
Concurrently, she sent the claimant’s checks late, was rude to
him on the telephone and openly told others that “he is faking,
and I do not like him.”
Still no psychological consult approved by her.
More and more surgeons became involved, and the patient clings
to the belief that he needs an anterior cervical disc fusion.
The injury is now 15 months old.
With great difficulty, the adjuster finally relented, and the
patient was seen in psychological evaluation.
It was determined that he has an IQ of 85 (he is in the lower
16th percentile of intelligence). He quit school in the 7th
grade at 16 years of age. He has never had a career; always done
temporary manual labor.
His family, including his wife and children, are in Oklahoma to
which he desperately feels he must return since he knows his
wife is being unfaithful. He cannot send child support ($175 per
week) while on workers’ compensation ($225 per week). He has
nowhere to live.
He misunderstood one surgeon who recommended epidurals and
believed that to mean “a fusion” which he feels is being
deliberately withheld. He refers to his bulged cervical disc as
a “broken neck” and believes that he will awaken on morning
paralyzed.
Prior to the psychological consult, no one was aware of these
issues in his life.
The resolution has been clear since the first week of injury:
a. He needs (and now will receive) a very simple and direct
explanation of his problems.
b. He will be provided with a PPD rating (which is actually
quite low)
c. He will be explained the concept and appropriateness of MMI
release
d. He will offered a settlement so that he can return to
Oklahoma
This was a “simple” case which was not managed appropriately and
extended for a year longer than necessary. Unfortunately, this
is also common.
Tuesday, June 1, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #289)
This Week's Topic: “Sunday Neurosis”
Question: “Is there a way for a family to determine if someone
is unmotivated to return to work?”
Dr. Adams Replies: “One way which is very reliable is the
absence of “Sunday Neurosis.”
Sunday neurosis is not a clinical diagnosis but an observation
that people often feel quite miserable about mid day on Sunday
progressing into the evening and bedtime.
Most healthy Americans are exhilarated, albeit tired, by Friday
afternoon. We look forward to the weekend relaxation and
recreational/family activities.
Americans treasure their weekends. They have hobbies, interests
and activities that are reserved for the weekend period.
However, by Sunday, the dread of the workweek ahead, the
mourning of the passage of free time, and anticipation of
obligations for the ensuing week begin to mount. Some people
become saddened, moderately anxious, and fatigued just thinking
about this.
Those in retirement, after an adjustment period, do not have
these emotions. They have adjusted to a lower level of
self-expectation, and the weekends and weekdays begin to blend.
When an individual is first injured, that “Sunday Neurosis”
remains, and on Monday, it is a grim reality that others are
going to work, and the injured worker is not.
Those motivated to return to work tend to maintain those
feelings…the longing to be back in the marketplace.
However, all too many individuals, adjust to a no-demand
lifestyle in which they have no schedule, go to bed and arise
when they wish, and if there are any expectancies, it is solely
the expectancy that someone will visit them or dictated by the
TV schedule.
Determine how an individual feels on Sunday after ~1 year post
injury, and you can begin to see whether he/she has adapted to
this lack of Sunday Neurosis.”
Monday, May 24, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #288)
This Week's Topic:
“Pain Disorders”
Question: “There
seem to me so many pain disorders, and it has become so diffuse
that it is hard to tell which is real and which is not.”
Dr. Adams Replies:
“Actually, while there may be multiple types of pain, there are
only three pain disorders.
Pain disorders are
classified as a somatoform (so-mat-o-form) disorder (physical
symptoms that suggest a medical condition but are not fully
explained by that medical condition for this individual
patient). In other words, in somatoform disorder, the
complaints of pain are not fully explained by the objective
physical findings (Eg. The lack thereof).
I. Pain Disorder
Associated With A Medical Condition: The psychological factors
play little or no role in the onset or maintenance of the pain.
II. Pain Disorder
Associated with Psychological Factors: emotional factors have a
major or in the onset, severity, exacerbation or maintenance of
the pain. The medical condition plays no role or, at most, a
minimal role.
III. Pain Disorder
Associated With Both Psychological Factors and A General Medical
Condition: emotional factors compete with physical factors and
play at least an equal role in the onset, severity, exacerbation
or maintenance of the pain complaint.”
In disability claims of
any kind, the third (III) form of pain disorder is often
predominate because the individual may be being financially
compensated, there may be litigation, there may be many
physicians and drugs involved, and the patient’s role within the
family and society has changed.
It is crucial to know
with what type of pain disorder you are dealing and how to
proceed.”
Monday, May 17, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #287)
This Week's Topic:
“Quality of Care”
Question: “We need a
psychologist in _______ , GA, and Dr. ______ is the only one
practicing there. We have had some bad experiences with this
man and suspect he is either corrupt or incompetent or both.
What are our alternatives?”
Dr. Adams Replies: “I do
not see him listed among Georgia's board certified clinical
psychologists. If you look at a distribution of those who are
board certified, they become increasingly rare outside of
Atlanta.
In many of the smaller
communities, you may not find someone within a reasonable
distance who is board certified. And the closest board
certified psychologist may not see injured workers.
While there may be
protest that the patient cannot endure a ride of long duration
in order to be seen, you may have no competent option.
You have two needs with
an injured worker for whom someone has recommended psychological
care: diagnosis and treatment. These do not have to be provided
by the same individual.
Just as you may have an
orthopedic patient from Tifton, GA whom you refer to Atlanta or
Macon and then treated closer to home, you may be better served
using this same approach with the psychological aspect of care.
Arrange for the patient
to be examined in a major city that has clinicians who will and
have seen injured workers. Ask specifically the diagnosis,
cause of the disorders (if any) and recommended course of care.
You may then use that structure in making the referral to
someone closer to home if it is unfeasible for the patient to
return to the examining clinician.
Diagnosis and treatment
can be pursued separately. Use the recommendations of the
former to structure the care of the latter.
If, for example, the
patient has then (or previously) been seen for 8-10 visits, ask
the consulting psychologist to weigh in on whether the care is
appropriate, effective, should be altered or discontinued.”
Monday, May 10, 2004
(WEEKLY CASE MANAGEMENT UPDATE #286)
This Week's Topic: “Pain Is All in Your Head”
Question: “Is the surgeon’s statement of limitations
helpful to you in your exam.”
Dr. Adams Replies: “I very frequently see patients who
are released to transitional/light/alternate duty with
limitations on sitting or standing for more than 15-30 minutes.
I sit and read these restrictions with the patient seated across
from me in a straight back chair, without movement, for the past
hour. I ask the patient if he/she needs a break, and he/she
declines.
The patient takes a battery of psychological in a similar chair,
sitting for hours, taking rare and brief breaks.
The patient drives or rides several hours to the office and then
several hours home.
The patient’s true functional capacity appears to be much
greater than what the records reflect.
How does this occur?
As from a functional capacity exam, limitations are also
determined by patient complaints and requests/demands for
medication. Those office visits are often brief, and little time
is available for an extended observation of the patient.
By contrast, I have the patient in my office for ~5 hours, and
he/she often finds the tasks laborious and boring. As a result,
they are motivated to complete. Thus, they decline breaks, often
remove their lumbar support, set aside their cane and “forget”
to limp, moan, guard and to take medication.
The true “functional capacity” is determined by the context
(setting) in which it is examined.
This behavioral observation of a patient should be obtained on
any patient who claims chronic and unmanageable pain.”
Monday, May 3, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #285)
This Week's Topic:
“Capacity versus Willingness”
Question: “If you
have someone who is fully recovered, who seems to be honest, but
who passively blocks all efforts to return him to work…what is
the first thing to check?’
Dr. Adams Replies:
“Financial status. While people initially are deeply concerned
about the reduction of their income from full salary to
disability benefits, families adapt. The spouse goes to work,
they sell off extra possessions, they “belt-tighten” and they
begin to adjust to their new financial base.
As months, and sometimes
years, pass, their sense of connection to their job (which may
never have been a career in the first place…just a means of
making money) has emotionally ended. They cease to feel the
urgency each day to return to work…an urgency that was burning
within them when first injured.
They know that once a
week, a tax-free check will arrive, and during the week, they
can relax and have virtually no responsibility.
While this is most common
in those over fifty years of age, you do see it in injured young
adults as well.
Your first concern,
therefore, should be: “Does the patient and his family any
longer need him to work?” If the answer is “no,” you will not
be successful in motivating him to return to any form of
employment. You will have to consider some form of closure.
Monday, April 26, 2004
(WEEKLY CASE MANAGEMENT UPDATE #284)
This Week's Topic: “Psychological MMI”
Question: “Can an individual be physically MMI and yet
not be psychologically MMI? We have this (injured worker) who
has been released, and, yet, his psychologist says he is still
psychologically impaired.” from PsychIME.com
Dr. Adams replies: “Impaired by what? If it is PTSD, it
is possible that the patient is physically recovered but cannot
return to the environment in which the injury/trauma occurred.
But assuming that this was not PTSD, but was depression (mood)
or a pain disorder (somatoform), it is less likely that there is
a psychological disability after reaching physical MMI.
Additionally, returning to work is certainly more therapeutic
than remaining at home, napping, eating, smoking and watching
television. Work itself is a healing process. The individual has
human contact, is productive and is less dependent upon others.
Your first task is to determine what psychological disorder is
purportedly disabling the patient. Secondly, how does the
individual clinically benefit from not being in the workforce
since the psychologist is blocking him from doing so? (This is
rarely the case) And finally, are there other incentives to
remaining out of work (settlement considerations, financial
support by wife, enjoyment derived from having minimal
responsibility, and/or not having a rewarding job to which to
return.)
What can happen is this: The patient is physically released MMI
with a specified PPD rating. There is no work for which they are
trained/educated within those permanent limitations. They remain
depressed, and the depression immobilizes them. Even in this
case, however, the solution is not psychological treatment that
keeps the patient dependent and fails to return the individual
to some form of productivity.
Monday, April 19, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #283)
This Week's Topic:
“Drug Dependence?”
Question: “We have
an injured worker whose accident was substantial and likely
terrifying. He has been in psychological care and has been
released by those treating his physical injury. I do not know if
he is psychologically ready, but here is a complication: As
part of return to work, he was drug screened. He tested positive
for cocaine. What is our responsibility in this case?” from
PsychIME.com
Dr. Adams replies:
“Cocaine abuse is a Substance Use Disorder. It is a disorder of
choice and cannot arise from injury.
Bottomline – You have NO
responsibility for this patient’s drug abuse.
Also, cocaine use is
rarely a single event. If he is willing to become involved with
A.A. and N.A. as well as enter a drug rehab program, he may
begin the process of recovery. Again, this is not your
responsibility; it is solely that of patient and family.
However, you mentioned
that he was in psychological care. Does he have problems with
the work environment (e.g. PTSD or similar anxiety disorder)? If
you release him to the exact environment in which he was
traumatized, you may potentiate the psychological symptoms. You
need to avoid this.
Thus, if he returns to
work, it should likely be in a setting that differs from the one
(machinery, heights, closed space, etc) in which he was injured.
One final point: if the
employer has a zero tolerance drug policy, all of this is moot.
Even if he is capable, the employer may fire him.
Monday, April 12, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #282)
This Week's Topic:
“Yes but then what?”
Question: “OK,
here’s the bottomline…the patient is released by the authorized
treating physician…we suspend benefits…they still do not
mobilize…certainly, there is something we can do except throw
money at them.” from PsychIME.com
Dr. Adams replies:
“Most certainly. Answer these questions:
1.
Was the patient released because
he/she is fully recovered?
2.
Or was the patient released because
he/she has a PPD for which nothing more can be done?
3.
Or was the patient released because
you are suspicious about his/her symptoms?
4.
Or was the patient released because
this particular doctor had no more to offer?
Then answer these:
A.
Does the patient or someone close
to him/her truly understand what is wrong and why nothing more
can be done?
B.
Does the patient understand that
further change is very unlikely?
C.
Does the patient know it is his/her
responsibility to find a life for himself (accepting pain and
limitations and finding work or surviving on social security
disability…or living off family and friends?
D.
Does the patient trust and believe
this doctor?
a.
Do they have a functional
relationship?
b.
Does the patient feel that he/she
received compromised care?
E.
Is the patient disappointed…or
fearful…or depressed…or enraged?
Contact your consulting
psychologist and forward complete medical records. Have the
psychologist meet with the patient for one visit. Ask the
psychologist to answer any of the above questions which you are
unable to answer.
Finally, have the
psychologist summarize the current status, determine what the
patient needs for closure, explain that closure must occur but
that reasonable attempts will be made (or have long ago been
made) to answer these questions.
Most often the patient
does not like the message (chronic problems) and is angry at the
messenger (authorized treating physician) and has confused
disappointment with distrust. The patient needs a neutral party
to understand his/her fears, uncertainty and help them accept
their options.
Monday, April 5, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #281)
This Week's Topic:
“Out of Focus”
Question: “If
surgery has been successful, aside from motivation, drug seeking
and case building, what should we look for if the patient does
not recover?” from PsychIME.com
Dr. Adams replies:
“Marital problems. That is the single greatest contributor to
individuals languishing in care.
And those marital
problems can run the gamut from infidelity of spouse to tension
produced by being home all day with the children.
These problems are very
infrequently disclosed to case managers or primary providers.
The patient may feel that it is unrelated to their complaints or
be embarrassed about the nature of what I occurring.
These problems rarely
emerge solely because of injury; the injury merely provides as a
catalyst for expression of longstanding tensions and/or
incompatibility.
Whether the injured
worker is male or female, there is a very similarly held belief
that since pain (and often medication) blocks bedroom
activities; they feel their spouse will leave them.
As we have discussed
previously, financial collapse can be very rapid since there
were few savings and major indebtedness.
While the husband bemoans
having to find a new career, the wife and kids are burdened with
him sleeping away the days, doing little to nothing around the
house, and then being irritable when they arrive home.
Of equal importance is
the lack of concern for hygiene, weight and keeping late hours
due to having slept (or at least being sedentary) throughout the
day.
While functional capacity
exams are crucial, merely finding that there is “insufficient
effort” on these exams is insufficient. We need to know why the
person perceives themselves as defeated and what, at home,
contributes to this.
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