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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: July -
September, 2004 |
September 27, 2004
This is the 304th Weekly Case Management Update
This Week's Topic: “Employer Responsibility and Seminar
Topic”
Question: “I noted the title of the 2004-2005 seminar and
wondered if you could provide a summary of what this concerns.
Also, has it been approved for nurses as well as adjustors?”
Dr. Adams replies: “Yes, the seminar has been approved by
both credentialing bodies.
The topic addresses the chief cause of psychological claim – the
behaviors and decisions of employers.
In the quest to curb costs, the employer often engages in
counterproductive actions such as delaying care, inadequate
care, denial of responsibility and minimization of the
complaint.
Far too often, the depressed injured worker learns that delayed
or inappropriate care has resulted in a chronic condition, and
they are told “this could have all been prevented had you seen
me earlier, but the (Eg. “nerve damage”) is now permanent.
The injured worker already felt a sense of frustration, fear and
helplessness, but with that information, they now feel angry and
hopeless.
The seminar concerns ways of early detection of the employer’s
counterproductive decisions, how to intervene, when to be
aggressive with diagnostic studies and how to detect if current
care is merely going to further harm the individual.
Tuesday, September 20,
2004
This is the 303rd Weekly Case Management Update
This Week's Topic: “The Right to Read”
Question: “Can you explain to me why a patient can read
their MRI…which they do not understand…and cannot read their
psychological report?”
Dr. Adams replies: “No problem. The MRI or CT Scan or
nerve conduction studies, etc. make little sense to most
patients. They can research what these results mean, but most
patients are passive and dependent and merely let someone
explain those results to them.
Regardless of what the report says, the patient see it as
impersonal, distant and black & white.
By contrast, the patient sees the psychological report as
something with which they need to agree or disagree. It is
threatening; to some it is insulting. They feel that the report
is something they must dispute
and in which they must find
faults or exception.
The Board of Workers’ Compensation has supported the position of
not releasing such data to a patient since it may cause
confusion if not emotional harm.
We had a very tragic case recently in which someone released a
report (although there is a specifically stated warning not to
do so) to a patient who was making reasonable progress. The
patient has many, complex, underlying problems and the injury
has become a means of expressing those problems.
The patient who was moving toward seeing the separation between
the injury and those problems was set back by exposure to the
report. His focus became his disagreement with findings, and
progress was interrupted.
The patient can also be harmed by a report that paints him/her
as a suffering victim rather than a responsible individual.
Tuesday, September 13,
2004
This is the 303rd Weekly
Case Management Update
This Week's Topic:
“Angry Not Disabled”
Question: “OK, I
read this report where a psychologist says that this claimant is
very angry at his employer, the insurers and the doctor and
cannot return to work because of his anger. Is that possible?”
Dr. Adams replies:
“Short answer: No.
Many injured workers are
angry at a variety of things after injury. Sometimes that anger
is well justified. They may be receiving substandard care, the
injury was due to carelessness (or demands) of others, and there
are (often unnecessary delays) in their receiving care.
So they are angry.
Anger is not a mental
disorder, mental disability or mental handicap.
It is an emotion.
However, anger is like
joy, sorrow, frustration, impatience and other human emotions.
Admittedly, some angry
patients should not be returned to the setting where they were
injured if there is risk that they would inflict harm upon
others. Therefore, it may be prudent to determine the source of
the anger and whether this may represent a danger. If it
does represent a potentially dangerous situation, the employer
(or rehab nurse) may wish
to find an alternate setting for the
patient.
Tuesday, September 7, 2004
This is the 302nd Weekly
Case Management Update
This Week's Topic:
“Reviewing Medical Records”
Question: “Can
you make a diagnosis based upon medical records without actually
seeing the patient?”
Dr. Adams replies:
“Police Departments, the FBI, the CIA and other organizations
are able to determine why, how and when an individual performs
certain actions based upon behavioral profiling.
With a careful review of
medical records, you can form theories and suspicions as to what
is wrong with a patient and/or why the patient is behaving as
he/she is.
From reviewing medical
records, you can offer diagnostic possibilities and even
diagnostic probabilities.
Medical records reviews
are always performed when a patient is seen. Medical records
are also performed when, for a variety of reasons, a patient
cannot be seen in a face-to-face examination.
There is a consistency
and a meaning to all human behavior. Medical records provide an
opportunity to examine the pattern of behavior and to determine
why the patient is responding in a particular way and what the
patient is likely to do in the future.
Tuesday, August 30, 2004
301st Weekly Case
Management Update
This Week's Topic:
“God’s Will”
Question: “Have
you seen this very often…we have a claimant who feels her work
related injury is the punishment she deserves…”
Dr. Adams replies:
“This is all too common. Many injured workers are religious to
the point of being superstitious. Thus, when injured, they seek
a meaning for what has happened to them. They readily decide
that this was God’s punishment for their past moral crimes.
For example, I saw a man
who was injured at work. He sustained a severe back injury,
worked vigorously to return to work and was then blinded in a
second accident.
He seemed to accept this
second event far too easily. He appeared at peace with it.
Everyone treating him felt that he was “just a very adaptive
fellow.”
He revealed to me,
however, that he had been collecting and looking at magazines of
unclad females.
While he did nothing more
than to look at the magazines and fantasize, his religion taught
him that thoughts were as bad as the acts (infidelity).
As a result of this
belief system, and the associated guilt (of which he planned to
tell no one), he knew that God’s will w
as that he never return
to work. This was to be his punishment.
What everyone was seeing as a wonderful
adjustment was, in reality, a very unhealthy belief that his
blindness was punishment for having looked at the magazines.
Tuesday, August 23, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #300)
This Week's Topic:
“Cover Your Losses”
Question: “We
have an injured worker here at ________ (employer) for whom they
are not alleging “major depression” after she was injured four
years ago. This is suspicious to us all these years later. Is
this likely?"
Dr. Adams replies:
“Actually, no. A major progressive episode, in my experience,
is often seen in the months following an injury as the patient
deals with appreciable losses to income and often to mobility
and almost always losses to comfort.
Often, however, a less
disruptive, *adjustment disorder* may occur during the first six
months, referred to as “adjustment disorder with depressed mood
(or with anxiety and depressed mood). Few of us are prepared for
a drastic reduction in income and increased pain with uncertain
future.
As time passes, most
individuals adapt. However, for some, the depression becomes a
waxing and waning disorder which we call “dysthymic disorder.”
Such individuals can often list the losses that have occurred
for them, their fear of the future, their negative expectancies
regarding life that is to come and their sense of helplessness
to do anything about it.
In all cases, these are
treatable conditions. It is critical that symptoms of depressed
not be confused with “just one more symptom” of the injury.
Depression is a common
response to injury and readily treated. But very often the
symptoms of depression are ignored whereupon they increase and
become the central problem in case management.
Tuesday, August 17, 2004
(WEEKLY CASE MANAGEMENT UPDATE #299)
This Week's Topic: “When Right is Wrong”
Question: “How do you go about determining whether
someone is emotionally right for surgery or a pump implant?”
Dr. Adams replies: “You must assess the patient’s
preparedness. Among other information you must have:
• What do they know (in depth) about the procedure and its best
and worst case outcomes?
• Are they, at any level, prepared for a neutral or negative
outcome?
• How comfortable are they with whom, how and where this
procedure will take place?
• Do they know anyone (close friend or relative) who has
benefited from the procedure?
• Is the procedure mandatory or merely an possible option and
does the patient fully understand that?
• What are the patient’s plans after a positive outcome…what are
the backup plans if the outcome is suboptimal?
• What other clinical alternatives have been explained to the
patient?
• Does the patient have an adequate support system, but more
importantly, do members of that support system understand the
proposed procedure.
I would estimate that greater than 80% of patients whom I see
pre-surgically do not understand what is being proposed despite
repeated attempts to education them.
Tuesday, August 10, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #298)
This Week's Topic:
“It Makes You Tick”
Question: “I have
attended many, many of your lectures and seminars over the past
18 years. I saw you on Thursday [Gallagher Bassett] at the big
meeting, and I sensed that someone was bothering you…do you mind
sharing what concerned you?”
Dr. Adams replies:
“When I was in training, one of the interns was seeing a
psychoanalyst for intensive psychotherapy. One day he
entered
the psychoanalysts office and noticed that the curtains were
missing.
The analyst noted that my
friend had observed that the curtains were missing, and he
said:
“Greg, did you rip down
my curtains?”
Feeling shocked and
dismayed, Greg replied “My God, why would I do that?”
To which the analyst,
gave an almost imperceptible smile and said “Why wouldn’t you?”
And Greg understood. Do
you?
Why would Greg not have
torn down the curtains? Why would you not tear them down?
In the conference, there
was much talk about procedure, regulations, organization, and
structure. All of these are intended to provide a means of
persuading the injured worker to return to work.
Why is it that you and I
work? Simple: We expect it of ourselves, and others expect it
of us.
When we don’t do what
others expect…or worse…when we do who others disrespect, we feel
guilt, shame and sometimes humiliation. At a minimum, we feel
embarrassment, and we have a moral imperative that forces us to
work. It is yielding to expectancy of ourselves and others.
For want of a better
word, we call this “motivation.”
What I heard were
excellent, well-conceived, and beautifully implemented plans to
encourage a person to return to work.
But we rarely-if-ever
seek to know their motivation, the expectancies of their family,
and whether they could just as easily accept endless
compensation rather than become productive once again.
We have the tools to
measure motivation.
What bothered me was that
no one mentioned that we make no attempt to use the tools
available to us.
Tuesday, August 2,
2004
(WEEKLY CASE MANAGEMENT
UPDATE #297)
This Week's Topic:
“Getting What
I Want”
Question:
“First off, while I enjoy each case management
question, I most enjoyed the one from last week and could not
agree more with the writer…and I would like to recommend another
technique that I use…find yourself doctors who (sic) you can
call and get the claimant released…they’ll either do it or quit.
If the doctor will not do that, find one that will and use him.
Either way, you are done with them, and there are doctors out
there that will do that for you.”
Dr. Adams replies:
“Hmmm, this harkens back to the old concept of the “insurance
company doctor.” What you are saying is: find someone who wants
your business bad enough that clinical decisions are based upon
your approval and not the patient’s clinical condition and
needs.
Additionally, you feel that there is “nothing really wrong with
them anyway.”
Aside from obvious moral issues, let me outline what is wrong
with your scheme:
a. You cannot trick someone out of having a disc herniation or
other condition
b. A doctor who looks for your approval will not spend much time
looking for a solution to the patient’s problems.
c. Anyone who does not hold the patient as the top priority,
clearly communicates this lack of concern to the patient
d. Patients worsen when they feel demeaned, rejected and/or
distrusted
e. Physical problems do not go away simply because you do not
believe in them
What you are describing are not “tricks of the trade.” They do
not result in a patient getting well, going back to work, and/or
ceasing to suffer.
They most often result in patients becoming desperate and often
then finding care that is nonproductive, possibly harmful…or,
apparently your greatest concern, even more expensive.
Bottom line: Find quality providers who tell you the truth, even
if you find that painful.
Tuesday, July 27, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #296)
This Week's Topic:
“Keeping it Clean”
Question: “I
think you know my approach for dealing with injured workers. I
strongly suspect that to some extent they all exaggerate their
complaints. So, I send their checks late, delay sending mileage
checks, decline authorization for tests and procedures, return
their calls at my convenience and make sure they see Dr.
________ because he will not take any of their ______. OK,
let me hear your take on this.”
Dr. Adams replies:
“Well, that certainly was…ummm…candid. I would be tempted to
suggest you look into another line of work, but perhaps you have
already considered this.
Your techniques certainly
communicate your anger and distrust. You appear to believe
that your approach places you in a position of control over the
claimant. I am assuming that you anticipate that this will then
intimidate the worker into submission.
Unfortunately, such
approaches rarely, if ever, work.
Passive-aggression most
often results in a backlash. The patient becomes entrenched and
begins to misperceive that his symptoms are a means of dealing
with his increasing anger toward you.
In science, you must
control all variables and then alter just one to measure its
effect. Your approach, by contrast, is to alter everything at
once and then see what falls out.
However, there is another
concern: what if you are incorrect. What if the problem with the
patient is his relationship with this physician that you use, or
that he is depressed because of the pain, or is fearful because
of his financial plight? If any of those are true, then
sending his checks late or delaying prescriptions or procedures
will only amplify his problems.
Tuesday, July 20, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #295)
This Week's Topic:
“Single
Greatest Mistake”
Question: “What
do you feel is the single greatest mistake that is made in case
management?”
Dr. Adams replies:
“Falsely believing that you can manage a case by knowing the
nature of the injury.
That is what happens with people new to case management. They
think `oh, this is a back strain..we’ll send the injured worker
to Dr. X…and things will be fine.’
In reality, Dr. X will obtain the appropriate tests, prescribe
medication and P.T. and have the patient check back in a few
weeks. His nurse will then ask the patient, at each visit, if
there has been any improvement. They will adjust medication,
continue P.T. and/or recommend more diagnostic studies based
solely upon a combination of pain complaints and test results.
Many months will pass. The patient will be released to full duty
or transitional duty with restrictions.
If the patient does not comply, and/or symptoms actually
increase at the point of release, everyone is stunned. No one
was prepared, and at that point, no one knows what to do except
to force the patient to comply.
What is needed is for someone to ask the patient:
* What do you feel is wrong with your back?
* What impact has this injury had at home?
* Do you feel you will ever work again?
* Are you drinking to deal with your pain and fears?
* Are you sleeping much of the day?
* Do you get any exercise, or do you watch TV all day?
* Do you feel your primary doctor knows what is wrong with you?
* What do you feel needs to be done?
This will tell you much more than yet another negative MRI.
Tuesday, July 13, 2004
(WEEKLY CASE MANAGEMENT
UPDATE #294)
This Week's Topic:
“Covering Up Incompetence”
Question: “I have an
observation, and perhaps you can verify this for me. I find that
some injured workers, especially those in middle age, fear going
back to work due to feeling incompetent in the job in which they
were injured. Is this accurate?”
Dr. Adams replies:
It is very accurate and an important observation.
Blue Collar Workers:
Work at tasks which wear out the body; tasks that are often
easier to perform by younger workers who have more stamina,
strength, energy and do not fatigue as easily. Also, the younger
workers most often have less financial pressure and family
demands. Very often the injured middle aged individual was
feeling a decreased competitive edge prior to injury. The
thought of returning to work with any physical compromise is
alarming. They focus upon their physical complaints and
limitations as a means of avoiding the competitive market
place.
White Collar Workers:
Companies are downsizing; people are either replaced by
technology and/or must develop technological skills. Younger
workers with more recent education come to the job with training
in newer technologies and an enthusiasm for these skills. “Old
dogs and new tricks” are intimidating to middle-aged workers who
like to begin thinking about less job demands rather than a new
host of demands for which they have not been trained…and may
have little interest.
When you see an
individual who is resistant to return to their job despite
capacity to do so, you need to consider and investigate as to
whether the injury is being used by them as self-protection
against obsolescence.
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