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Monday, March
28, 2005
This is the 329th Weekly
Case Management Update
This Week's Topic:
P.P.D.
Question: I am a
new adjustor working for -------- (Insurance Company). This is
my first time with workers' compensation, and I am not certain
that I understand the concept of permanent and partial
disability. I understand that ratings, but what are the
implications for case resolution?
Dr. Adams Replies:
In the ideal world, the patient reaches (MMI) maximum medical
improvement with a Class level of (PPD) Permanent and Partial
Disability, most often expressed as it was years ago as a
"percentage of whole body."
Thus, a patient sustains
a back injury, surgery has been successfully performed, and the
patient is maximally improved, ready for medical release and has
a 15% permanent and partial disability.
Or if you want it
expressed in terms of psychological symptoms, the patient has a
10% psychological disability and due to the work-realted
assault, he/she can no longer work in non-secured environment
where large sums of money are kept on the premises.
This seems straight
forward if not intuitive. But invariably another problem
immediately arises.
This would be the time at
which closure can occur for the patient. However, the
authorizing treating physician (ATP or "primary physician") may
then throw a wrench into this resolution machinery.
After surgeries,
injections, physical therapies, and numerous medication
regimens, he/she refers the patient to a "pain center" where
much of the same care is then repeated.
However, the patient is
not told that this is for pain "management" but most often is
told that it is for "pain treatment" which, to the patient,
implies that as a result of this clinic, he/she will no longer
have pain.
This care then extends
over many, many months, and numerous procedures are tried, often
without significant change in condition.
What was a reasonable,
effective and timely resolution, now is associated with the pain
of the new procedures, incredible disappointment, and often
insurmountable frustration.
So, your most effective
time of intervention will be to coordinate with the primary
doctor that release is, indeed, the closure that the patient
desperately need, not merely a lateral pass to another provider
so that false hopes and unrealistic expectancies are not
created...and then dashed.
Monday, March 21, 2005
This is the 328th Weekly Case Management Update
This Week's Topic: “Arm Twisting?”
Question: “I have sent you many cases and feel I have the
right to whine a bit. What do we do with adjustors who openly
obstruct a psychological consultation…we are not asking for
permission to treat? We just want to know what, if anything, is
wrong with a claimant when they are making no attempt to return
to work.”
Dr. Adams responds: “That was an excellent and timely
question; a common complaint and concern. It is far easier to
authorize on more series of epidurals, one more referral to pain
management, one more MRI, and two more courses of physical
therapy than to find out what is wrong with this patient.
I had a patient referred this week solely because after two
years, he was claiming depression. However, it was a very
illuminating referral. He refused to answer any questions about
his life…even claimed to be somewhat uncertain of his age. He
would not reveal health problems, education, work history, size
of family, whether he was married, etc.
He said “you can only ask me about my pain.”
This was one of the most revealing referrals in recent memory.
In less than 10 minutes, this refusal/noncompliance was more
informative than all of the other studies, exams, tests, and
procedures to date.
I am certain that he is attempting to shield a life that is
replete with a criminal history, multiple past disability claims
and spotty-at-best work history.
Adjusters are overworked and under-rewarded. They want to
believe that if they provide the legally mandated care that the
case will resolve. This is frequently not the case. Often they
need exposure to a psychological report before they realize that
they benefit from authorizing (if not initiating) a
psychological referral.
March 14, 2005
This is the
327th Weekly Case Management Update
This Week's Topic: "I Hope You're Feeling Better"
Question: “At what point do you personally release a
patient?"
Dr. Adams responds: "An excellent and important question. My
gravest concern has been that when a patient is, for example,
orthpoedically MMI, he/she is then referred to a "pain clinic"
where a host of procedures are (often repeated) performed, the
patient shows no significant improvement but has wound up back
in the loop. Like many, I would like there to be an end point
where the patient is told that the only alternative is to learn
to cope with his/her pain and limitions.
Similarly, much of what "depresses" a patient are problems
inherent in the system:
a. Delays in care
b. Needs for authorization
c. Delays in compensation and reimbursement
d. Problems obtaining transportation
Or they are depressed by the normal aftermath of injury:
a. often severe financial plight based upon indebtedness prior
to injury
b. emotional upheavel with spouse and children, again often
festering prior to injury
c. intensified problems with employer and coworker often due to
employer's anger at the inconvenience of an injury
It is impossible for all of these issues to be resolved by
psychological care related to injury.
The goal is to achieve reasonable emotional stability so that
the patient can put closure on this event. This should mark the
end of care related to injury.
In summary, I personally release a patient: When I am certain
that the patient can manage their own situation. This may not
correspond to the patient's insistence that he/she remain in
care (the latter is often no more than dependency triggered by
inactivity).
Monday,
March 7, 2005
This is the 326th Weekly Case Management Update
This Week's Topic: Know When They’re Lying?
Question: “Is it not very easy for someone to lie about
their depression? How do you know if they are jerking your
chain?”
Dr. Adams responds: “It is very easy for someone to lie
about depression, anxiety or pain. Indeed, patients in general
practice routinely lie about the severity of some of their more
frightening symptoms. Patients being paid for symptoms
frequently emulate the symptoms of post-traumatic stress
disorder. It is quite simple to lie about problems with sleep.
It is easy to attribute weight gain to depression.
If we relied solely upon what the patient said, we would be
quite vulnerable.
The reasons tests are ordered to clarify what is causing a
reported symptom; diagnostic tests are also ordered to
demonstrate what is not the cause of the reported symptom…and
often to demonstrate that the symptom could not even exist.
With all of the media coverage on depression, phobias,
generalized anxiety, and PTSD as well as access to the internet,
it is very easy to learn what symptoms you are supposed to have
in order to be diagnosed with those disorders.
Falsification of psychological symptoms is a great concern in
cases where the patient receives compensation. I have seen
patients who have received disability payments for 20 years, and
yet upon examination, it is clear that they have no
psychological disorder which suggests any degree of impairment.
Thus, two additional things are needed: A meticulous history
that looks for other possible causes of the reported symptoms
(anything from past abuse to current greed). Secondly, what is
also needed is a careful examination of the diagnostic data to
determine the inconsistencies and/or the excess to which
symptoms are being reported.
February 28, 2005
This is the 323rd Weekly
Case Management Update
This Week's Topic: Family
as Friend & Foe
Question: “Don’t you
think that the family is our best support in helping an injured
worker recover?”
Dr. Adams responds:
“While it is true and logical that family members would assist
an injured worker, there are a number of cases in which this
does not occur, and they fall into two categories:
a.
Conscious and
deliberate subversion – the family has been angry at the injured
worker for an extended period prior to injury. The injured
worker may have been unreliable, nonproductive, demanding, and
self-indulgent. The injury is seen as something that serves as
a punishment for past misdeeds. The family feels that the
suffering will bring the injured worker back under family
control. They place themselves into positions of control
regarding finances, medical care including dispensing of
medication and even the injured workers’ compliance.
b.
Unhealthy
pampering and nurturance – the family misperceives that coddling
the injured worker is a sign of love and affection. They take on
all tasks, responsibilities and over respond to the injured
workers’ subjective complaints. They make no demands or
requirements, and they have reduced (if any) expectancies. This
is largely an unconscious process, and it reinforces the injured
workers’ dependency and delays, if not eliminates, the patient’s
motivation to mobilize.
Family members can be
powerful allies. They have the capacity to insure that the
medical regimen is followed and that the patient fully
understands and participates in recover.
Quite often, however, the
family has unresolved issues with the injured worker for which
the aftermath of injury serves as an opportune time.
February
20, 2005
This is the 325th Weekly Case Management Update
This Week's Topic: Great Expectations
Question: “I would prefer some of these patients to have
attorneys. I cannot talk to them, they do not understand, their
telephone calls are endless and they do not appreciate what I do
for them.”
Dr. Adams responds: "This is more of a statement of
preference than a question per se, but it is valid nonetheless.
For many injured workers, the workers’ compensation system is a
morass of confusing requirements and restrictions. Some truly
need an advocate to transverse this maze.
Often this can be a brochure outlining how the system works and
its limitations. More often it is a nurse case manager who can
clarify issues for them and also help them and their physician
communicate more effectively.
However, sometimes an attorney is needed. The patient does not
understand why all health care is not authorized (especially
those of longstanding duration or those that arose independently
in the months following injury). The patient also does not
understand why some doctors are not authorized to treat them,
why some diagnostic studies are not approved and why some
treatment/therapies are contested. The patient feels inordinate
frustration if not provided a reasonable explanation.
However, in some cases, their legal representation results in a
distorted belief of their rights and benefits, a high/false
expectation of what will occur medically and financially, and a
misdirecting of them to put trust in those who are not truly
invested in their recovery.
It is much like selecting a doctor; the right attorney can be of
great assistance to you and the patient in getting them through
the recovery process. The wrong doctor or lawyer can insure that
they become so entrenched in their limitations that they are
unnecessarily slowed (or halted) in their progress to return to
work.
Monday,
February 13, 2005
This is the 324th Weekly Case Management Update
This Week's Topic: Assault & Pepper
Question: “You seem to indicate that all assault victims
need a psychological evaluation. Do they always have
psychological problems after being assaulted in the workplace?”
Dr. Adams responds: "Not at all. There are many assault
victims that see their trauma as a uniquely horrible experience
that is unlikely to ever occur again. As long as the perpetrator
is caught and punished, they feel safe and vindicated.
However, there are some important reasons to routinely order a
psychological exam on anyone injured in the workplace:
a. First and foremost, it is the decent and responsible thing to
do. Even if the injured worker is doing well after the assault,
a psychological referral communicates that you are sufficiently
concerned that you want reassurance that they are doing as well
as they seem to be doing.
b. Those individuals who are assaulted by coworkers have a
difficult time since they must process how their employer and
coworkers see the perpetrator. It is not infrequent for some
employers to blame the victim for the assault, feeling the
victim provoked the attack, and equally as often, these same
employers feel that the victim is now a burden to them and
source of unrest among other workers.
c. Male and female employees respond differently to being
assaulted regardless if it is a coworker or as part of a crime
committed by an outside party. Males often feel that their
masculinity has been impugned, and males will obsess for
extended periods regarding the way they *should* have handled
the assault. This is made all the worse when the males found
themselves showing signs of terror in the presence of their
assailant. By contrast, women chiefly want to know that the
assailant will not harm them again. They uniformly believe that
the attacker has a need to return and do further harm.
d. But the most disappointing occurrence after an assault is the
victim seeing this as an opportunity. This quite often occurs
where several employees have been assaulted in the same incident
and then band together and conspire to use the assault as an
opportunity to be compensated for what then becomes an "extended
vacation."
Thus, referral of assaulted workers is mandatory. Many will not
require care. Those who do require care deserve out empathy,
support and assistance. If an assaulted worker requests care but
then begins to manipulate (cannot leave home, cannot travel far,
and/or has specific criteria as to whom they see), then one
should begin to watch for signs of malingering.
Monday, February 7, 2005
This is the 323rd Weekly
Case Management Update
This Week's
Topic: Hispanic Patients
Question: “In your
experience, do Hispanic patients represent a greater diagnostic
and treatment challenge…are they easier or more difficult to
return to work?”
Dr. Adams responds: I see
many Hispanic patients, and uniformly they are more difficult to
return to work for several important, and often overlooked,
reasons:
1.
Whether they
were skilled or even professional workers in their native
countries, with the absence of English skills, they have been
reduced to manual labor (and repetitive motion) jobs in the
U.S. If they now have restrictions that preclude such work,
they have no back up options.
2.
Many are used to
living in poverty and in crowded conditions; essentially living
with little hope or optimism. They too readily accept an injury
as just one more discouraging example of how difficult their
lives are, and they do not struggle against their limitations.
3.
They
understandably cluster with their countrymen where their lack of
American culture and English language is expected. One patient
moved here from Los Angeles and was shocked that in Atlanta
“some English was expected.” He had lived two years in Los
Angeles and had never needed to learn any English.
4.
They are prey to
lawyers who know that they are frightened and who essentially
capture their whole community. They dependently allow such
people to make decisions for them. They remain passive and are
directed like drones; the same way they behave in the workplace.
5.
While they are
quite often depressed (even before the injury), their culture
has a less meaningful way of dealing with the depression – they
are told by family and friends that “everything will be
okay…don’t worry about it.” They then wonder why everything
feels so difficult.
With regards to
treatment, they need to accept that the future belongs to them
and that current passivity will not provide them with a
meaningful/fulfilling future. They need to accept that new
skill (and language) development will be necessary
and is quite available in their community.
Monday, January 31, 2005
This is the 322nd Weekly
Case Management Update
This Week's Topic: Guilty
Until Proved Innocent
Question: “To me,
as a claims adjustor, dealing with these people who fake or
exaggerate their physical injury is the most disheartening
experience. Is it your impression that they are the most
difficult cases to manage?”
Dr. Adams Responds:
“No, I would rank them second in difficulty. Whether they
are malingering with regard to their physical complaints and/or
psychological complaints, careful examination will most often
reveal their motives? Do not forget that a person with a valid
injury can also be malingering. This is called partial
malingering and occurs when the complaints far exceed the
objective findings.
The most difficult
patients to assist are those who live in an environment/culture
in which they hear the bragging of malingering individuals, yet
their own complaints are sincere. They feel quite accurately
that they are often lumped with those who fake or exaggerate
symptoms are, therefore, not believed by their doctors, employer
or insurer.
They often come from a
background where work within their limitations is not likely
available from their employer and/or the employer truly does not
wish them to return. They have increasing financial despair and
yet they are certain (and often accurately so) that the insurer
believes that they could mobilize if they wished to do so.
Concurrently, they have
neighbors/acquaintances who boast of their “milking the system.”
The one case I most often site was a woman with a failed
fusion, sitting in the waiting room of a pain clinic and
listening to the enthusiastic discussion of the other patients
regarding the ability to amplify their symptoms for probable
financial gain.”
Monday,
January 24, 2005
This is the 321st Weekly Case Management Update
This Week's Topic: “Turfing”
Question: “Do you see the pattern that I do? When an
injured worker, almost always with a back complaint…is no longer
a surgical candidate, he/she is then referred to a pain clinic
where they (sic) languish. What’s up with that?”
Dr. Adams Responds: “It is, indeed, a common observation.
The cause of this is the reluctance of the surgeon to state
simply that not only does he have nothing further to offer the
patient, but that he feels the patient must now begin to
independently cope with the pain.
However, instead of the patient beginning to cope with the pain,
or being shown how to cope, he/she is sent to a clinic where
they are heavily medicated, injected and eventually offered a
stimulator or pump implant. This “last ditch” care then spans
1-2 years…or more.
The patient learns to exist in a heavy sedated life, “living”
between dosages of medication, tracking when the next pill or
patch is to be used. There is no investment in friends, family
or hobbies much less consideration for sedentary work options…or
education leading to such work.
In my experience, there is nothing in these settings that
directs the patient toward recognition of his/her strengths and
residual capacity for alternate or part time or even volunteer
work to make life at least meaningful.
We are not meant to live without daily tasks and
responsibilities. If there are no goals and/or medications are
substituted for our responsibility to find meaning in our lives,
we simply exist only for the medication. The patient is not
served by such a frame of reference.”
Tuesday, January 18, 2005
This is the 320th
Weekly Case Management Update
This Week's Topic:
Betrayal
Question: “As a
claims adjustor, I get blamed for many things that are not my
fault. Often the claimant’s attorney causes more harm than
good.”
Dr. Adams
Responds: “Many injured workers do not have financial or
emotion reserves to deal with an injury. They are quickly
financially ruined and equally as quickly abandoned by employer,
coworkers, friends and family.
The victimization does not stop here. They can arrive in medical
offices where they are dismissed, denigrated, belittled and
demeaned. They are ridiculed for complaints, told that "it
cannot feel that badly" and kept waiting long hours in the
waiting room only to be seen for 3 minutes...by a P.A.
And it gets worse, they are desperate and seek legal
representation from someone who has no time to talk to them,
does not return calls, and has a formula by which to manage
cases that undermines
the goals of the patient.
Case in point was a
very
nice middle
aged woman sent several months ago for failed back.
Her attorney told her not to comply with the
requirements
of the
visit. She did not wish to follow his dictates but was
dependent. She begged him to relent. He would not. She left the
office in tears.
Her benefits were suspended for noncompliance. She went into
financial ruin. She applied for social security, but the same
attorney offered her little information as to why she was twice
declined.
Further, this same fellow had her not comply with orthopedic
IMEs. She spiraled downward, ever dependent, increasingly
depressed and in financial
depletion.
In summary, the injured worker can be victimized as much after
the accident as by the accident itself. We quite often do not
fully know what goes on behind the scenes.”
Monday, January 10, 2005
This is the 319th Weekly Case Management Update
This Week's Topic: Return to Light Duty
Question: “The employer has light/transitional duty
available, but the injured worker went two days and then did not
return. Does that not indicate malingering?”
Dr. Adams Responds: “Likely not.
If he/she had refused to attempt a return to work even though
the employer had sent a job description within the patient’s
restrictions, I would be concerned about some degree of
malingering.
However, just because the employer says that there is
transitional work available within the treating doctor’s
restrictions does not mean that the employer is accurately
describing what is being offered.
Too many times, I hear of a patient return to work with specific
bending, lifting, standing and sitting limitations. The patient
arrives at work and within hours, he/she is being asked to do
work exceeding their limitations. Quite often they are then
asked to do the very work they were doing when injured.
The patient becomes fearful, then angered and then depressed and
refuses to return. The employer reports only part of the story.
For one automotive manufacturer, patients with limitations are
placed in a large group in a day room. There they can read,
watch TV, play games or just nap and chat. It is boring,
unfulfilling and demeaning. In such a setting, some patients
become more depressed than when attempting to do work that
exacerbated pain.
Any time that a patient declines transitional or light duty,
some attempt should be made to determine what interaction
occurred with management when he/she attempted a return to work.
Determine what was specifically said to the patient, and
determine if their were covert threats of consequences should
he/she not comply.
Injured workers can be manipulative, but so can employers,
especially those who have staff limitations and production
quotas.
Monday, January
3, 2005
This is the 318th
Weekly Case Management Update
This Week's Topic:
“Post Holiday Behavior”
Question: “Like
most case managers, I dread the passing of the holidays and
returning to the doldrums of my daily schedule. What should we
expect from injured workers at the end of this holiday season?”
Dr. Adams Responds:
There are three things you will find; each representing a
specific response to injury –
There is the positive
future expectancy (PFE) group of claimants who anticipate that a
forthcoming surgery (postponed for the holidays) will restore
them to pre-injury functioning. This positive expectancy will
contribute to good compliance and favorable response to
surgery.
However, this PFE will
also be associated with crushing disappointment if pain and
other limitations persist. The optimism, while to be
encouraged, must be tempered with a caution that “recovery takes
time,” and “with that degree of damage, there may well be some
remaining problems/discomfort.” Hope is a highly researched
aspect of healing, and it has been documented to have a positive
impact. When hope is unrealistically high, it sets the stage for
disappointment, anger and depression.
For far too many, the end
of the holiday is associated with negative future expectancies (NFE)
in which the individual is thrust back into days of pain,
loneliness, guilt, and helplessness. If this converts into
hopelessness, then there may be the risk of more severe
depression, including suicidal ideation.
Additionally, as we have
previously discussed, the NFE group may feel that the holidays
were an oppressive contrast between their empty lives and those
of others whom they see in stores and on television. They
dreaded the holidays, are glad they have passed, but there is
nothing for which to look forward.
Post holiday
periods are difficult for healthy individuals; this period is
unquestionable complex for those with significant physical
problems.
Contact the
Practice |
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.