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Monday, June 27, 2005

This is the 341st Weekly Case Management Update

This Week's Topic: “Great Expectations”

Question: “What do these people expect from me?”

Dr. Adams Replies: “I am going to guess that you are talking about claimants and not members of your own family.

Let’s assume that you are, indeed, talking about injured workers. In that case, the concept of “expectancy” is incredibly important…essential.

When first injured, they expect an immediate recovery. After all, it is “only a sprain or a strain.”

This is followed by expectation that mild/conservative care will resolve all symptoms.

Next is the expectancy that the first specialist they see will “fix it all.”

Then there is the procession of expectancy from surgery, expectancy of recovery time and expectancy of functional capacity.

Importantly, there is also the expectancy of some form of cash reward from having endured it all…expectancy that the employer will be supportive or punished if he is uncaring…that coworkers will be empathetic and that the family will be patient and understanding.

As these expectancies are dashed, the emotional condition of the patient worsens.

Early in the process, their expectancies need to be examined, exposed and resolved.”

Monday, June 20, 2005

This is the 340th Weekly Case Management Update

This Week's Topic: “Easiest to Fake”

Question: “Do you believe that injured workers are mostly honest or mostly dishonest, and if you feel that they are mostly dishonest, which injuries are easiest to fake?”

Dr. Adams Replies: “Most injured workers are sincere, suffering and want to rapidly return to work. Obviously, there are those who are too impaired to return to work at this time or to the same job or able to ever return to work. Thus, the answer to the first part of your question is `most are very honest about their limitations.

Now, in answer to the second part of your question as to which symptoms or disorders are easiest to falsify, there are three:
a. Pain
b. Depression
c. Fear

At present, we have no definitive way to objectively identify any of these three. So when a patient states that they hurt, are depressed and/or are fearful of returning to their job, then we must assume that this is true.

Very often (but not always) the determination of their being disingenuous is made by looking at the nature of their presentation. Are their behaviors consistent with being in pain. That is do they exhibit pain behaviors or do they describe pain yet actually function with little or no limitations.

There are symptoms (called neurovegetative signs) of depression. A patient may say that he/she is depressed yet fail to have symptoms that would confirm that a depressive disorder is present. Stating that they are depressed is one of the ways in which patients can avoid returning to work.
Fear is most often expressed as though posttraumatic stress disorder exists. Complicating this is the overuse of that term to describe seemingly any emotional response after an injury (especially motor vehicle accidents). This is arguably the most difficult emotion to disprove. If the patient states that he/she is grossly fearful and cannot leave their residence, they can demonstrate that by merely staying home all day, every day, and watching television. Again, the only way to demonstrate that this is not accurate is to observe behavior which contradicts the claim of fear.”

Monday, June 13, 2005

This is the 339th Weekly Case Management Update

This Week's Topic: “Kept Prisoner in Treatment”

Question: “You have addressed this briefly in another form, but we have a serious problem with three cases. They are all being seen in psychological care due to PTSD. They being seen 1-2 times per week and have been in care for at least one year. When we requested a timeframe for treatment concluding, we were told “2-3 more years.” How realistic is that, and what can we do?”

Dr. Adams Replies: PTSD arising after an injury is most frequently associated with either an assault or a motor vehicle accident, both under horrific circumstances. While there are other potential causes of PTSD, assaults and MVA account for most.

The goal is to treat the patient effectively and efficiently so that he/she may return to their job and continue their career.

In some cases, the individual may have lost his/her job after this event and/or have physical limitations which preclude returning to that particular job. In other cases, the horror of having to return to the job is simply too great, and the patient needs other/alternate employment.

Before anyone even enters psychological care, it must be determine if the individual has the option desire to return to the job. If there are no plans (or opportunity) to return to the job, care can be confined to making the patient comfortable enough for other employment.

Often, extended treatment occurs because:
a. The doctor makes the patient dependent upon continuing care
b. Matters being addressed have nothing to do with injury and/or
c. The doctor has misidentified the problem

We had a recent case in which someone was requesting authorization for what would be three years of psychological care. However, even a cursory review of the case indicates that the care being delivered will actually make the problem worse…and it has.”

Monday, June 6, 2005 

a.    the sensory dimension of pain, "which localizes where pain is and determines its intensity;"

b.    the cognitive dimension, "what people think about pain and how they respond to it;" and

c.    the affective dimension, associated with the emotional processing of pain. 

This Week's Topic: “We are not married”  

Question:  “OK, this involvement of the husband or wife in an injury is quite a burden for this office.  We have to go through a spouse in order to deal with the claimant, and the spouse most often is unreasonable, demanding and belligerent.  What causes this, and how do you approach it? 

Dr. Adams Replies: “This annoyance is caused by one of three things (which vary among cases): 

1. There are cultural differences, and some societies which are re-created in America bring the old world traditions in which the husband makes all of the decisions.  For these same cultures in which the husband is the one who is injured, the wife then takes an uncharacteristic leadership role.  The husband (injured worker) resents his loss of power, but he is often quite dependent as well as pain intolerant.  The children then defer to the mother for decisions, and the husband feels his masculinity is impugned: the wife and kids think he is less of a man.  Yet he dependently clings to both the wife and the kids and perpetuates the problem.

2. The wife or husband of the injured patient is now getting “pay back” for years of infidelity, abuse, substance dependence, financial irresponsibility and other domestic problems.  This husband or wife then steps in and becomes the controlling demanding person they always wanted to be but could not for fear of retaliation from their mate…who is now disabled.

3. Most often, however, this is nothing more than “business as usual” for this couple. The spouse has always made virtually all decisions and plans to do so now.

Frankly, I prefer my way.

Monday, May 23, 2005

This is the 336th Weekly Case Management Update

This Week's Topic: “Vengeance is Mine”

Question: “We have an injured worker who is best described as truly hateful. We are an occupational medicine center, and this guy is nasty, noncompliant and verbally abusive. We cannot tell how much he is suffering because no one here wants to treat him. What’s his problem?”

Dr. Adams Replies: “There are three potential sources of his sour attitude:
a. Someone there or at the insurance company did something to offend him
b. Something is going on in his life/marriage/finances which has him frustrated
c. But quite often such patients are simply angry at their employer

They see their employer as either the cause of the accident and/or totally unsympathetic for their plight.

The first step would be to have him describe in detail the nature of the accident and then directly ask him “do you feel that someone else is to blame for what happened to you? Could it have been prevented?”

Then ask if he feels that his employer “was truly concerned about this accident and providing prompt medical care.”

Ask him if there are any needs not being met (promptness of checks or filling prescriptions or ordering tests).

Finally, ask him “is there something other than the accident which is a problem right now?”

Patients can and do misinterpret, misrepresent and misunderstand much of what is done or told them.

Monday, May 16, 2005

This is the 335th Weekly Case Management Update

This Week's Topic: “Demons Rising?”

Question: “Let’s say that you have a good patient…one that wants to get better, cope better and get back to work…do these cases ever sour…or turn bad?”

Dr. Adams Replies: “Excellent question, and the brief answer is “yes.” These always occur in a specific fashion:

The patient progresses well. He/she stops using excessive medication and often takes no medication at all. They understand that some of their limitations/pain will be permanent, and they are ready to confront life with that realization.

Their primary physician (typically a surgeon) has released them and given them a reasonable PPD rating.

Suddenly, the patient wants another opinion for purposes of a higher PPD percentage rating. The surgeon, who was well liked, is now denigrated by the patient. The patient suddenly wants social security benefits and catastrophic status, and the key words begin something like this: “this was not my fault and someone has (is going to) pay for this no matter how long I have to wait.

A recent patient had progressed well, was given a 25% PPD, was told that he could function in part time or full time work with restrictions. The patient then began to borrow money from relatives so that he could use “as much time as it takes to make them pay me what I deserve…I talked to one guy, and it took him 15 years, and if it takes me that long, I am willing to wait.”

At that point, it is no longer a psychological problem; it is purely a financial one, and further care would be of no assistance.”

May 9, 2005

This is the 334^th Weekly Case Management Update 

This Week's Topic: “Are You Ready?”  

Question:  “If you determine than an injured-worker needs psychological care, how does that begin?  What do you explore first?” 

Dr. Adams Replies: “Importantly, the very first thing is to determine whether they perceive that their injuries will preclude them from ever returning to work, at any job, and in any capacity.  This must be compared to what their authorized treating physician (ATP) is saying. 

Monday, May 1, 2005

This is the 333rd Weekly Case Management Update

This Week's Topic: Surgical Suitability

Question: “I am wondering if you recommend pre-surgical psychological examinations chiefly because that is what you do.”

Dr. Adams Replies: “Yes, that’s likely it. But perhaps I can think of some minor justification anyway.

When a patient is fat, forty and a failure (deconditioned, middle aged, and having limited or no skills for re-employment), the patient is quite unlikely to respond the same as a younger, more fit, and educated patient.

Motivation and goals are almost everything.

If a patient anticipates that their pain will vanish after a fusion, that they will be able to be as active as prior to injury and are able to return to work unloading pallets of frozen food, they may be in for quite a disappointment.

Let me give you a recent example. This patient has had two cervical fusions unrelated to his work-injury. He responded very well to both.

At work he then herniated two lumbar discs. Fusion has been recommended.

He was referred pre-surgically to determine if all would proceed well.

This is what I found: He is bright but has no usable formal education. Even needing a fusion, he can walk a quarter mile without any discomfort. While he has a 10 minute sitting restriction, he drove two hours to the office, sat for five hours and drove two hours back. He never, ever exhibited pain behavior of any kind.

At home, since injury, he has sat at his computer for 7-8+ hours per day, buying and selling items, again unimpaired.

He “lives on” (quoting him) prescribed narcotics (unwise since he used to abuse alcohol…no one asked, and his father was alcoholic…again, no one asked).

He believes that as with his cervical fusion, this lumbar fusion with instrumentation will enable him to return to heavy equipment operation, to working out and running/walking long distances without any pain whatsoever. He has gained >50 pounds.

There may be clinical indication for a fusion, but it is clear that he does amazingly well compared to other patients awaiting the same procedure. All of this needs to be addressed with him prior to surgery…especially his narcotic dependence and very high (if not unrealistic) expectations from surgery.

Monday, April 25, 2005

This is the 333rd Weekly Case Management Update

This Week's Topic: Is It Physical

Question: “Increasingly over the past couple of years, we have these claimants who are understandably depressed. But the people treating them insist that this is a physical problem, is disabling and then put them on a zillion medications that make them sleep the days away. You likely have a position on that.”

Dr. Adams Replies:  “Yes, likely I do. First off, depression is associated with chemical changes in the brain; then again so is hunger and a bunch of other biological drives.

If certain neurotransmitters, the chemicals that cause brain cells to talk to each other, are depleted, a person will become depressed.

Now the debate is twofold:
a. Did the depression cause the brain chemistry to change or because of the change in brain chemistry did the person become depressed? The old chicken and egg debate.
b. Secondly, if this is a physical problem, should it be treated with chemicals?

People continue to argue both sides of (a), but unquestionably a change occurs in the brain chemistry.

Does medication alone help these people? Most studies indicate that medication and talking to someone (psychotherapy) is needed.

Here’s a provocative case that I saw this week: A 43 year old man has been disabled from work for three years, and he has been in treatment for 12 years, due to his depression. He states that he has “been on every medication and combination of medications there are, and none seem to be helping.”

He then adds “I have no issues; this is a chemical problem in my brain, and I would go to work each day and cry all day long. When I was taken out of work, the crying stopped…oh, and so did my asthma.”

I asked him if he were the oldest child, was expected to excel and be more independent than his brothers and whether the youngest brother received more attention and affection from his mother. He tearfully confirmed that this was true, and as a result he had gone further in his career than had his brothers. He added that when he was sick, however, his mother was then very attentive and put less demands upon him.

I then asked him if she were paying him attention now that he was disabled. He again became tearful and said “no, she thinks that this makes me weak.”

Obviously, seeing this as a purely biological problem would be a grave error.

Monday, April 18, 2005

This is the 332nd Weekly Case Management Update

This Week's Topic: The Catastrophe

Question: Do you find that catastrophic injuries routinely require psychological care?

Dr. Adams Replies: No. And I also question whether those whose injuries are classified as catastrophic are always genuine about their physical and psychological status.

Unquestionably a very seriously injured individual with tragic permanent consequences to their injuries may need psychological support to deal with their limitations. However, increasingly, I am seeing patients who seek a catastrophic classification for purely financial purposes. Characteristic of these patients is failure to tell me that their authorized treating physician has released them, with restrictions, to return to work. Instead, they tell me that they are still in care, still seeing their physician and do not know when they are being released.

This is, again, an instance when it is mandatory that surgeon and psychologist coordinate efforts so that there is no confusion as to the patient’s status.

Allow me to provide you with an example: A woman seen this week had been injured at work, stated that she both wished to return to work but also wished to return to college. She stated that she was emotionally unable to tolerate a return to the setting where she was injured, and, as a result, had applied and been accepted to a nursing program at a local university.

She stated that she was supported in this decision by her surgeon who felt that she was not physically capable of returning to work. However, I was in receipt of a letter from the surgeon outlining his release of this patient, delineating her restrictions and stating that he not only felt she could, but that she must, return to the workforce.

The patient was attempting to play us against each other, knowing that her physical limitations were not severe and, consequently, wishing her psychological limitations to appear even more severe.

These situations are disheartening since time spent with manipulative patients is time away from sincere and suffering patients.

Monday, April 11, 2005

This is the 331st Weekly Case Management Update

This Week's Topic: Cracked Eggs

Question: I do not see how these minor, work-related injuries, especially orthopedic injuries, can cause someone to go crazy; seems like utter nonsense to me.

Dr. Adams Replies: You are quite correct. An orthopedic injury does not change someone from a normally functioning adult into a strange ranger with delusions, hallucinations and a range of bizarre symptoms.

The exception would be where the individual’s injury is “outside the range of normal human experiences” which is what we typically associate with posttraumatic stress disorder in which the injury has been shocking, horrific and of prolonged duration.

However, again, you are correct that a neck, lumbar, knee, shoulder etc injury does not result in truly bizarre psychological symptoms.

When this does occur, and assuming that these symptoms are not under voluntary control, it is likely that the injured worker was fragile (subclinical symptoms) and may have actually chosen his/her line of work to avoid stressors with which they could not deal.

He may have chosen to work in solitude, to do repetitive motion, to do simplified tasks, etc. all to avoid stressors with which he knew he could not cope.

After injury, he/she is thrown into uncontrolled hospital, clinic and office environments, taking mood altering medications, left isolated for days on end, and having an uncertain future.

At that point, all that was contained/controlled begins to come forward, and we see truly bizarre behavior.

We recently had a patient who had been very effective in her work. However, she had never married, had few friends, had many pets, and lived in rural isolation. After injury, she stopped personal hygiene, began to talk to her pets (and insisted that they responded) and developed bizarre beliefs about her condition. Recognizing this, we were able to get her into day programs and have home health visit her until she was mobilized enough to return to work. The symptoms subsided as soon as she had daily activities and human contact.

Monday, April 4, 2005 

Dr. Adams Replies: Not necessarily.  It does, however, tell us some very valuable things about their current life and past life:

·         If their criminal record is for recurrent DUI charges (and or “possession”), then their medication regimen needs to be examined, discussed with them and carefully monitored

·         If their past criminal record includes charges of spousal abuse, domestic violence and/or criminal assault, their volatility and impulse control when frustrated by appropriate medical care can be an important concern

·         If their past criminal record includes serving time for one or more felonies, they may be quite comfortable in withholding information not only from you, but their doctors and attorney

·         If their past criminal record is decades ago, it may have taught them lessons in life, and they may be of greater integrity than those who commit crimes but are never prosecuted

·         If their criminal record involves multiple charges in which they avoided prosecution (acquitted, charges dismissed, etc), they may be very skilled at using the legal system without regard to guilt and remorse 

A case example is a patient seen in IME who is in weekly psychological care in another office. In that “injury related care,” he is actually seeking treatment for depression related to probable future incarceration.