July 19, 2005


This is the 345th Weekly Case Management Update

This Week's Topic: "Withering on the Vine"

Question: "Do you ever track patients that were injured years ago and simply have done nothing with their lives?"

Dr. Adams Replies: Most definitely. They are sometimes referred to by the not-so-flattering term of "old dogs." They are patients that actually reached their current level of disability 3+ years ago, but they languish within the system.

In most cases, their physician has been astute astute enough to realize that they have limitations, specify a percentage of disability and know that the individual cannot benefit from additional care.

Then someone else becomes involved, sends them back through a repeat of all tests and care that have already been completed, and the patient is back in the system. This can occur multiple times, and it leaves the patient believing that health care is now their "job;" it is what they do with all of their time, and there must be something wrong that needs fixing.

How does this occur? This is simply lack of strength on the part of those who are treating the patient. Some would say it is also a lack of accepting responsibility for the patient. A truly strong clinician will tell the patient what is, and what is not, wrong, and place some/all of the responsibility for coping
upon the patient. The individual need not, and should not, spend their life
in the patient role. This dependency rarely occurs in the private sector.

Other doctors will feel guilty/concerned and continue to offer the patient everything from chiropractic care, to massage and (in one recent case) spiritual healing. Some of this is greed, but most of it is simply avoidance of drawing the line.

It is the responsibility of all involved to help the patient accept when additional care will truly not significantly benefit them.

This is the 342nd Weekly Case Management Update of July 25, 2005

This Week's Topic: "To Sleep...but to Dream"

Question: "Is there a central problem for all patients in pain,regardless of the cause of the pain? What I am asking is, whether there is something that would help mobilize any patient faster?"

Dr. Adams Replies: "Yes. First, be certain that their problems with sleep are among the first things addressed.

But be aware that most often problems with sleep are among the last things addressed.

Rapid eye movement (REM - the part of sleep in which we dream) sleep deprivation may cause increased sensitivity to acute pain.

Even healthy persons without acute pain demonstrated more sensitivity to acute pain following a four-hour general sleep restriction that included a 2/3 decrease in REM sleep.

The relationship between disturbed sleep and pain is two-way - not only does pain disrupt sleep, but disrupted sleep may enhance pain.

This is important: Analgesic (pain) medications have an acute REM-suppressing effect, so they may not work as well during the night due to this side effect (patients being more sensitive to pain).

In an acute pain situation, patients may experience increased pain due to sleep disturbances, and this preliminary association between REM loss and hyperalgesia (increased pain) suggests that improving patient sleep may be an important aspect of pain management."

July 25, 2005

This is the 346th Weekly Case Management Update

This Week's Topic: "Mommy Dearest"

Question: "It is very difficult for us to treat injured workers whose family members become involved. I am assuming that this is common. If so, what can e do to stop it so that we can get our job done?"

Dr. Adams Replies: Most often it is the husband or wife who becomes (overly) involved and interferes with proper treatment.

However, very often it is the mother of a male patient. She assumes that you are not treating her boy well, that you are not meeting his needs, and her evidence is that he seems completely miserable in her presence.

The reality is:
* Sons can and do use their injuries as a means to punish their mothers for things of which you may not be aware * Mothers who have otherwise neglected their children now rally to "help" the child now that he is injured * Mothers who have problems in their marriages relish having the son as a target of attention.and a means of attacking their husbands * Mothers who enjoy attention from doctors can now gather attention
indirectly through the complaints of their sons * Mothers, who have problems with authority and control, now have a means of taking control from others.

How it is handled is as follows:
1. Find out what purpose this is serving in this dysfunctional family
2. Since the son has a right to not share data with the mother, it is appropriate for you to express an unwillingness to share those data yourself
3. Insist that communication come from the son, that he is the patientand that
you will not compromise whatever trust he has developed with you.
4. Inform the son that your office cannot function as a mother-son
liaison officer
and resolve their problems.which existed before this injury.

August 1, 2005

This is the 347th Weekly Case Management Update

This Week's Topic: "Just Drug Seeking"

Question: "How often do you see drug seeking in an injured worker, and is there a common profile...I mean who should we suspect?"

Dr. Adams Replies: "Let me answer the second part first: There is no common profile. There are some cases that should trigger suspicion:
a. A patient with a minor injury who requests medication (narcotics) in excess for what the injury would be expected to indicate
b. The patient who requests increasing amounts/strength of medication while other
indications are of improved (or at least stable) condition
c. The patient who has two or more prescribing physicians
d. The patient who seeks ER visits between visits to the authorized treating physician
e. The patient who has a valid injury but has a questionable past and/or lack of motivation for the future
f. The patient who is irritable, labile, accusatory, and hostile and holds himself  blameless for all the negative interactions which occur in offices
g. The patient who requests specific medications and disparages others which have less potential for getting "high" (E.g. specifies that only Xanax calms him and/or only Vicodin manages his pain)
h. Finally, the patient who continually produces new and seemingly unrelated
complaints as soon as an attempt is made to reduce access.

Monday, August 8, 2005

This is the 348th Weekly Case Management Update

This Week's Topic: "Foreign Bodies"

Question: "We are seeing quite an increase in injuries among immigrant workers; some are not even here legally. My question is whether they are more prone to psychological problems after injury."

Dr. Adams Replies: "In my experience, there tends to be less psychological disorder in recent immigrants to our country. They often come from poverty or are fleeing some form of oppression in their native countries. They have spent their lives attempting to survive with little attention to emotional concerns.

Often their culture ties a depressed mood to basic realities: "I do not have enough money to feed my family or myself...someone in my family is ill, and we have no money for health care."

Most are quite eager to return to work since they see pain tolerance and hard work as essential to life.

However, there is, indeed, a psychological complication - They are prey to those who would make money from their plight. Those who cannot speak English and/or  those whose lack of (education/information) understanding of their options become readily dependent upon anyone who is willing to take control of them.

They are often manipulated by such people who build practices around (mis)directing the dependent.

In the latter case, the patient is used as a pawn for the sake of the settlement of their disability claim. True objective understanding and concern for these foreign workers is often absent.

Monday, August 15, 2005

This is the 349th Weekly Case Management Update

This Week's Topic: "Cartoon Characters"

Question: "...is more than able to return to work. She lays around the house, getting fat and being hateful on the telephone...what's up with that and what do we do?"

Dr. Adams Replies: Character pathology (Cf. "personality disorders") forms in the first 18 years of life and become all-but-unchangeable by age 30.

Personality disorders interfere with social and occupational tasks. They result in poor and sometimes self-destructive decisions. Yet people rarely seek treatment for a personality disorder since most believe that they are right, and the world is wrong.

When someone with a personality disorder is injured, employers, doctors and insurers must cope with the injured worker's character pathology.

The individual is overly clingy, whiney, non-compliant, hostile, manipulative, dramatic and/or suspicious.

Most involved with the patient will not take time to identify the personality disorder and then have the tools for dealing with the patient. They will, instead, simply refer to the patient as strange, weird or hateful.

The rule-of-thumb should be: "If the patient is capable of returning to work but blocks all attempts to move that direction, then he/she is either depressed and/or has a personality disorder."

In either case, the problem is an obstacle and must be identified and addressed.

Monday, August 22, 2005

This is the 350th Weekly Case Management Update

This Week's Topic: "Completely Incompetent"

Question: "We are not going to let Dr. ____ see this patient. He is completely incompetent, don't you agree?"

Dr. Adams Replies: "Incompetence is considered a form of impairment; not in the sense of disability, but in the sense that the doctor is unable to effectively practice. Just as drugs, alcohol or psychosis can impair a practitioner, so can incompetence.

Incompetence is revealed in different ways in different professions:
a. Incompetent psychologists inaccurately diagnose and then keep patients in care for conditions that do not exist while missing disorders that do exist.
b. Incompetent surgeons...well, that's a no brainer...the wrong procedure, delayed procedure, inadequately performed procedure...
c. Incompetent pain centers over prescribe, inappropriately prescribe and fail to fully understand the patient. They treat the subjective complaint of pain without knowing the patient that is reporting the pain.
d. Incompetent attorneys either abandon their clients or provide them biased data that angers, frightens or frustrates them, having no true concept of the patient's life and suffering.
e. Incompetent employers are trying to trim costs in counterproductive ways by limiting access to care and contributing to the patient's physical complaints.
f. Incompetent insurers vengefully limit access to care, procedures and even medications and will spend money on surveillance before spending money on diagnosis.
g. Incompetent nurse case managers lose clinical objectivity and fail to fully grasp the manipulative nature of the patient.

It is a very large health care community; you can readily find individuals who will competently assist with management of an injured worker.

Monday, August 29, 2005

This is the 351st Weekly Case Management Update

This Week's Topic: "For All I Can Get"

Question: "It is not our imagination; cases turn "psychological" after they have played out all their physical games and manipulations...as soon as the heat is on that they have to return to work, they are then "depressed." It is annoying, and it is just plain wrong."

Dr. Adams Replies: "Let's first separate out those whose pain and limitations are valid, and they feel they are emotionally unable to work, will be fired if the return, or are are bound to re-injure themselves.

That leaves us a group, and I agree that it is not a small group, of those who are encouraged by others to milk the system with this seemingly intangible disorder called depression.

I recall a patient whose attorney called the office stating that his hand injured client was now "psychotically depressed" because he had just beat his wife, was carrying a gun and tearing up doctor's offices.

The reality is that he had just received word that his "settlement" offer was about 10% of what the attorney had led him to anticipate. He was, therefore, trying for a hospitalization and a whole new level of disability determination. It failed, but the attempts are not uncommon.

I also have noted several times that while someone may want a patient to feign depression, a patient rarely does this very well. They have things to do, places to go, and people to meet. They do not have time to lay around with the shades drawn and lose a lot of weight. Instead, they are often engaged in many physical activities far beyond their claimed limitations and having a grand time socially engaged with friends.

These bogus claims are not likely to ever cease. The most effective means of case management is gathering as much objective data about the patient as feasible. If the patient is depressed, there will be a consistent clinical picture. Where that consistency is not found, the depression is not a valid claim.

Monday, September 5, 2005

This is the 352nd Weekly Case Management Update

This Week's Topic: "Vengeance Is Mine"

Question: "We have seen this numerous times...this guy will not show for any appointments, likely has a significant injury, his surgeon is frustrated and has released him so we have to find someone else to see him...any idea as to what is going on...do you see this a lot?"

Dr. Adams Replies: "Yes, this is very frequent. What most likely is occurring is a combination of:* Distrust* and Revenge

Likely when he was injured, he believes his employer tried to minimize his complaints and delay treatment. Then when treatment was finally authorized, they sent him to a doctor who they trust to return him to work. He got worse.

Even after seeing a specialist, there was control how much care he received, whether tests would be authorized and whether/when prescriptions would be filled.

Feeling physically trapped and financially strapped, he has become angry.

He now does not trust anyone to whom he is sent by the insurer, and as a result, he is quite vulnerable to being sent someplace perhaps worse.

He mistakenly feels that his lack of recovery will punish his employer whom he (likely accurately) senses does not want him back at work. He feels (again probably accurately) that they intend to fire him so he believes that he can seek his revenge by obstructing anything that anyone attempts to do for him.

Seem self-destructive? Well, it is. But until someone is able to determine exactly what has triggered his anger and distrust, then he will continue to seek revenge in a self-destructive manner.

Monday, September 12, 2005

This is the 353rd Weekly Case Management Update

This Week's Topic: "Bad As It Gets"

Question: "How do we recognize a bad psychological evaluation?"

Dr. Adams Replies: There are two types of "bad" psychological examinations:
a. Biased
b. Incompetent

And most bad exams are a combination of both.

Biased and incompetent exams can often, but not always, be determined by noting who made the referral. Does the referral source stand somehow to gain from the patient being diagnosed with an injury-related disorder?

The report will not be clinical and objective. It will be emotional. The biased exam has reference to the injury as being "horrible," "miserable," "traumatic" and references to how the injury has "destroyed" the patient. It will appear as though the patient has no role or capacity to manage this injury due to its horrific nature. The report often contains many subjective references to how the patient has suffered, how "terrible" it has been for patient and family, and may make reference to how he/she has been mistreated by those caring or financially responsible for the patient.

The patient's history will be painted as remarkably free of any past psychological events. There will be no reference to past drug/alcohol addiction, past recovery for other injuries, past legal entanglements or even an accurate description of the patients development.

Past medical history will be sorely lacking. There will be minimal reference to the patient's health behaviors; diet, exercise, obesity, nicotine, or caffeine. There may be no reference to complicating health problems such as diabetes, hypertension and respiratory problems.

There often is no reference to how much medication the patient receives, takes or seeks.

The report of the examination, and the patient's life, will appear as though it began on the date of the injury. Divorces, loss of jobs, goals/ambitions, relationships with parents, sibs, in-laws and friends, will not be found.

There will be references to how sincere and honest the patient was and how he/she bonded immediately with the examiner.

Diagnoses may be inappropriately applied, and pre-existing personality disorders are simply not mentioned in the report.

In toto, the report will read as if: The referral agent "wants me to find something wrong with this patient, and it is all to be attributable to the injury." From the opening sentence of the report, there is a sense that the report will not be accurate or complete. And indeed, it will not."

Monday, September 19, 2005

This is the 354th Weekly Case Management Update

This Week's Topic: "But then what...?"

Question: "We have all seen very bad psychological exams and that is why employers fear and loathe these referrals. So what, in your opinion, constitutes an excellent exam?"

Dr. Adams Replies: "we talked last time about biased reports in which the patient is portrayed solely as a victim and had no significant existence prior to injury. This is unfair to the patient, and it is clinically incompetent.

A clinically objective report is based upon review of all medical records, examination of the patient, and obtaining psychodiagnostic test findings.

The examiner describes and explains who the patient is in context of the injury.The patient's life prior to and following the injury is described in detail.

The report should begin with the patient's family, their education, work, and health histories. It should include any problems that existed in the patient's development and may range from being abused, to learning problems, to behavioral problems including problems marriages, childrearing, occupation, and with the law.

The report must contain a past medical history including past health problems, prior injuries, surgeries, infectious disease, disorders and conditions that have, and continue to, impact the patient. A mental health history of the parents and sibs as well as the patient is mandatory.

A complete report will examine where, and for how long, the patient has worked at each job, whether the work has been discontinuous, notable for conflicts with coworkers or authority and/or whether it has shown a definable career path. In other words, does the patient have a career goal in life other than financial survival.

The report will compare and contrast the patient's behavior in the office to behavior described in other offices for consistency, and it will look for behavioral consistency within the examiners office (E.g. Walking well but carrying a cane).

A complete exam will address how the patient sees the injury as having occurred, how the employer and coworkers are seen, whom he/she sees as to blame for the injury, how care has proceeded, and what the patient defines as successful care.

The report itself is objective, non-emotional, and merely presents the facts and draws reasonable clinical conclusions from those facts."

Monday, September 26, 2005

This is the 355th Weekly Case Management Update

This Week's Topic: "Defining the Limits of Care"

Question: "You know, most injured workers already have pretty chaotic pasts with problems that should have been addressed years and years ago, but they ignored them. Why should that be my responsibility?"

Dr. Adams Replies: A troubled past is often present, but when that person gets injured, some anxiety, some depression and definitely some pain will increase.

This does not, however, imply that all of their past problems are now to be addressed. For that they need private care or care from a community mental health system.

So how do you handle this? Comparatively simple and direct:
a. You should not avoid an MRI because of what can be found, and for similar reasons, you should never avoid a psychological examination/diagnosis
b. The pre-existing problems will often be the bulk of what is bothering this patient since it is a domino effect, and the injury allows the others to fall into play.
c. Authorize care for the exacerbation of the problems, and make it clear to the treating doctor that the patient needs to be referred back to his/her community for care of the longstanding issues.
d. The doctors' notes should reflect that he is not addressing those pre-existing problems, merely the problems with mood, anxiety and pain that are associated with the injury.
e. Care related to injury should be specifically delineated and targeted and not extend over countless months *unless* the patient is going through a series of procedures which complicates his/her adaptation.

Overall, when you receive a psychological exam that indicates appreciable pre-existing problems, do not run from authorizing care for injury related problems; merely define the *limits* of the care that is authorized. 

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