Monday, November 28, 2005

This is the 364th Weekly Case Management Update

This Week's Topic: “Behind the Scenes”

Question: “You see, this would all seem to be straight forward. You get injured, for whatever reason…someone’s fault, your fault, no one’s fault….it doesn’t matter. It happened. Get over it. Go to the doctor, get treated, get as well as you can, and get on with life…you can’t tell me there is more to it than that.”

Dr. Adams Replies: “Your life is that simple? That straight forward? That uncomplicated?

Mine is not.

There are all manner of complications if I become ill or injured. Indeed, many things around me would collapse (not the least of which is your then having someone to whom to refer these supposed “straight forward” cases).

And it is true for everyone. There is nowhere in our lives that is prepared for us to drop out for awhile in order to heal.

We have endless commitments, emotional, professional and financial. Regardless of our support system, savings or insurance, this deteriorate quite rapidly.

Let me give you an example: I have a patient; nice young fellow with serious hip injury, two surgeries and probable hip replacement. His family is not financially able to assist. His girlfriend is totally supportive, but she has not begun to accept that some of his limitations are permanent.

He is fearful of marrying her, concerned that he cannot support her, does “want to saddle her with a cripple,” and feels that he can never have children “because what kind of father can (he)?”

He was a hard working fellow who had active hobbies. He can never do that particular work, those hobbies, and his friendships were based upon both work and outside interests.

After all of these years, it is hard for me to fathom treating an injury independent from the person whom the injury impacts."

Monday, November 21, 2005 

This is the 363rd Weekly Case Management Update 

This Week's Topic: “Missed That One Completely” 

Question: “…OK, then while you are at it, tell us about other problem patient populations.” 

Dr. Adams Replies: “As I have often stated, the workers’ comp system is ill-equipped to deal with those of above average intelligence, greater than high school educated, highly motivated, in great physical pain and understandably depressed. 

For such people, the workers’ compensation system is a quagmire.  

Everyone, to them, seems bent and determined to label them as manipulative, exaggerating and attention seeking. 

The very nature of workers’ compensation case management is maladaptive. It is based upon a common bond of distrust.  If a patient does not have an attorney, they are fair game for manipulation by the system. If they do have an attorney, they are then seen as unscrupulous and conniving. 

However, these white collar workers, who are involved in work-related injuries, are placed in an environment that is not designed for them. 

These are individuals who are used to private care, selecting their own physicians, who are considered good patients and most of all are treated with respect. 

Now that they are injured, they sit in crowded waiting rooms, ordered to see doctors who, to them, feel largely cold and indifferent, and seldom-if-ever does anyone attempt to explain to them where treatment is going…or why. 

Throughout the years, such patients have referred to this process as “I don’t belong in this system” or “this system was not meant for me” or “why do I feel like everything thinks I am after something?” 

“A few bad apples” is the best explanation to give them.  A few bad apples have made us all suspicious and distrusting. A few bad apples use this system to solve problems that they have been unable to otherwise solve. A few bad apples use this system as a source of income and financial advantage. A few bad apples have created something in which you are now trapped. 

My experience has been that the honest and motivated patient is in a disadvantageous position. 

I suggest that if the patient is a well-educated one that the unfairness and unsuitability of the workers’ compensation system is most likely to leave them feeling weak, futile, helpless, hopeless…and, ultimately, depressed."

Monday, November 14, 2005 

This is the 362nd Weekly Case Management Update 

This Week's Topic: “Thank Heavens…No Psych” 

Question: Actually this is a statement made to me at recent seminar -  “thankfully, we have not seen any psych in several years…”  

Dr. Adams Replies: “There is no case of work injury that does not involve “psych”.  All cases do. 

“Psych” is the science of human behavior. It is what people do, think, feel and believe. 

“Psych” is two things in cases of claimed disability:

a. It is a mental disorder caused, or exacerbated, by injury

b. Or “psych” are those factors that impede an injured workers’ willingness to return to work. 

Mental Disorder frequently arises from injury in the form of mild depression, pain (somatoform) disorders, and/or anxiety disorders (most notably) posttraumatic stress disorder. 

In these cases, Psych, if competently treated, psych care can expedite, not impede, the speed of recovery. 

The second category, “psych” factors, is found in virtually all facets of all cases.  Psych, in this sense, refers to the patient’s goals, motivations, compliance, honesty, integrity, and ambition.   

Psych involves whether the patient is accurately reporting the injury, truly complying with care, honestly reporting symptoms and limitations and is willing to work hard to get back to work. 

Without “psych”, we have no idea as to why this patient’s physical complaints are in gross excess of the physical findings…why the MRI (etc) suggests no, or minor, defect, yet the person states that they are immobilized by pain. 

It is only with “psych” that we find out whether the injured worker is being negatively influenced by friends and family or other outside sources, and it is only through “psych” that we can determine if the patient is capable of (intelligent enough for) understanding their diagnosis and the goals of treatment. 

In each and every case, you can either deal pro-actively with “psych” or be blind-sided by it."

Monday, November 7, 2005

This is the 361st Weekly Case Management Update

This Week's Topic: “An Obstruction Was Found”

Question: “Don't you find that psychological evaluation is blocked by many people involved in a case?”

Dr. Adams Replies: "Most involved in a case obstruct psychological examination much less psychological care. It is sort of an urban myth..."don't go there!"

Several years ago, I was part of a panel presenting to a group of doctors and nurses. One member of the audience asked the surgeon on the panel what he does with the psychological aspects of a case.

He basically said "pffft, it is all hocum...unimportant...you fix it surgically and send them packing."

About three months later, he began referring patients. He found that they did not go back to work regardless of how successful surgery had been. And he also found that many injured workers had great demand for disability ratings, low compliance with physical therapy and increasing demand for narcotics.

Contrast that with attorneys and adjustors who eschew psychological examination because they are fearful as to what will be revealed. Adjustors and defense attorneys are just certain that an exam will reveal a very expensive-to-treat psychological problem. This is almost never the case. Indeed, to date, I have not seen an expensive psychological problem.

Patients and claimants attorneys obstruct psychological examination for fear of what will be revealed: other injuries, pre-existing pathology, criminal history, and/or outright deception.

So...yes, psychological examination is quite often obstructed, but chiefly the justification for the obstruction is based upon urban myth and legend."

Monday, October 31, 2005 

This is the 360th Weekly Case Management Update

This Week's Topic: “Too Many Office Visits” 

Question: “Does this year’s seminar deal with the issue of fraud among doctors?”  

Dr. Adams Replies: “Everyone is concerned about inappropriate claims. They are, today, a major aspects of problems in workers' compensation. As many as one-quarter of all claims have an aspect of impropriety. The possible causes, include simple misunderstanding, honest mistakes, context of injury, employee anger and resentment, unscrupulous doctors, and outright deception and malingering (fraud).  

In this year's seminar, I address the issue of what is happening in Workers' Compensation, how and why it has occurred...more importantly, how you can identify the problems and what to do about them.  

The original inter-relationship between employer and insurer has now become subdivided to include doctors as a third component.  Quite often, doctors and insurers, doctors and employers as well as doctors versus other doctors are not on the same page. 

Patients are shuffled among offices, return too frequently for care, care is extended over very long periods of time with protracted periods of workers away from their job...and the workforce. 

An example is offices that require that the patient come each week for medication refill. There is no true justification, other than being able to bill more for services.  Another example, is placing a patient into multiple treatment modalities because that particular office has these services “for sale” on site.  

Initially, the patient sees his/her injury as a temporary burden.  The injured worker believes, and impatiently, awaits the several days (or weeks) to return to work.  But as he is shuffled between practices, with attendant delays in scheduling, he begins to adapt to this new sedentary role.  He arises later, lays around and watches television, smokes more, eats more, and may drink more. General health declines. 

The longer he lies around, the more the focus becomes upon what financial reward he will receive. He begins to see himself, and seek doctors who see him, as having a partial but permanent disability.  

If you look at the history, intent and course of the concept of workers' compensation, we have strayed quite far from the original and lofty goal.  

Monday, October 24, 2005

This is the 359th Weekly Case Management Update

This Week's Topic: “All Patients Are Liars”

Question: “You seem to believe that patients will tell you things that they do not tell others. How do you know that they are not lying to you?”

Dr. Adams Replies: “Almost all patients lie.

They may lie because they are afraid of being negatively judged. Or they may lie because the true will not provide them with the outcome that they want. Sometimes they lie because they cannot handle the true of their own lives.

Individuals are less likely to lie to certain authority figures; priests are one example. Patients are less likely to lie when they feel that lying may result in their needs not being met.

Most often patients feel that lying solves problems. They lie to obtain more drugs, more time off from work, special exceptions and considerations…they lie because it works for them.

Why do patients lie less to one doctor versus another? There are many reasons but much of it has to do with the skill of the person asking the questions, something in the method that puts the patient at ease.

While patients can, and do, lie to me. They more often call back to give me information that they “forgot” or avoided telling me when they saw me.

Not all liars are dishonest. Some are merely needy and fearful.

You cannot extract the truth from the dishonest; all you can do is be certain that they are, indeed, being dishonest.

But with training and experience, you can obtain the truth from those who are hiding due to fear. This, however, cannot be accomplished in a 10 minute office visit in which the patient is there to be asked about their pain, have their medications refilled and to be rescheduled.

In order to obtain the truth, the doctor’s agenda needs to be set aside, and the patient’s agenda addressed. The patient needs to perceive that there are not time constraints or judgments associated with having the chance to tell the truth.”

Monday, October 17, 2005 

This is the 358th Weekly Case Management Update 

This Week's Topic: “Fear of Discovery” 

Question: “Well, people avoid even looking for the psychological issues and disorders…is this fear or avoidance?”  

Dr. Adams Replies: “Both, fear and avoidance in this case are inseparable.  

The authorized treating physician becomes concerned or suspicious as soon as the patient's complaints exceed the doctor's findings.  

After several more visits, the doctor becomes concern whether the patient is deliberately exaggerating or whether other factors are causing this excessive response.  

At this point, he has two options:
a. Fix what I can and let others deal with it
b. Find out what's going on so time and money are not wasted 

If the patient is deliberately exaggerating, he/she does not want a psychological examination due to fear of being discovered. 

The employer/insurer does not want a psychological examination due to fear that some terribly expensive, underlying problem will be discovered. 

So the exam is postponed, often for many months.  

Importantly, over those many months, much more money is spent on unnecessary and repeatedly nonproductive tests. 

Finally, everyone relents, and the patient is examined.  

Lo and behold, he/she has marital, sexual, drug, alcohol, legal, financial, and other problems unrelated to the injury.  

Everyone is thrilled, including the patient that these are revealed, and the patient is encouraged to seek care at a County mental health agency in their area. 

Even with this positive outcome, the process usually remains unchanged, and the next patient is managed the same way.”

Monday, October 10, 2005 

This is the 357th Weekly Case Management Update 

This Week's Topic: “Copping Out” 

Question: “If so much of this failure-to-recover is mental, how do so many doctors miss it?” 

Dr. Adams Replies: “Hmmm, that may be the question of the decade.  Unfortunately, the risk to life and risk of law suit, forces everyone to practice defensively.  

This means that even though you find nothing, you continue to look.  A woman from another country wrote me recently that her all lab tests indicate that her depressed daughter is physically healthy, yet she runs a low grade fever every day. 

While it is tempting to say that the fever is stress-related, you immediately become concerned that some significant physical problem is being overlooked.  

Thus, when an injured worker has no objective reason for the pain, the search for a physical cause continues for many months beyond the point where the doctor is certain that there no physical cause will ever be found.  

The patient is then sent to a pain center which also assumes that the pain is physical and numerous procedures and medications are used for another period extending months…and sometimes years. 

Then, three years after the injury, someone takes a gamble and says “this is probably psychological.” 

I see the patient at that time, and it is stunning how many horrible (not related to injury) events have happened and are happening in the patient’s life. 

By this time, the patient may have become completely resistant to accepting that his/her problems are not related to injury.   

Early cop-outs on the psychological diagnosis always lead to later problems.

Monday, October 3, 2005

This is the 356th Weekly Case Management Update 

This Week's Topic:  Southward Migration

Question: “How do these rather straight forward back or neck injuries suddenly become pain all over the body?” 

Dr. Adams Replies: “There are six causes for this:

1.    While there was a cervical injury, the lumbar (and other) injuries were not investigated, were minimized or the pain was masked by the more severe neck pain

2.    In competency:  Whoever is treating the patient dismisses any complaints for which care is not authorized (i.e. being paid)

3.    The patient has gained weight and has become more de-conditioned

4.    The patient is malingering and either there is no pain or the other pain comes from non-compensated events

5.    The pain is somatoform – it provides the patient with secondary gain such as attention and affection

6.    The patient is drug seeking 

Often, it is a combination of two or more of the above factors.