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CASE MANAGEMENT UPDATE 

Monday, September 25, 2006

Dr. Adams’ Case Management Update
This is the 402nd Weekly Issue 

This Week's Topic: "How can we help when they don't help?" 

Question
We have a terrible time in gaining compliance for orthopedic second opinions. We sometimes have to schedule the patient three or more times before they show for the appointment.  Don't these people want to get well?  It is really frustrating.  Do you have the same problem?

Answer

Compliance is an extremely frustrating aspect of patient management.  A patient insists that they are not comfortable with their doctor, with care or with their lack of progress and want another opinion. Then they fail to show for that appointment.  Or before the patient becomes frustrated (or even frightened) of care, you realize that they would benefit from a second (or third) opinion.  You set it up, and they fail to show.

Is it a problem in my practice?  Yes, a large one.

Patients insist that they are depressed and then fail to show, intermittently show or suddenly break off care.  They have the disabling symptoms of posttraumatic stress disorder which they insist are destroying their lives. Yet they fail to show for initial or follow-up appointment.

This is a greater problem in workers' compensation than in other areas of health care. 

A great part of it arises because they are not paying for the appointment, they are not scheduling the appointment and there are no consequences to not showing for the appointment.

This noncompliance becomes another aspect of their decreased motivation and self-responsibility.  They know that somehow, someway, someone will take care of it for them, and it will not stop the flow of money, medication or result in any consequences with which they need to concern themselves.

A partial solution may reside in directly telling the patient that "when you fail to show for an appointment, everyone is aware of it, and it makes us all concerned with not only your motivation to help yourself but also your honesty.  If there is any reason that you are not going to show for the appointment, you need to let us know now."

This, of course, is only a partial solution since the injured worker always has the seemingly contradictory excuse that "I was too sick to come."

I strongly recommend that noncompliance be meticulously recorded and reported to all involved in the patient's care; not only to determine if there is a consistent pattern of this behavior but also out of the awareness that there are a limited number of patient care hours in a given day. It is unfair for those who will comply to have their appointment postponed while the noncompliant patient simply keeps that appointment time open."

Monday, September 18, 2006

Dr. Adams’ Case Management Update
This is the 401st Weekly Issue 

This Week's Topic: "The Corruption of Health Care Delivery or For How Much Can I Sell My Bodily Parts?" 

Question
 

[This is the 401st weekly (injury) Case Management Update from Atlanta Medical Psychology; the 8th year.

On this occasion, I want to depart from the question-answer format (apologies to those whose questions will not be addressed this week) and, instead, to share an observation and concern that I have for injury management.]

Answer

The following case history will be very familiar to most of you. This is a middle aged man, sustaining work-related back injury while working a clerical position for an accounting firm.

His lumbar injury occurred when his manager required that he help lift huge executive desks to save on moving expenses.

Due to compromised gait, he then fell and tore the meniscus in his right knee.

It then became the frequently seen "house of cards:"

  • The employer denied that even the initial injury was work-related,

  • the insurer delayed in authorizing tests,

  • and the providers repeatedly attempted to return him to work after communication with the employer.

The patient required more than expected psychological support. He was angry, resentful, increasingly suspicious and in chronic pain. He was frustrated by delays. He was fearful that the knee would never be addressed and that he "would become paralyzed from the back injury."

No one had spent time educating him about his back or his increasingly poor health habits (morbid obesity, smoking, drinking, etc). His financial situation became grim.

With appreciable effort in getting everyone involved to understand his plight, he finally received authorization, care and the surgeries he needed.

However, after a mediation hearing and settlement agreement, the patient then became secretive and guarded (to all), having "been told not to tell anyone the details of my settlement" (although these details impacted future treatment planning for all involved in his care).

It was much more difficult to treat the patient after the mediation. Up until that point, he pleaded for any assistance he could find. After the hearing, he became unworkable. This, unfortunately, is yet another part of the psychology of injury management, and one for which you need to anticipate.

Monday, September 11, 2006

Dr. Adams’ Case Management Update
This is the 400th Weekly Issue 

This Week's Topic: "Foreign Bodies?" 

Question
"We are finding it increasingly difficult to manage those injured workers who are foreign born. The vast differences among various ethnic groups are amazing and very frustrating. I am not talking only about language barriers but cultural differences, differences in values and certainly differences in pain tolerance and motivation. I am truly at a loss as to how such individuals are to be managed."

Answer
OK, let's look at some of the problems and then the solutions.

Problems with the immigrant injured worker:

  • may well be in the country illegally and, therefore, very secretive about their life other than their most immediate injury-related complaints

  • obtaining a valid and reliable past medical history may be impossible due to non-disclosure, complicated by language barriers

  • may have come to this country due to hardship in their native land  [especially true in (former) Soviet countries].

  • have expectations that more will be done for them in America, with less personal responsibility, than was true in their homeland.

  • may well approach all health care providers with suspicion and distrust

  • may not understand and/or may refuse to comply with care as it is prescribed

  • will find it easier to accept disability income than to seek another job in our country

  • will have complex family and social problems that governs the course of their recovery

  • may be vulnerable and dependent upon those who instruct them not to put forth effort
     

Solutions:

  • do not impose American values upon those who do not share them; begin with a clean slate that essentially says "this person may not share my urgency in their returning to work."

  • always have access to an objective interpreter who understands the customs, values and ethics of the homeland (and America) and who can explain them what you are willing and able to do for the injured worker

  • make certain that all involved in care are aware that this individual may have needs that we may not frequently see in our own culture

  • do not be victim to the patient's wishing this injury to compensate for a past life of misery

  • accept that administrative closure may be needed earlier in these cases in order to best help the injured worker mobilize

Please note that some of these individuals, injured while doing semi-skilled production work in America were, in fact, doctors and lawyers in their homeland. Prior to being forced out of their country, they held positions of power and prestige. Fleeing their country in fear, only now can they process their bitterness and resentment.

Monday, September 4, 2006

Dr. Adams’ Case Management Update
This is the 399th Weekly Issue 

This Week's Topic: "Are we stuck?" 

Question
“We have an out-of-State injured worker who has reached physical MMI with regard to his back and shoulder.  He came to us from Florida where he was seen twice weekly for three years by a psychiatrist.  These visits appeared to have nothing to do with his injury and addressed such things as his marital problems, his son's drug abuse, his financial difficulties, problems with his parents and arguments with neighbors.  Well now he is in Atlanta and wants more treatment.  Are we stuck with this and what do we do?"

Answer
"Mental health care is rarely delivered weekly much less twice weekly.  For injured workers, it is best to keep such care to once every 2-3 weeks with focus exclusively upon the injury.

I have, to date, never seen an injured worker that needs to be seen twice weekly.   When this occurs, it is always a matter of the patient using such visits as a social outing, someone to talk to, and a place to air all problems in life.  This "treatment" does not result in productive change in any form.  It merely makes the patient more dependent.

You will not be successful in convincing the patient of this because rather than twice a month for 3-4 months, you describe twice a week for three years.

The best approach is to authorize twice weekly visits for three months and for progress notes that specifically indicate that these visits focus upon injury-related problems.

If the psychologist seeing the patient realizes that there are boundaries as to what is treated as well as time boundaries, he is less likely to stray from the appropriate course of care.

The problem stems largely from people who do not specific a treatment plan and adhere to it. They permit the patient to determine how long treatment continues.  This approach does not serve the patient's needs even though it may serve his wishes.

Monday, August 21, 2006

Dr. Adams’ Case Management Update
This is the 397th Weekly Issue 

This Week's Topic: "...okay...and then?" 

Question
“I very much enjoyed, and benefited from your explanation, as to how injured, blue-collar males, see their injury (and loss of material possessions) as a narcissistic insult.

That really, really made sense to me when I think about how they grow fat, de-conditioned and whine, moan and focus on catastrophic status for actually fairly minor (or moderate) injuries.

That explains why it occurs, but now tell me: what I am supposed to do we do with these cases...there are an awful lot of them.?"

Answer
"You are quite correct; it is very common, but it is a great deal easier than you may suspect:

The injured construction worker needs to deal directly with the reality that his assuming a passive role, giving up more of their existence, appearance and objects will not work for them.

Becoming fat, lazy and whining, will not change their plight.  Being angry, embittered and defining themselves in terms of their misery will accomplish very little.

They need to be directed to see how their own response to injury is actually worsening their situation and that taking a position of poor pain tolerance will make them look worse in their own eyes. It will also erode how they are seen by people whom they respect and admire.

They need to see the complications to their future that they are themselves creating and how their current approach is not only ineffective but is actually severely counterproductive.

You cannot passively approach this pervasive pattern among males; you cannot merely diagnose the problem and then do nothing about it.

You must have someone actively and directly confront them with what they are doing, point them in the right direction and have them participate in their own resolution of this injury."

Monday, August 14, 2006

Dr. Adams’ Case Management Update
This is the 396th Weekly Issue 

This Week's Topic: "Reflected Glory" 

Question
“Most of our injured workers are construction workers.  That is a very rough job, yet they whine and complain and actually tolerate pain less well than do female production workers.  Any reason for this?"

Answer
"Actually there are two:

First, in general, women are better able to tolerate pain.

But equally as important is the concept of narcissism.  Many construction workers have minimal formal education. Many began working in their early teens and terminated their education by the 8th to 10th grade.

Their pride comes in generating very good income without the burden of having to complete high school, much less college. They often own many objects that are of high status in their socioeconomic group, and these objects have become evidence to them of their power, success and even their identity.

They become highly narcissistic - self-involved and self-absorbed.

They are injured, and their status in their community declines very rapidly. Spending power is immediately curtailed, and often they were working more than one job to permit the the status that they had.

Rather than acquire more, they are alone at home, watching television, going to physical therapy, and sitting in waiting rooms.

Then two things happen:  Aside from being angry, bored and restless, they now also believe that they will somehow, by some means, be compensated for their injury at a level that will restore their prior status.  Thus, they must be both a victim (their new "career") and very demanding (which likely characterized their personality before injury).

Their "whining" becomes both a means of expression frustration but also a means of bolstering what they feel will be their financial future.

It is almost futile to attempt to motivate such patients since they can readily entrench themselves in the healthcare system and merely allow years to pass. There becomes no "profit" to rapid recovery."

Monday, August 7, 2006

Dr. Adams’ Case Management Update
This is the 395th Weekly Issue 

This Week's Topic: “Liar, Liar" 

Question
“One of the surgeons told me that `all patients lie' and that it is very hard for us to know how to help them because they lie so much.  That really seemed pessimistic to me. Do you believe it is true?"

Answer
"To a large extent, most patients will lie to protect themselves from admitting humiliating things.  This is to be expected, and it is not necessarily dangerous.

However, patients will also lie about quite serious things such as past health problems including injuries and treatment.

When a patient knowingly omits data from their own history, this is called dissimulation malingering.  They may deny past alcohol or drug abuse, past health problems that resemble current problems and they may believe that lying about their past will somehow help them today.  They believe that it gives them control.

For many patients, lying begins almost innocently as a means of not revealing too much data.  They feel that they will exclude just some information that really is not all that important, and also it is no one's business.

Soon, however, they get caught up in this choosing what to reveal and what to conceal. They do not realize that they are now making their own health care decisions without the education and training to do so.  Anyone attempting to assist them is restricted by the amount of information that the patient wishes to disclose.

Some patients can become quite adept at hiding important information. They begin to think of it as an acquired skill. They think of your attempts at getting the data from them as almost a game.  They believe that they are simply better at this game than you.

Most commonly, patients will deny those past events that they feel will influence your willingness to treat them in the present.  This may include past doctors seen, but it also may extent to past surgeries they have had and even past adverse reaction to medication.

Arguably one of the most important clinical skills to acquire is the ability to insure that you obtain not only accurate information but also thorough information especially in areas which will influence the course of future care."

Monday, July 31, 2006

Dr. Adams’ Case Management Update
This is the 394th Weekly Issue 

This Week's Topic: “Implications" 

Question
“We see a good number...perhaps most patients in chronic pain on these incredible medication regimens...literally a dozen different drugs, taken at different times...from our standpoint, it is expensive, but from the patient's standpoint, it has to be confusing. Thoughts?"

Answer
"This is a frequently expressed concern. 

You have someone who:

  • Has minimal understanding of what their medications do

  • May have limited intellectual ability to even understand the function (and interactions) of the medication

  • Are desperate in their quest for pain relief and will dependently take anything prescribed

  • Are sleep deprived

  • Are medicated to the point of sedation throughout the day, every day

  • Have to remember which medications to take with meals, take on empty stomach, take twice daily, three times daily, four times daily and/or at bed time

  • Will spend more time tracking their medication schedule than they will getting encouraged exercise

Now, at the same time, the individual is to make realistic decisions regarding surgery, second and third opinions, future occupational choices, complex problems in the home and deal with sometimes overwhelming financial concerns.

What I find most often is that patients do not take medications as prescribed although if asked in the incorrect fashion, they will claim that they do.  If, however, you ask them "I know you are prescribed many medications, and I understand it is difficult to remember to take them all at the right time...tell me how you handle all of this."  They will then tell you that they take many of the medications as they need them, will skip some because the drugs "upset my stomach...make me dizzy...make me sleepy...do not do anything at all..

A common finding is that they are prescribed Medication A at (for example) 100mg three times a day.  They do not like how it makes them feel.  When asked if it helped with their pain, they will say that "it really did not help."  The medication is then increased, prescribed more often, and this goes on and on.

In reality, the patient is either not filling the prescriptions or just lets the pills sit in a drawer.

The more realistic question should be: "Do you feel that the medications are helpful?  Are there any that you feel you cannot or should not be taking?  Have you had to change the schedule that I recommended?  Have you stopped taking any of the medication?  Do you feel that it is taking much of your time trying to remember when to take which medication and how much to take?"

There is a psychology of matching the individual patient to the schedule of medications prescribed.  If you do not understand how the patient responds to the complexity of the regimen or how he/she is self-modifying the regimen, then you will not succeed in helping the patient reach their goal."

Monday, July 24, 2006

Dr. Adams’ Case Management Update
This is the 393rd Weekly Issue 

This Week's Topic: “Great Expectations" 

Question
“We have an injured worker who has recovered very well, all things considered, but he is not mobilizing. He keeps asking for more opinions. He does not seem the malingering type. What is up with him?"

Answer
"You absolutely must know the patient's expectations for his future. These expectations dictate how many opinions he will seek, whether he can accept chronic (even mild) problems in the future, and the time frame in which he plans to mobilize.

Here are the most common expectations:

  • No residual symptoms whatsoever

  • A new job or career

  • A cash settlement that pays for all of my pain and suffering

  • An apology from the coworker who caused this

  • An apology from the insurance company

  • An apology from my doctors

  • A fix for my marriage and family problems

These are the thoughts that run through his head during the day, every day.

While you work on securing an MMI release and PPD rating, he ruminates about his anger, disappointment and discomfort.

You need to determine what he expects to happen and help him understand which expectations are not going to be met...and why they are not.

Until that time, he will remain (or keep himself) within the "system" because of his underlying fear, anger and disappointment.

Monday, July 17, 2006

Dr. Adams’ Case Management Update
This is the 392nd Weekly Issue 

This Week's Topic: “Ignorance Is Not Bliss" 

Question
“If the average injured worker has subaverage education, what are the implications for their recovery?  Does education or even intelligence have much of an impact upon the course of recovery?"
 

Answer
"This is not complex, but it bears close examination:

If a patient has a complex back, shoulder, neck or knee (etc) injury, the question is how much of the information about there problems are they able to retain.  If school was difficult for them, and high school graduation came with difficulty if at all, are they able to understand the role of an epidural injection, the action of medication or the results of an MRI?

I believe that the answer is an overwhelming "No."   They do not understand or retain information given to them regarding their condition.  They may retain some of the terms, but they are very likely to fail to fully understand what is told to them.  They may feel that the information given them is too much to remember and certainly too much to utilize.

On the other hand, the injured worker who is very bright and highly education may feel that he/she is not being provided enough information; that they are being treated as though they are incompetent to understand their own condition.

Educating a patient pre- or post-surgically must take into consideration:

  • intelligence

  • education

  • interest

If these patient variables are known, you know how to educate the patient to maximize their understanding of their condition.   If these variables are unknown, then you make false assumptions as to how prepared that patient is to understand and accept his/her condition."

Monday, July 10, 2006

Dr. Adams’ Case Management Update
This is the 391st Weekly Issue 

This Week's Topic: “Trustworthy?...think again" 

Question
“We have this injured worker, and the more we do for her, the less she seems to appreciate it.  She seems to have a great sense of entitlement, and she acts like we are out to get her every time we make a suggestion.  Any tips?"
 

Answer
"A variety of people are likely telling this patient that your goals are exclusively cost containment.  This includes sending her to the worst doctors, trying to settle her case so that you can save money, and wanting her to return to work long before she is ready.

She has little in life to offset what she is being told.  She has all day to sit and ponder whether these accusations about you are correct.

She may have no other activities other than sitting in doctors' offices listening to the complaints of others and hearing their interpretation of their own care.  People are very free with advice without regard to its impact upon others.

I refer to this as the "poor man's paranoia."  It is what truly paranoid individuals will do although they do it on a much grander scale.  But the one commonality between the frankly paranoid schizophrenic and the distrustful injured worker is that you have two tasks in front of you.

1. Is there any reality to their beliefs?  Are you choosing inadequate providers and truly trying to do all the things of which you are being accused?

2. If you are innocent of these charges and allegations, then keep everything very simple and direct.  Explain why you selected a particular doctor.  Describe the process you will be following to see that they maximally improve.  Be certain that you know their goals which are likely to be very different than your own, and explain how their goals and your own are at odds. Do not fall prey to accounting for your good behavior and all that you have done.  Simply outline the steps of injury management and answer their questions.

You likely learned long ago that all you can be is fair and honest. You can never compensate for the distortions being fed and fueled by others."

Monday, July 3, 2006

Dr. Adams’ Case Management Update
This is the 390th Weekly Issue 

This Week's Topic: “Most Likely to Succeed" 

Question
“Is there any way to predict which case will have a psychological overlay?"
 

Answer
"There are actually two forms of psychological overlay:

  1. Injuries that result in a mood disorder such as major depressive disorder or anxiety disorder such as posttraumatic stress disorder

  2. Injuries for which psychological factors such as a pain disorder are more of an influence than is the physical injury itself

For individuals who are unable to stop reliving their accidents (such as assault victims or individuals who have a horrifying injury), you need merely to look at the way in which the injury occurred or the nature of the injury (amputation, severe burn, electrical shock, etc).  You can reasonably expect those whose injury was characterized by a threat to life or a threat to the integrity of the body will develop at least acute stress symptoms. Approximately 25% will go on to develop posttraumatic stress disorder.

You can anticipate that a pain disorder will arise in those who have severe financial and marital problems, who have few alternatives for their occupational future and/or who reasonably feel someone else was responsible for their injury.

An injury is always a disruption to the normal course of life.  For many injured workers, there is also the added complication of blame and fear of the future.

Patient place a lot of emphasis on the anniversary of their injury.  If they have not returned to work after one year, pessimism emerges. 

Always remember while the patient may complain of pain, their underlying concern may be far more complex.  You need to know the patient's true concerns rather than relying solely on the current physical findings."

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©2006 David B. Adams, Ph.D.