Monday, January 8, 2006

Dr. Adams' Case Management Update
This is the 417th Weekly Issue 

This Week's Topic:  "Little Criminals"

Q^uestion:
"I am curious as to why you feel that past history of legal problems is important when evaluating an injured worker."

D^{r. Adams replies:}  
Two-thirds of the time, it provides no data that is useful in treating the patient, but one-third of the time it reveals a range of potential problems for which you need to be prepared.

They fall into four categories:

a. Those that will impact pain management - this include history of DUIs, drunk and disorderly, and narcotics charges that suggest a potential for abusing (or even selling) prescribed pain medication.

b. Those that complicate the financial picture - these include ongoing legal battles, past (or current) bankruptcies, or any conflict that places additional financial burden or responsibility upon the patient and/or family.

c. Those that call into question the patient's honesty - these include arrests for bad checks, various theft charges or any legal entanglement in which the patient has taken advantage of others for material gain.

d. Those that can create conflict in doctor's offices - these are often associated with assault or verbal aggressive behaviors in which the patient has demonstrated difficulty in maintaining control of hostile impulses.

In any situation in which you are predicting probable patient behavior, the best predictor of the future is always the past.  If this patient has engaged in one or more of the above four categories of illegal activities, the tendency will be for him/her to engage in the same or similar behaviors in the future.

---

Monday, January 15, 2006

Dr. Adams’ Case Management Update
This is the 418th Weekly Issue 

This Week's Topic:  "They're Not Listening"

Q^uestion:
"Have you seen pre-surgical patients that believe they have a herniated disc when they do not, or a post-surgical patient who does not know that they have had a fusion?"

D^{r. Adams replies:}  
Yes, and that topic is addressed in this year's seminar, "The Psychology of the Surgical Patient."

The bottom line?  The patients are not listening to the surgeon when told what is wrong with their back (and/or neck).  They are do not give their full attention when the surgical procedure is explained.  And they are not listening when they are told about the results of completed surgery or the time and rehabilitation necessary for recovery.

They do not listen because they are anxious.

Medication may complicate their capacity for concentration.  And most do not read the informed consent documents regarding the procedure being performed.

They do not ask questions, do not seek clarification and rarely admit that they do not understand what they have been told.  Often they are embarrassed to do so, but equally often they do not know how to formulate the questions.

Importantly, they do not know terminology, do not understand even when presented with educational materials, and their mind wraps around dreading the procedure and expectancy of full recovery even when they have been told that there will be residual problems.

They are more likely to listen to their neighbor who had similar problems or medical advice from their attorney.  They will gravitate toward surgeons whom they like since they cannot weigh whether a specific surgeon is skilled even if he has poor bedside manner.

I routinely ask patients to describe their impending or past spinal surgery, and consistently, they have an extremely poor understanding of what has occurred and/or what is planned.

It may well be that such understanding is not furthered by additional discussions with the surgeon since anxiety level may not decrease in his presence. 

Quite often, the patient needs to discuss his/her understanding of procedures and outcome with a neutral third party before we even know how poorly they understand their condition.

---

Monday, January 22, 2007

Dr. Adams’ Case Management Update
This is the 419th Weekly Issue

This Week's Topic: "In Oprah We Trust"

Q^uestion:  

You said last week that injured workers are difficult to manage because they do not listen to what they are told. If this is so, then we are doomed. You indicate that they do not listen to anyone...ever, correct?"

D^{r. Adams replies:}  
Yes, that about sums it up.

Well, except for one thing. They do listen to a few people; a very select few.

They listen to their spouse, various family members, their friends, a fellow that they met at the convenience store, Oprah, their attorney and almost anyone on the internet.

Unfortunately, the average injured worker does not have education or training that permits them to fully and competently handle the information that is provided them. This is further complicated by the anxiety that arises over their condition, anger that arises over delays in care, and frustration that ensues as many months pass since injury.

We then place them in someone's waiting room for several hours, shuttle them over for an MRI, tell them they need an invasive procedure that makes minimal sense to them and ask them if they have any questions.

And, indeed, they do.

They ask their wife or husband what they should do. They ask their brother-in-law who had a similar injury even though it was to the knee rather than the back. They ask a guy at the convenience store who wears a cervical collar, turn in Oprah to watch some poor soul tearfully relate the horror stories about their own fusion and then ask their attorney who is the best surgeon.

They receive an abundance of information. Enough information to Google the procedure and read of painful or crippling outcomes. They gain just enough data to be frightened, discouraged and hopeless.

Noting their blank, pale stare through eyes conveying lack of sleep, noting their weight gain from attempting to seek comfort from food, indict them for their narcotic use and are certain they could at least try to do more to help themselves.

The trouble is, aside from "where do you hurt?", no one seems to ask them much of anything.

Monday, January 29, 2006

Dr. Adams’ Case Management Update
This is the 420th Weekly Issue

This Week's Topic: "If It's Not One Thing; It's Your Mother"

Q^uestion:  
"I know that we have all been frustrated by the intrusion of family members into the course of treatment for an injured worker. What is behind this? Protection?"

D^{r. Adams replies:}  

As you clearly suspect, there are many times when the intrusion of a family member has insidious motives. In some cases, the injured worker was a source of emotional pain and suffering for his family. In a convoluted way, pampering him now may be used by the family to bargain for better behavior from him in the future or even to shame him by comparing their caring behavior to his abusive behavior.

In other cases, the family may be hoping for a windfall financial settlement. Realize that their financial position may create an intense financial need. The concept of "settlement" is very appealing, and they may be being misled to believe that they can influence the amount of that settlement.

A variation on the settlement-theme are those spouses who plan to leave the injured worker and attempt to build the value of the claim/settlement to insure that they can leave the marriage with a large sum of money.

But be aware that, by far, the greatest reason for family intrusion is that they are responding to the helpless, dependent position of the injured worker. That injured family member may, to them, appear lost in a sea of crowded offices, delayed authorization and endless pleas from the patient for emotional support.

In such cases, the overly protective family member will be less of a burden if you say to him: "I really need your help with all of this; so please keep a journal (or list) on the things that you observe." These data can be helpful to the authorized treating physician and, clearly, this gives the doting family member something productive (and less diffuse) to do with his time.

Monday, February 5, 2007

Dr. Adams’ Case Management Update
This is the 421st Weekly Issue

This Week's Topic: "That spinal thingie"

Q^uestion:  

"I gather that you examine many patients as part of a pre-screening for spinal column stimulator implant. What do you see as the reason and goals for such an examination?"

D^{r. Adams replies:}  

This is covered in the new Seminar Series. I recall many years ago when I asked a patient "what comes next in your care?", to which she replied, "He is going to put in a spinal thingy tomorrow...whatever that is...and whatever it does...but it will make me well, and I can go back to my (heavy lifting) job."

It became evident that:

· Patients quite often do not understand what they have been told about their condition or a pending procedure

· Because most of these patients have severe back pain along with radiating leg pain, they mistakenly believe this procedure will alter their back pain (and it does not).

· Patients quite often expect an unattainable level of recovery and believe that they will be pain free after the procedure.

And obviously, I believe (and private insurers and Medicare require) that a psychological examination prior to stimulator or pump implant is mandatory:

1. To determine the intellectual capacity to understand and retain what they have been told about the procedure

2. To determine the level of emotional lability (mood variability) prior to the procedure and whether psychological stabilization is needed prior to surgery

3. To determine the means by which the patient has dealt with past disappointments in life.

4. To determine the existence and appropriateness of the patient's plans if the procedure is effective.

5. To determine the patient's concepts and goals with regard to future use of narcotics.

Remember that implantation is typically performed long, long after injury, and usually after many other procedures have proved unsuccessful. A psychologist is needed to determine how this particular patient is going to respond to that particular procedure...and whether the patient is even a good psychological candidate for such a procedure.

Monday, February 12, 2007

Dr. Adams’ Case Management Update
This is the 422nd Weekly Issue

This Week's Topic: "Culture and Compliance"

Q^uestion:  

Do you, or must we, take into account the culture of the individual with pain complaints? I am asking if different cultures experience pain differently...or if they have difference in pain tolerand and/or if they use medication differently.

D^{r. Adams replies:}  

I am reminded of the young man who lost the tip of one finger on his nondominant hand and decompensated. His puzzled surgeon referred him to me for an evaluation in which it was revealed that in his culture, as the eldest son, he would have to play a musical instrument to guide his father into the next world upon the man's death. Without the tip of his finger, he could not play the instrument and would bring shame to himself and his family.

Pain, and medication to relieve it, is the primary reason most people seek healthcare, not just in workers' compensation. However, the expression of that pain varies widely among cultural groups. Unlike clinicians in other countries who are responsible only for understanding their own society, increasingly, American healthcare providers must deal with a wide range of ethnic and cultural differences.

What is the point of knowing these differences? In America, we often measure a patient’s pain by their use of medication. We measure their compliance by whether they manage medication as expected and take it exactly as prescribed.

But many non-Americans believe Western medication is simply too strong, and compliance only occurs until symptoms improve, or if no side effects develop. The concept of taking an antidepressant for a week while awaiting adequate blood levels, and dealing with initial side effects, is out of the question.

Even the reason for overuse of narcotics can be variable. Arabs are expected to express their pain openly and expect immediate relief, preferably through injectable or IV medications.

Conversely, many Asian/Pacific Islanders are reluctant to express pain, believing it is God’s will or a punishment for past sins.

In the Hispanic population, it is generally acceptable to be in the sick role, regardless of the reason, without feeling guilty. Family steps in and assumes the responsibility of daily life, and visions and hallucinations are not seen as signs of mental illness.

So what do you do with the patient who appears noncompliant with their medication or the treatment plan?

You must know:

Their cultural expectations regarding pain and its relief

Their family support system and acceptance of disability

Their understanding of the treatment plan

Their plans for the future

Their ability to look objectively at chronic limitations and willingness to work on an alternate future course

This information is clearly critical to effective patient management, and can only come from a psychological evaluation. Do it sooner, rather than later.

Monday, February 19, 2007

Dr. Adams’ Case Management Update
This is the 423rd Weekly Issue

This Week's Topic: "Psychosomatic - Part I"

Q^uestion:  

Could you explain what the term "psychosomatic" really means and what sort of role it has among injured workers?"

D^{r. Adams replies:}  

Psychosomatic refers to one or more psychological or behavioral factors that affect an individuals general medical condition. These psychological or behavioral factors may contribute to the development of a medical condition, they may exacerbate the condition or they may delay recovery from a medical condition.

The diagnostic code for this is 316.0 Psychological Factor Affecting Medical Condition and is a frequent diagnosis with injured workers.

Allow me to cover three of these now, and I'll cover the remaining three next week:

1. First we have cases in which Mental Disorder Affects Work-Related (e.g. orthopedic) Injury - This occurs when a diagnosed clinical disorder (e.g. Major Depressive Disorder) or a diagnosed personality disorder (e.g.Dependent Personality Disorder) complicates the course of treatment for the injury. For example, the individual is so depressed that he/she fails to follow-through with physical therapy or does not consistently take medication or remains in bed all day and becomes further de-conditioned.

2. Secondly, we have cases in which Psychological Symptoms Affects Work-Related Injury. These patients do not have symptoms sufficient for the diagnosis of a mental disorder. But they may have some symptoms of depression, some indications of anger, observable levels of resentment or distrust. These symptoms, in turn, keeps them agitated, tense and affects their level of muscle tension/spasm, capacity to effectively use pain management strategies or effect the course of recovery from surgery.

3. Thirdly, we have cases in which Personality Traits or Coping Style Affect Work-Related Injury. These patients may have an enduring pattern of behavior which is not sufficiently severe to be diagnosed as a personality disorder but severe enough to complicate recovery. Examples include the passive-aggressive style that results in non-compliance with prescribed care and leads to worsening of their condition. There is also the driven, compulsive and demanding (of self and others) coping style that may impact the ability to accurately process pain symptoms.

The most important thing to keep in mind is that psychosomatic does not mean "imaginary." The person is not believing they are in pain when they are not. In fact, there are psychological and behavioral factors which are making their pain worse along with less capacity to deal with pain.

Monday, February 26, 2007

Dr. Adams’ Case Management Update
This is the 424th Weekly Issue

This Week's Topic: "Psychosomatic - Part II"

Q^uestion:  

(Continued from last week's question on Psychosomatic Disorders impacting injured workers)

D^{r. Adams replies:}  

[from last week "Psychosomatic refers to one or more psychological or behavioral factors that affect an individuals general medical condition. These psychological or behavioral factors may contribute to the development of a medical condition, they may exacerbate the condition or they may delay recovery from a medical condition. The diagnostic code for this is 316.0 Psychological Factor Affecting Medical Condition and is a frequent diagnosis with injured workers."]

The final three are often key elements pre-existing injury and pivotal in determining recovery from injury:

4. Maladaptive Health Behaviors Affecting Working Related (e.g. orthopedic) Injury - Include sedentary lifestyle, overeating, drug abuse and/or excessive alcohol use. Thus, the individual has, or has developed, maladaptive ways of spending his/her days. Time may be spent eating large, unhealthy and frequent meals. It may also include failure to comply with dietary restrictions that have led to diabetes and hypertension. The individual makes no attempts at exercise and engages in unsafe health practices, fails to seek regular medical care and may self-treat conditions that should be treated by a physician.

5. Stress-Related Physiological Response Affecting Work-Related Injury. Physical responses due to environmental stressors complicate the treatment of a neurological or orthopedic problem. Tension type headaches and stress-induced back pain are the clearest example. There may be tension in the home against which the patient continually braces for confrontation. As a result, he/she may have muscle contraction pain which then complicates the diagnosis of injury-related pain.

6. Unspecified Factors Affecting Work-Related Injury. This includes complex behavioral patterns, response styles and personality characteristics which combine to complicate the course of recovery. An example of this would be a dependent individual, obese and borderline hypertensive, seeking comfort from food, angered when this maladaptive behavior is disrupted by family and developing chest pain in response to the stressor.

The psychosomatic (also called psychophysiologic) interplay of mind and body lead to frequent complications in the treatment and course of recovery for an injured worker.

Monday, March 5, 2007

Dr. Adams’ Case Management Update
This is the 425th Weekly Issue

This Week's Topic: "The Insurance Company Doctors...and worse"

Q^uestion:  

We have been told that (patient's name) is a good candidate for this one procedure, but instead of being pleased, the patient is surly and resistant. This makes us suspicious. What are we missing here?

D^{r. Adams replies:}  

An injured worker has the right to expect that whomever he sees is competent and independent. The competent aspect appears self-evident, but many injured workers believe that employers and insurers use highly biased doctors. The old, but entrenched, term is "insurance company doctor." Injured workers believe that their employer contracts with marginally competent and highly biased doctors.

When an employer/insurer can influence what a doctor says in a report, influence when a patient is returned to work, or even influence what care the patient receives, the injured worker's worst suspicions are validated.

Here is a more insidious and concerning fear that injured workers carry: this biased doctor refers me to his partner and/or his friend without regard to others who may be more skilled and more objective. A frequent complaint of the injured worker is that he/she was referred to someone in the same office, same building or someone whom they have been led to believe has business or social ties to their treating doctor.

There are many treatments for which patients must be screened. Chief among them are the prescription of drugs like oxycontin or the implanting of a spinal column stimulator or morphine pump. Ideally, if a patient is shown to be a poor candidate for the narcotic or the implant, then alternate treatments will be used.

But who screens for these things? Can such screening be done by in-house staff? Can you objectively screen for something from which you will make money? Can you hire someone to perform the screening when you are the source of their income, and then ask them to objectively deny a procedure from which you (and indirectly they) make money? Screening was intended to be an external process.

Patients feel that this cannot be done. They wonder why they are referred to practice partners or close friends. They wonder why they are screened for a procedure by personnel in the same practice where a procedure will be performed.

I fear that we often disappoint those who come to us for care by behaving as though they cannot see the transparent flow of monies or the needs to please referral sources. And it is difficult, if not impossible, to reassure a patient that opinions made on their behalf are honest and objective.

Monday, March 12, 2007

Dr. Adams’ Case Management Update
This is the 426th Weekly Issue

This Week's Topic: "Failure to Show...Failure to Comply"