Dr. David B. Adams - Atlanta Medical Psychology

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Monday, September 24, 2007

Dr. Adams� Case Management Update
This is the 454th Weekly Issue

This Week's Topic:� "Wrong...again!"

Q^uestion:
"Do you feel there is a single best way to approach a new injury case, or are there several alternatives?"

D^{r.
Adams replies:}

The last thirty years have taught me that there is truly only one effective approach, and this applies to surgeons, nurses adjustors and employers:

Wherever possible, be certain that you do the following:

Stop talking to the patient and listen carefully. Do not ask "yes" or "no" questions regarding the injury, but, instead, ask for a narrative as to how the patient sees the injury to have occurred, and how he/she feels it could have been avoided.
Rather than interrupting the patient, allow the patient to complete the narrative and then ask for clarification of key points.
Summarize back to the patient what you feel you were just told to be certain that the two of you share in understanding the patient's rendition of events.
When explaining to the patient, regardless of your perception of his/her educational and intellectual limits, simplify what you are attempting to explain; avoid the use of terms that you assume both of you understand.
Realize that you may have gender differences in how you perceive the patient's plight: Males and females have vastly different perceptions of their responsibilities and roles. Do not impose yours upon his/hers.
Similarly, there are cultural differences. Be open to hearing that the patient feels that the injury was an act of God or that a melodramatic response to injury is culturally expected for this particular patient.
Be certain that your true level of availability is clearly communicated. Too often, in an attempt to be supportive, we behave as though the patient can "call us at any time" and are then stunned to find out that the patient took that literally.
Ask the patient to summarize for you what he/she feels that you have just explained (this may obviate believing that a fusion entails "putting fuses in my back"...or...that the plan is to "take out these ruptured ones and put brand new ones in there").
Note that the effects of medication, pain, anxiety, depression and distrust effectively impede with the patient's ability to listen and remember. Look for one or more of these obstacles and slow the discussion to insure that data is accurately being communicated between the two of you.
Always assume that the patient has many things going on concurrently in his/her life and that this injury is not the only event of which you should be aware. Sometimes, it is not even the most important. Suspect that the patient has numerous complications in life and provide an environment wherein he/she can share these with you.

If you, for any reason, feel that you have neither the time, inclination, training or skill to secure and impart data as outlined above, have someone else see the patient to insure that the interchange occurs.

Monday, September 17, 2007

Dr. Adams� Case Management Update
This is the 453rd Weekly Issue

This Week's Topic:� "They're Watching You"

Q^uestion:
"I cannot help this guy. He thinks that all the doctors are "on the take" and that I "work for the insurance company" and "something is seriously wrong that we do not want to pay for." He is beyond reason and truly, I have not a clue as to how to proceed.'"

D^{r.
Adams replies:}

So much of our society works via a process of invoking fear. This is how our smoking, drinking, eating and exercise habits are shaped. We are told of the horrific fates that will befall us if we do not do as we are told. This, of course, begins when we are young. Our parents structure our behavior around a series of "this will happen if you...(or)...if you don't."

While not ideal, it is likely harmless except when this approach is used with individuals who are frankly paranoid. I am not referring to those who are paranoid schizophrenic and believe that they are part of some greater and mystical plot. I am referring to those with paranoid personality.

Paranoid Personality Disorder is characterized by a pervasive distrust and suspiciousness of others. The motives of others are seen as evil. There is not sufficient justification for their belief that they are being harmed, exploited or deceived. They are preoccupied with doubts of loyalty and trustworthiness of others and they are unlikely to confide in others because they believe data will be used against them. Such individuals, by adulthood, read critical or threatening meaning into benign events or remarks. They bear grudges for even minor insults and are quick to anger and counterattack. Not infrequently, they believe that they are being betrayed by their sexual partner. Most often such individuals do not perceive themselves as having a problem and that any suggestion that they need assistance is proof to then that they are, indeed, under attack.

TV commercials selling legal services, other patients in doctors offices, remarks by family members and neighbors all conspire to convince this patient that he (or she) will be manipulated and somehow harmed. Some of these fears may be well-founded in some cases (Eg. employers who do not wish to report an injury or an insurer who wants an injury minimized). But just as some music or video games will evoke bizarre behaviors in some individuals, it is better to know which patients are most vulnerable to these paranoia-evoking commercials and input from others.

The use of these fear-tactics in patients who have paranoid personality traits will be extremely destructive of any trust between doctor and patient. As with the compulsive patient, the solution lies in providing the patient with a sense of control where possible: "When do you want that appointment?" "What would you prefer to do?" "What would make you the most comfortable."

You must work within the confines of a personality disorder that formed years earlier. Since you will not talk the patient out of his/her perceptions and beliefs, your best approach is to accept that this is the way the patient assesses the situation and what would provide him/her with at least some belief that the control is ultimately their own.

nday, September 10, 2007

Dr. Adams� Case Management Update
This is the 452nd Weekly Issue

This Week's Topic:� "Organized or Burdensome"

Q^uestion:
"In my practice (orthopedics), I don't always find it helpful for patients to have such detailed information about their condition. For some patients these data create more problems than solutions. Do you know what I mean?'"

D^{r.
Adams replies:}

I do, indeed, understand. These are the patients that come to each visit with all xrays, lab reports, MRI results, progress notes, correspondence and detailed outlines of symptoms plotted against date, time of the day, weather conditions and activity levels. Rather than being able to effectively interact with the patient, the agenda appears to be to note, appreciate and comment upon the detailed work that they have provided.

These patients comprise that group of obsessive-compulsive personalities who have been injured. Obsessive-Compulsive Personality Disorder is a developmental defect in which there is a preoccupation with control and orderliness.

The person is often inflexible/stubborn and may have been more invested in work than family, friends or leisure. Such individuals become detail-orientated, and, for them, organization has more importance than the larger picture of their lives. Such individuals often cannot allow others to work effectively, concerned that others cannot work as precisely or efficiently as they. This need for control can be all consuming such that the very quality of life, especially family life, is undermined.

They cannot appreciate that in order for the rest of us to do our work, they must willingly accept the role of a patient and defer in large measure to our judgment and decisions. They become agitated when their control is threatened.

The solution? Give them control. Before you reject that out-of-hand, realize that you will not change their personality disorder, talk them out of it or have them relinquish it. They may even be aware of it, but deferring to others is not within their makeup. So, give them specific assignments. Assure them that you appreciate all the records that they carry, but those records are now in their chart and that you have, indeed, reviewed them. Tell them that you admire the detailed records that they keep upon their symptoms but that you have a new and very important assignment for them. You need them to keep a journal on the non-injury activities in which they engage such as walks they take and out-of-home interactions in which they engage. Remind them that their medical records will be more complete if they can provide a single paragraph summarizing their (emphasized) progress since their last visit, that such concise summaries are helpful.

There are, in fact, many ways in which their personality disorder can more effectively serve, rather than thwart, the doctor-patient relationship and enable for effective use of brief office visits.

Monday, September 3, 2007

Dr. Adams� Case Management Update
This is the 451st Weekly Issue

This Week's Topic:� "...continued from last week..."

Q^uestion:
"Is it true that if a person is depressed that when they will get well on their own, and if they get depressed again, they are not likely to get as depressed as the first time? Do they develop an immunity to depression?'"

D^{r.
Adams replies:}

The relationship among stressful life events, our mind and body's reaction to stress, and the onset of clinical depression is a complex one. Some, but not all, people develop depression after a stressful event in their lives. Either positive or negative events can become a crisis that precedes the development of clinical depression. This is why some patients become more depressed after settling their injury claim than they were during the course of care for that injury.

In many cases, people become depressed even when there is little or no stress in their lives and everything seems to be going very well. And, no single stressful event will cause depression to develop in every person. The same type of stressor may lead to depression in one person, but not another.

When a stressful experience causes a person to become depressed, it may happen indirectly. A young man with a family history of major depression suffers a serious lumbar injury; he may become clinically depressed. It is not necessarily the trauma that caused the development of depression, but the combination of a genetic predisposition with the stressful event that made him vulnerable.

For those who struggle with more chronic depression, the effects of stress may be more complicated. A stressful event such as injury may trigger the first depressive episode. After that, further depressive episodes may develop spontaneously. Researchers have theorized an explanation called the "kindling effect," or "kindling-sensitization hypothesis." This theory holds that past depressive episodes trigger changes in the brain's chemistry and limbic system that make it more prone to developing future episodes of depression. Early episodes of depression make a person more sensitive to developing depression, even small stressors can lead to later depressive episodes.

Some people may become depressed as a result of having to struggle with chronic stressors. These constant difficulties with pain, financial loss and an empty meaningless existence may be enough to trigger clinical depression.

The theory of "learned helplessness" states that when people experience chronic or repeated stressful events, they learn to feel helpless. This feeling of helplessness is strengthened when a person believes he or she has no control over the stressful situation. Unable to control income, when a disability check arrives, when social security is approved, when procedures are authorized and what a spouse will do in response to changes in the marriage lead the individual to perceive that he/she is helpless to control any aspect of life.

Monday, August 27, 2007

Dr. Adams� Case Management Update
This is the 450th Weekly Issue

This Week's Topic:� "It's Not About Burning Wood"

D^{r.
Adams replies:}

^{Simply put: No.}

^{Depression can be triggered by life
stressors including pain or loss. Depression is not an emotional
condition. Depression is a physical condition.}

^{Let me give you the briefest of
courses in depression:}

^{The brain functions by sending
electrical impulses from brain cell to brain cell. In order to do this, it
must have availability of dopamine, norepinephrine and serotonin.
The secretion of these transmitters help each cell to fire sending electrical
impulse to the next cell where the process continues.}

^{If you do not have enough of any of
these neurotransmitters, the brain does not work properly and thoughts, feelings
and behaviors change, sometimes dramatically.}

^{There are several reasons why a
person would not have enough of a specific neurotransmitter. Neurotransmitters
can be depleted by stress. When cells in the brain (especially key areas like
the hippocampus) cannot fire correctly, we develop a series of symptoms that we
refer to as depression.}

^{The so called "anti-depressant
medications" help replenish one or more of these neurotransmitters (by a process
we can discuss at another time).}

^{If the supply of neurotransmitters
continues to be lacking, the brain structure itself changes. Patients who
are depressed for long periods have different brains from "normals" when seen in
PET scan.}

^{Depressed patients actually become
depressed more easily and often more severely each time.}

^{This thing we call "depression" also
impacts the immune system and makes us vulnerable to specific disease and
disorders. Among other diseases, diabetes has been linked to depression.}

^{This is why depression is most often
measured by the number of specific physical symptoms like a certain sleep
pattern, problems in decision making, problems in concentration, changes in
libido and continual-unwanted thoughts.}

^{Both positive and negative events
may precipitate a depressive episode since either can be stressful. A
person may become depressed over the loss of a job or even when entering into a
new marriage. No single stressful event will cause depression to develop in
every person. The same type of stressor may lead to depression in one person,
but not another.}

^{Thus, a person with a comparatively
minor injury can, conceivably, be more depressed than a patient with more
serious losses.}

Monday, August 20, 2007

Dr. Adams� Case Management Update
This is the 449th Weekly Issue

This Week's Topic:� "Strange Interpretation"

Q^uestion:
"We have an increasing number of foreign-born claimants and must send them to an orthopod with an interpreter. We have had some problems with this. We are never certain what the interpreter is telling the patient and whether the interpreter is telling the doctor everything about the patient's complaints and symptoms. You have seen a fair number of these patients; has this ever been a problem in your office?'"

D^{r.
Adams replies:}

^{There is an old parlor game in which
a person whispers a story into the ear of the person next to them who, in turn,
whispers that story to the next and so on. At the end, the final person
states what they have heard, and we are always amazed at how it differs from the
original.}

^{I share your concerns regarding the
use of interpreters, and this is a growing problem:}

^{The nonEnglish-speaking patients are
dependent upon someone to assist with communication to and from them:}

^{The patient has no way of
determining if what they are saying/feeling is being accurately
communicated.}
^{We have no way of knowing if
this is precisely what the patient means.}
^{We have no way of knowing if
what we are telling the patient is being accurately communicated back to
them}

^{We must be certain that the
interpreter is objective and is not slanting communication to meet the needs of
whoever recommended them for this translation job. This becomes of
particular concern when the same interpreter is repeatedly assigned to the same
patient. While this may meet the dependency needs of the patient, over
time, some interpreters assume an authoritative role, believing they know what
the patient wishes to communicate without asking.}

^{Additionally, they are not medical
personnel, and there is every likelihood that they also do not understand what
is being said by the clinician, and further distort the information.}

^{It is for this reason that I refuse
to do a psychological evaluation with an interpreter previously known to the
patient. I want to know what the patient's perception of their problem is,
and I do not want their feelings filtered through someone else's perceptions,
especially someone with a stake in a specific outcome.}

^{The other, very real reason for
having a new interpreter present is that many patients do not wish to share
intimate details of their life in the presence of someone whom they will be
seeing again. It diminishes their spontaneity and ultimately, honesty.}

^{And finally, having an interpreter
who is in tune with my office procedures, ensures more efficient and objective
assistance in this difficult world of cross-cultural barriers.}

Monday, August 13, 2007

Dr. Adams� Case Management Update
This is the 448th Weekly Issue

This Week's Topic:� "How to Create Trouble for Yourself"

Q^uestion:
"Strikes me that employees are totally inappreciative of what employers attempt to do for them.'"

D^{r.
Adams replies:}

Here is a bit of irony - employers are the most vigorous in their denial of the psychological aspects of a work-injury claim. They often assert that any emotional problems certainly pre-dated injury and is not their responsibility.

Interestingly, one of the most frequent reasons why I am referred an injured worker is that he/she knows that the injury was preventable, knows that a coworker or employer was culpable and is aware that they have been denied timely and appropriate medical care. The injured worker feels angry, helpless, unsupported, fearful and frustrated.

All employers have two immediate and obvious roles in managing the workplace:

a. to prevent injuries, and

b. to respond in a timely fashion when injuries occur.

We assume that they understand the consequences of an unsafe workplace, but many patients whom I see have been injured on equipment that is either substandard and/or has long needed repair. These cost-containing attempts by the employer result in the injury of their employees.

These same employees then feel, accurately, that they have been abandoned following injury. They note that they are provided care that is brief and often designed to minimize their complaints while diagnostic studies are denied or postponed.

These problems appear to be worse among the smaller employers in the construction industry. To keep their companies profitable, they either attempt not to carry workers' compensation insurance, or, more often, they tell the employees that they should not file a workers' compensation claim (in an attempt by the employer to contain cost of their insurance premiums).

It is, unfortunately, not unusual for an employer to set up roadblocks so that the employee cannot file within allowed time limits, thereby insuring that the claim is denied.

The most effective injury management involves listening to the patient, not only with regard to how the injury occurred, but how he/she feels it could have been prevented, and how the employer facilitated or obstructed access to care.

Monday, August 6, 2007

Dr. Adams� Case Management Update
This is the 447th Weekly Issue

This Week's Topic:� "11 Things You Should Know"

Q^uestion:
"Can you give me an overview on the diagnosis of depression and what, from your perspective, you feel I need to know when seeing these patients?'"

D^{r.
Adams replies:}

Here are eleven things you should know about depression:

1. It is most often diagnosed incorrectly and thus under-diagnosed. The diagnosis of depression is offered by those with some, but often not a great deal, of information about the disorder. There are, for instance:
a. aspects of a patient history (forgetfulness, irritability, early morning awakening, etc) that will reveal depression
b. tests (MMPI/2, etc) that will expose depression
c. spects of history (for example weight loss) which may or may not be a relevant indicator
d. aspects that tests (for example, sleeping too much) fail to measure
The diagnosis of depression is not a casual or quick assessment.

2. Women may be more prone to obsessive worry, and their basic hormonal chemistry may make them more responsive to their life stressors. In either case, women are more than twice as likely as men to suffer from depression.

3. There are many different forms of depression, ranging from situational depression arising from a recent event and often only a transient problem, to a major depressive episode in which the patient may be significantly incapacitated, to depression that is a recurrent problem within a bipolar disorder.

4. Depression is interpreted differently between cultures. White Americans are often more comfortable referring to themselves as "stressed" when they are, in fact, clinically depressed. Hispanic individuals may be more acceptant of the diagnosis of depression but may not use the same terminology. Importantly, there is research that demonstrates that doctors from the same culture as their patients are NOT better at correctly differentiating between anxiety/stress and depression.

5. Medication does not affect all ethnic groups in the same way. Almost half of Asians and blacks metabolize drugs more slowly than do whites due to differences in liver enzymes. They may, as a result, have more adverse side effects to antidepressants without the benefits, and seek to discontinue the drug(s) as a result of these side effects.

6. Depression is not genetic. There are genetic tendencies to be stress intolerant. There are genetic tendencies to develop depressive symptoms under stress, but depression itself is not caused by a single gene. However, the pattern of depression and stress intolerance in families can help you understand how a patient's family managed depression in other family members.

7. Patients do not gain weight because of antidepressants but some antidepressants (which raise serotonin levels) do result in increased appetite. Indeed, an unsuccessful approach years ago was to give Elavil to anorexic patients to make them eat. This was foolish on two counts: a. anorexic patients do not starve themselves because they are not hungry. They starve themselves because they irrationally feel that they are fat, and b. making someone hungry does not guarantee that they will eat. The danger in some antidepressants is that the serotonin can make you store more fat and sugar. But, again, weight gain will be determined by how much is taken in and how much exercise occurs.

8. Physical illness and injury can trigger pain and the release of cytokines, which are part of the body's immune response and can make some patients depressed or even suicidal. A mood disorder can affect the body�s ability to fight an illness. Stress can lead to arterial spasms and heart attacks. Depression is also associated with a poorer prognosis for diseases including stroke, epilepsy, and diabetes.

9. Not everyone should take antidepressants even when depression can be verified. These are not benign drugs. Also, in our society, there is less and less tolerance of having down periods. We run to the pharmacy for every untoward symptom. Very often a person can get through a bad period by simply talking it out with someone whom they feel can help them better understand their options. The danger in the run-to-medication approach to life is that you learn very little about yourself and fail to learn how you contribute to your own problems.

10. Patients given antidepressants do not become suicidal. This concept has been fruitful for those who benefit from lawsuits. In reality, most depressed individuals lack the energy to take their own lives. As they become less depressed, they have more energy, and some will then feel strong enough to make a suicidal decision. What this means is that someone who has been severely depressed may need close monitoring. They may begin to emerge from their depression but see life as futile and feel strong enough to make a decision to end their life. This is another reason why medication alone is a suboptimal way of treating depression.

11. It is estimated that 80% of injured individuals develop some form of depression during the course of their medical care.

Monday, July 30, 2007

Dr. Adams� Case Management Update
This is the 446th Weekly Issue

This Week's Topic:� "Not Enough and Too Much"

Q^uestion:
"Have any thoughts on how much or how little a patient should be told about his/her condition?'"

D^{r.
Adams replies:}

"A few weeks ago, a patient was referred with a very severe orthopedic injury. She had recovered well from surgery and was making significant progress. Suddenly, the physical therapist reported that she had become sullen, withdrawn and was often late for physical therapy if she came at all.

The physical therapist told this to the surgeon who, in turn, suspected that the patient was depressed due to pain and referred her to me.

The patient was, indeed, depressed, and to some degree it was due to pain. However, the true cause of her depression was that in one return visit, on a day when the surgeon was particularly busy, he had responded brusquely with words to the effect "look, you are going to have to prepare yourself...you are never going to be like you were...in fact, you may not get much better at all, and with age, things could get worse." With that, he went on to the next patient.

From a clinical standpoint, he likely was conveying a very accurate summary of the patient's plight. From the standpoint of patient preparedness, it was definitely off the mark. The patient was prepared to hear that "it was a serious injury, and there will be limitations, but I need you to put every effort into your rehabilitation."

I have seen the opposite in which the patient begins to believe that he/she is doing something wrong because no matter how hard, and for how long, they work, they just do not seem to improve. They have not been adequately prepared for the chronic nature of their complaints so they falsely believe that complete recovery is probable.

Any change in the patient's level of motivation should call into question what they have been told, have been led to believe or have begun to suspect regarding their ultimate level of recovery. Importantly, they often do not tell surgeon, friends, family or case manager the reason for their sudden pessimism.

Most often, however, the patient will share these concerns with a third party if directly asked "what have you been told about your ultimate level of recovery."

Monday, July 23, 2007

Dr. Adams� Case Management Update
This is the 445th Weekly Issue

This Week's Topic:� "The Gift Horse"

Q^uestion:
"There must be some patients that you feel should have never been referred, right?'"

D^{r.
Adams replies:}

I strongly believe that any lost time injured worker should be referred for evaluation if they are 3-6 months post injury and not progressing. There are unquestionably factors that are impacting this patient, and just as obviously, no one as yet knows how to address them or even what they are.

However, I very often am referred patients for care simply because the authorized treating physician believes: a. the patient is depressed and b. since he/she is depressed, they can. therefore, benefit from psychological care.

The reality is that there are a substantial number of lost-time cases for whom psychological care (as well as physical therapy or even routine medical visits) are incorporated into their lives as "recreation."

These are bored, lonely and empty individuals who once filled their time with work, family and recreation. Now they spend endless, meaningless days, often uncomfortable and having few financial resources to permit them to entertain themselves.

They eagerly accept a psychological referral because "it is somebody to talk to," but it is very quickly obvious that they see their appointments as a way of leisurely way of spending their surplus time. They do not understand the purpose, do not invest energy into the process and are not pusuing goals. They are not seeking to understand and resolve conflicts; they are simply looking for companionship.

These are, of course, also the patients who wind up in open-ended psychological care without productive change.

It is very difficult to communicate this to the authorized treating physician, the nurse case manger or adjustor; all of whom make the referral in good faith. They had not considered that the patient is actually not in conflict. They are not truly anxious or depressed. They are simply leading empty and meaningless lives, and for this group, psychological care may not be of value.

Monday, July 16, 2007

Dr. Adams� Case Management Update
This is the 444th Weekly Issue

This Week's Topic: "The Referral That Comes Too Late"

Q^uestion:

"I gather that you believe that everyone can benefit from psychological care.'"

D^{r.
Adams replies:}

That would be naive of me since 80% of those who need care, never seek it. And many who seek it, do not benefit.

Most patients who are referred to my office have been out of work for 6+ months. The referral question is often a. is the patient depressed; b. are there issues of secondary gain; c. does this patient have PTSD, or d. is this patient a candidate for surgery or SCS implant.

However, what I often find upon examination is a de-conditioned person with marginal education and job skills. Often there is a history of arrest ranging from DUI to spousal abuse and more.

There may have been frequent job changes without a specific career track. The patient feels that the injury was preventable, coworkers were to blame, and that the �unsympathetic� employer obstructed access to quality care.

To these patients, the primary provider is seen as a tool of the insurer, and they believe their attorney is competent to choose physicians, specialties and procedures.

The patient�s days are spent tracking numerous medications, often supplementing them with recreational and prescription drugs from family and friends. These may be mixed with alcohol. There is poor quality of sleep at night, napping during the day, no exercise, a high caffeine intake and impressive nicotine dependence.

While the patient may once have needed psychological care in order to return to work, such care may have been obstructed, or the referral was not made to a skilled clinician. The resultant care may span many months without productive change while the patient continues to deteriorate. As income dwindles, others advise the patient to maximize complaints toward the goal of a larger financial outcome.

Monday, July 9, 2007

Dr. Adams� Case Management Update
This is the 443rd Weekly Issue

This Week's Topic: "The Alcoholic Claimant"

Q^uestion:

"My client was injured in a work-related fall. He now drinks somewhat heavily to cope with the pain. I need someone to step forward and say that his drinking is a direct result of that fall.'"

D^{r.
Adams replies:}

Alcohol dependence and abuse are considered primary mental disorders. There may be a mood disorder (Cf. depression) or a somatoform disorder (Cf. pain) existing concurrently with the alcoholism. The major depression is, for example, considered a co-morbid diagnosis.

However, alcoholism cannot be the direct result of any injury. It is often referred to as a �disease� of choice. An injury (or divorce or financial hardship) can be an alcoholic�s excuse for his/her substance abuse, but it is not the cause.

The alcoholic�s plight is made worse by those who �enable� (reinforce, reward, support or even fail to confront the true nature) of the problem. Telling an alcoholic that his/her drinking is due to a spouse�s infidelity, for example, fails to address the very nature of that disorder.

It is very important to determine if someone taking narcotics is potentiating his/her pain medication with alcohol. This can be an exceedingly dangerous practice, and, at a minimum, merely adds one more chemical to the abuse picture.

An alcoholic injured worker may need to look at available sources for de-tox under his/her general health insurance. The patient unquestionably needs to be regularly involved in A.A. meetings and the family involved in related meetings.

We are of little benefit to injured workers when we fail to diagnosis a personal history, family history and current pattern of alcohol intake. The alcoholic very much wants us to ascribe causation to events and people outside him/herself, and we do a significant disservice to the patient if we fail to diagnose the true cause-effect relationship.

Monday, July 2, 2007

Dr. Adams� Case Management Update
This is the 442nd Weekly Issue

This Week's Topic: "It's all in their head"

Q^uestion:

"You appear to have a handle on why cases deteriorate. How about a summary.'"

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