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OBSTACLE TO RECOVERY
Once a worker is
injured, all that is required is prompt and appropriate medical care.
With such care the patient will respond predictably, and if capable of
returning to work, the patient will do so. Any other outcome is
illogical, improbable and not worthy of further consideration.
For an increasing number of injured workers, this rational statement
is not predictive of outcome. In fact, many patients do not return to
work when they reach maximum medical improvement. Patients do not
leave surgical care even though they are released. And patients often
do not comply with efforts to rehabilitate them and return them to
productivity.
This is not inexplicable, mystical or even unanticipated once you know
all the data that goes into a patient’s response to even the best
clinical care.
FACTORS THAT EXIST ON THE JOB
While we
refer to injuries as
accidents,
there are situations in which they are not, situations in which
coworkers, supervisors or aged/faulty/failing equipment contribute to
the occurrence of an injury. Additionally, preceding the injury there
is job discontent, rancor among coworkers, conflict with employers,
and resentment of supervisors. The injured worker sees the accident as
preventable. It is not infrequent that they see the accident as
deliberate. And equally as often they feel that their employer’s
response is not timely, supportive or the least bit caring. They
perceive that coworkers are enjoined not to speak with them, and that
they, the injured-worker, have become persona non grata. Aside from
their family and their attorney, they feel that they have no advocacy.
And until you understand this
context of injury,
rehabilitating the patient becomes improbable.
LOST TIME AND LOST JOB
Additionally, the patient is quite often told, most often
inaccurately, that if they make any attempts to return to that
employment, they will then be fired and be without recourse. This was
summed up well, recently, by a patient who received a call from the
employer stating that “you do not have to worry, you have caused us
great expense, but we have no intention of firing you.” Prior to the
call, the patient had never considered that outcome.
FAMILY HISTORY AND FAMILY RESPONSE
Borrowed from studies and treatment of alcoholism, the family quite
often
enables
disability in two distinct, yet critical, ways.
§ There
may be one or more family members who is spending, or has spent,
considerable time on disability. This serves as a role model not only
for remaining inactive to the passage of life but also a standard for
resentment of how the disability was managed, both by the employer and
by treating physicians.
§ The
often cited concept of secondary gain cannot be over-emphasized:
patients receive more attention, affection, relief from responsibility
and forgiveness for transgressions when they are demonstrably in pain
and/or have observable limitations.
These are crucial data, not readily noted in assessment of the
patient’s physical status nor sufficiently explored in most cases, yet
these factors can guide and determine the outcome of case management.
THE
MYTH OF PAIN TREATMENT
There needs to be grave concern for the patient who has access to not
only his/her own narcotics, but to narcotics of friends, family,
through more than one physician, via emergency room visits, and from
the streets. Even patients with a negative addictive history (yet with
a extended family history of addiction rarely explored), the problem
of medication abuse can become a central issue.
Dependence and abuse are not the only concerns. There are also the
disorders that arise from narcotic use, even at prescribed levels:
mood disorders, anxiety disorders, sleep disorders and sexual
dysfunction. Quite often the patient’s psychological complaints are
traced to the way the patient is (self-)medicated and the
idiosyncratic ways in which his/her nervous system responds to the
presence of narcotics.
A complicating issue is that large, complex and cumbersome medication
regimens in patients whose spouse’s control dispensing and/or in which
the patient has limited reading and comprehension leads to a lifestyle
in which the passage of the day is marked by awaiting the next
dosage(s) of the numerous agents to be taken. The other side effects
such as somnolence (drowsiness) and consequent napping as well as GI
distress, weakness, fatigue, and confusion result in further
preoccupation with bodily function.
THE
PATIENT WITHOUT ALTERNATIVES
Injuries are most common in high risk settings, often involving heavy
equipment and/or construction work. This work is often undertaken by
males who have learned to adjust to comparatively high income despite
lack of education. Such males have very traditional ways of
determining their masculine role. They are to be rough, tough and
sexually invulnerable. They now find that identity impugned by their
limitations/pain. Perceiving no alternative, they over-compensate by
aggressiveness toward doctors, case managers as well as family. They
often know, but dare not admit, that their masculinity was tenuously
based upon strenuous tasks. Remove that capacity, and their sexual
identity is, for them, lost.
THE
IRONY OF THE WINDFALL
Injured workers can be tragically short sighted. They believe, or are
led to believe, that administrative closure with financial settlement
will, in fact, improve the quality of their lives. Follow-up contact
with these patients reveals that their funds are rapidly depleted,
purchases unwisely made, and that indebtedness had become so great
that there was never the potential to financially recover.
AS
GOOD AS IT GETS
For a variety of reasons, when they are told by the surgeon that they
have reached maximum medical improvement, many/most patients fail to
incorporate that reality. This is further complicated when, rather
than being discharged, they are
turfed
to another provider rather than dismissed from care. When this occurs,
the patient’s erroneous belief that they will be “totally cured” is
again resurrected.
While these factors ultimately determine case outcome, they are
infrequently explored and utilized. |
