The problems encountered in the course of recovery.
What is it that happens as cases begin to span many months, if not years…what are these patients looking for? As time passes, patients do not become more acceptant of their limitations. Quite often, their resistance to accepting permanent and partial disability increases. They see their financial, marital and social situation deteriorate. With the passage of time, they perceive that they need more and different care, not less, and they need more financial compensation, not closure. Also, not surprisingly, their financial and marital plight worsens. The problem originates early in case management. When a patient is post-surgical and clinically optimal, yet care is continued because the patient continues to have pain complaints, the patient becomes conditioned to a series of new trials, new attempts, and often a procession of physicians. Their life becomes a schedule of various visits, therapies and often a drug regimen that ...
Take as an example, an injured worker who is prescribed hydrocodone twice daily. He does not seem to be abusing it; but he is dependent upon it. But lately he has been surly, nasty, hostile and verbally abusive when I talk to him. The abuse may not be of the hydrocodone per se but of the combination of hydrocodone and alcohol. Alcohol can potentiate not only the effects of hydrocodone but also its mood-related side effects such as irritability. Staying home all day, inactive, mobile only when physical therapy or monthly doctor visits are required…it is easy to fall into the habit of drinking beer and watching television. This feeds upon itself. The first order of business would be to differentiate between what is pain…what is depression…and what is alcohol abuse for this type of patient. Although direct questioning is usually met with denial, here are ways of obtaining the data regarding what factors are causing the mood changes. ...
Injured workers are initially very aggressive in their compliance and urgency to return to work, but once they reach ~9 months post injury, they slow down, and after a year or so, it is difficult to move them forward regardless of injury. Too much time and too few perceived options are at the core. For the first year, an injured worker may belief that rehabilitation, even with surgery, will be brief. As the bills continue to come in, as the children still have needs, as their mate has to shoulder the financial burden, as their pain continues, they begin to habituate to doing very little with their days. Initially, they do home exercises and help around the house. Soon, they become discouraged, nap during the day, watch mindless TV, and they remain most often socially isolated. They begin to feel guilty, embittered, enraged, fearful and frustrated. This is expressed as irritability. It is not discussed with family or friends, and, indeed, friends ...
As they proceed toward settlement, an injured worker, at the very last moment, suddenly asks for another opinion, a change of providers or some other obstacle toward closure. Why do they consistently do this, and can it be predicted?” I am tempted to reply with “what else are they supposed to do?” What I mean is that very often these individuals have nothing to do once their “case” settles. They know that the money will not last, and they have established no future plans. After 1-3 years of living as a workers’ comp patient, they have little other meaning or direction to their lives. As anyone approaches a goal, the closer you get, the more anxiety you experience. This is why people fail to show for their own weddings, or why they back out of closing on the purchase of a home. Closure implies a commitment and acceptance of its long term implications. Closure is frightening for some individuals. Yes, it can, indeed, be ...
Clearly, this would seem not to be a clinical matter, merely a financial one. But I suspect that early settlements occur because an insurer or employer has found case management to be burdensome, unrewarding, unending and often punitive. Many insurers and employers perceive that ultimately the patient and his/her family solely want a monetary conclusion. While this may be true in some cases, my clinical experience is that insurers/employers (including adjustors/nurses) are not able to discern the patient’s goals and try to find a dollar amount that allows closure since the underlying goal appears elusive. Many patients want the unachievable: they “just want things back the way they were” (pre-injury status)… “want my life and my family back” … “want to go back to the work I did.” These often unattainable goals are often unrecognized and, therefore, never addressed. The patient languishes, all become frustrated, and the money ...
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