Monthly Archives: June 2015

June 18, 2015

Nancy’s super-simple guide to pain

Nancy Grover’s June 15 column on Work Comp Central is a super simple guide to pain for anyone who isn’t really interested in the latest science of neurophysiology — but who wants a basic understanding of how the science of pain is changing our view about how to treat it.

Nancy interviewed me and wrote her column after reading a white paper entitled Red Herrings and Medical Over-Diagnosis Drive Large Loss Workers’ Compensation Claims released by Lockton Companies.  I am one of the co-authors, along with Keith Rosenblum, senior risk consultant at Lockton Companies and Dr. David Ross, a Florida neurologist who is CEO of NeuroPAS Global,

Our goal was to draw attention to an issue that is driving UP costs for payers and driving DOWN quality and outcomes for patients.  In short, all of us (physicians and patients, claims payers, employers, lawyers, judges, etc.) have been getting seduced by the false certainty created by “objective findings” of diagnostic imaging, especially by MRIs.

Before proceeding with invasive procedures and expensive/risky surgeries (that often fail to relieve the pain or create worse problems), we really should be making a good faith effort to identify (and treat) other things that are either causing or worsening the patient’s distress.  Before that first cut is made — are we sure all soft tissue problems have been identified, and then treated by skilled professionals using evidence-based methods?   Have all emotional, psychological, and other human issues known to manifest as bodily distress been identified, and then treated by skilled professionals using evidence-based methods?

If you’re a WorkCompCentral subscriber, read Nancy’s excellent column Low Back Ache: A Pain in the Brain.  If you’re coming to the SIIA conference which is October 18-20 in Washington DC, plan to attend our session on Medical Red Herrings — I’ll see you there!   (SIIA = Self Insurance Institute of America)

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June 18, 2015

Pain-free without surgery — despite horrible-looking MRI

Sounds like at least one spine surgeon is in danger of working himself out of job.  Several years ago, David Hanscom, MD in Seattle developed an alternative to spine surgery called the Defined Organized Comprehensive Care (DOCC) program.  He says it helps people suffering with chronic back pain to calm down their nervous systems, starting with the anxiety and anger that chronic pain causes.  He offered the DOCC program to patients when he wasn’t sure that surgery was going to relieve their pain.  A lot of them got remarkably better — so better that they declared themselves pain-free.  The number of surgeries he did dropped, but his patient outcomes improved overall.  The non-surgical patients got better, and the surgical ones did too — because now he was only operating on the ones where it was crystal clear they needed the operation.

Then he took it up another notch.  Based on the success of the DOCC program, Dr. Hanscom decided to try using it to prepare people who had already been scheduled for surgery to have a smooth post-operative recovery.  We’re talking about people with horrible-looking MRIs that revealed structural problems entirely consistent with their symptoms.  The result has stunned and delighted him.  He says that more than 40 of these people have decided they don’t NEED surgery anymore after the DOCC program because their pain has pretty much gone away!   See more about this surprising development on his recent blog posting.

And if you work with people with back pain, or have the problem yourself, go to Dr. Hanscom’s website Back-in-Control.com and start calming down YOUR nervous system too.  The DOCC program is all laid out on the website — and it’s free.  All that’s needed is an open mind and the willingness to try a different path up and out of that deep hole.

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June 17, 2015

Communications Clarity Dept: Useful distinctions

I keep getting reminded how fuzzy words can be — and how much clarity matters to those of us who work across traditional boundaries between specialties, disciplines, or sectors of society.

We just submitted in a paper that will be presented at the McCrery-Pomeroy SSDI Solutions Conference on August 4 and then published later this year.    During the peer review process, it became clear that we, the authors, were confusing readers by using terms differently than they do:  “disability,” “early intervention,” and “recovery” .  So in our new and improved version of the paper, we began by making three key distinctions.  I offer them to YOU, in case they are useful.

Disability vs. Work Disability
According to the ADA, disabilities are impairments affecting major life functions (such as work).  In the world of employment and commercial insurance, work disability is absence from or lack of work attributed to a health condition.  Having a “disability” need not result in “work disability”, a core concept embodied in the Americans with Disabilities Act.   Similarly, having a health problem need not (and usually does not) result in work disability.

What this might mean for you:   Train yourself to add a modifier in front of the word “disability”, especially when you are working with someone in another organization or discipline.    I try to say “work disability” or “impairment disability”– because even if I define how I’m using the word “disability,” people LISTEN their habitual way. 

Medical Recovery vs. Functional Restoration
Medical recovery refers to the resolution (disappearance or remission) of the underlying pathological process.  Functional restoration refers to re-establishing the usual rhythm of participation in everyday life.  That means the ability to go about one’s regular daily business: performing necessary tasks and enjoyable activities at home and work, and participating fully in society.  Functional restoration does not necessarily require medical recovery.  It may include figuring out new ways to accomplish the stuff one needs or wants to do.  So function can be restored through rehabilitation (broadly defined), and can even include the successful use of assistive technology, adaptive equipment, and/or reasonable accommodation in the workplace.

What this might mean for you:   Remember to consider these two issues separately in every case.  In order for the affected individual to end up with an optimal outcome, especially when there’s not much to offer on the medical side, paying specific attention to functional restoration is important.

Early Intervention vs. Immediate Response
Our opportunity to influence the occupational outcome of an injury or illness episode DOESN’T really start the day a problem is reported, or the day YOU first get involved. The opportunity clock DOES start on the first day an affected individual stays home from work or admits to having difficulty working – because that is when the period of life disruption and uncertainty starts.    A pro-active work disability prevention program involves immediate response which begins within the first few days and no later than 6 or 8 weeks after onset.  This triggering event (and timeline) is different from the so-called early intervention used in many programs.  In general, those programs start from an administrative date:  claim notification,  date of referral or application for benefits, etc.  It is PATHETIC to see how LATE most referrals for early intervention are ACTUALLY made:  typically 6 or 9 months.   Naturally, the intervener WANTS to look responsive to the paying customer so they hop on the case promptly, within 48 or 72 hours. But hey:  Life moves at the speed of life, you guys, not administrative procedures.

What this might mean for you:   It is inappropriate to let anyone get away with counting from administrative dates — unless you are content with LOOKING responsive rather than BEING helpful.  On EVERY chart or file, keep an on-going record (at every visit or update) of how many days have elapsed since the episode began.  Also include data about how many days it typically takes someone with that particular condition to get back to work.  It will keep your and your collaborators’ feet to the fire.

Personally, when I’m doing my physician version of case management,  I use MDGuidelines.com to keep track of how long the episode SHOULD last, and a website called timeanddate.com to calculate elapsed time to date.   I put those numbers at the top of my reports. This keeps me and my customer REALLY aware of the passage of time, because otherwise, the days just keep slipping away — along with the individual’s chances of EVER going back to work.

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June 15, 2015

Introducing Dave Clarke MD & the Psychophysiological Disorders Society

I had the honor of meeting a innovator in medical CARE on Sunday:  David Clarke, MD, founder of the Psychophysiological Disorders Society.   He is a gastroenterologist by trade who has developed expertise in diagnosing and compassionately treating what he calls “stress illness”  — distressing symptoms and even physiological upsets  — without any actual evidence of disease.  Stress illness is an extreme version of the body expressing what is going on in the brain (upsetting thoughts, feelings, emotions, memories, etc.)  However, we are ALL familiar with the more common everyday versions of this same thing:  sweaty palms and butterflies in stomach when worried, blushing when embarrassed, diarrhea or constipation before or after a stressful event.  Although we don’t THINK of these things as the brain expressing itself through the body, that’s what it is.

Stress illness occurs for many reasons, but one of them is because other communications channels are blocked.  Long before I got my professional education, my family taught me that people who bottle up their feelings —  who won’t let themselves cry or be angry — are going to have those feelings leak out somewhere else.  It’s a form of pent-up tension..

Dr. Clarke’s book (and audio CD) are on Amazon, entitled “They Can’t Find Anything Wrong“.  You will find many case stories that illustrate (a) the power of stress to cause bodily dysfunction / symptoms; (b) the healing impact of simply noticing then acknowledging the contribution that stress is making to symptoms; and (c) the various sources of stress:  current life predicaments; childhood trauma; PTSD; anxiety and depression.  As Dr. Clarke said, some of his patients were “cured” as soon as he listened and ask questions until they SAW the connection — and accepted it.  Others needed to learn more — read a book or two, look things up on the web.  A third group needed to spend some time working with a good mental health professional to learn how to feel and release the pent-up stress, and then learn better ways to deal with the ups and downs of life.

There are several medical terms for this puzzle of distress without disease:   medically-unexplained physical symptoms (or MUPS), somatization, and functional disorder are among the most widely used.  They all describe cases in which the patient feels sick and is complaining of symptoms but there is no objective evidence of pathology .  Often, an organ or system is not functioning normally, but there is no sign of any disease process.  In other words the “doctors can’t find anything wrong!”

I wondered if there are any estimates for how frequently this occurs.  Turns out this type of disorder accounts for a surprisingly large fraction of all visits to doctor’s office — estimated by various researchers as 25 to 60%.

Maybe we should think of it this way:  Just like our facial expressions sometimes betray us even when we’re trying to keep a poker face — our bodies do the same thing.  The body is just another channel the mind / spirit / brain can use to express itself — whether we are aware of it or not, and whether we want it to or not!

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June 12, 2015

First-ever CDC-sponsored “disability prevention” event

Even if you missed it, you can still listen in to a milestone event:   the first-ever public webinar hosted by a federal government agency on the topic of “disability prevention.”   The umbrella hosting agency was the CDC (Centers for Disease Control) which is the main preventive health arm of the Federal government.

The webinar was actually put together and co-sponored by two specialized units buried deep inside the CDC:  the Center for Workers’ Compensation Studies and the Office for Total Worker Health within NIOSH (National Institute of Occupational Safety and Health).  It was an EXCELLENT kick-off  that I hope reflects a sea change and expansion of focus at NIOSH — and maybe eventually the CDC.

Two invited experts spoke about SECONDARY PREVENTION:  mitigating the impact of injuries and illnesses after they occur by preventing adverse consequences.   This is quite different from NIOSH’s traditional focus on PRIMARY prevention:  avoiding the injuries or illnesses in the first place.

The event wasn’t perfect.   Listen carefully and you’ll notice vocabulary problems — a signal that the speakers, the sponsors, and the audience are not yet quite on the same page.   Various people used the word “disability” to describe quite different  things.   For example,  some spoke about  preventing medical or anatomical problems:    obesity, diagnoses, symptoms, anatomic losses and impairments.   The invited outside speakers referred mostly to the dynamic impact of injuries/illnesses on everyday life:  loss of ability, activity limitations, work absence, loss of jobs and livelihoods, descent into a life of poverty and economic dependency.

The speakers’ POWERFUL AND FACT-FILLED presentations with many citations made the nature and extent of the problem of preventable adverse consequences of injuries very clear. They ALSO made it clear that these problems are NOT unique to workers’ compensation.  They are just EASIER to DETECT in comp because both medical AND wage replacement costs are captured in a single dataset.  Even the Q&A portion of the event featured good questions, pithy remarks, and revealing comments from listeners which led to stimulating dialogue.

The featured speakers were:

You can download pdf’s of the speakers’ powerpoint presentations at the end of the webinar.  If you would like a copy of the unedited transcript from the session, please email vqq3@cdc.gov.

Do make time to listen to it!  It will make you think.   Even though I attended the live event, I listened again because the VIIRPM was very high .  [VIIRPM = Very Important Information Rate Per Minute (smile) ].  Here’s a link to the webinar recording (audio plus slides)   https://nioshtwh.adobeconnect.com/p9law27cnd3/.

I’ve been wondering:   What do those vocabulary problems mean for us?  We need to agree on a lexicon, a shared language in which we use terms the same way across all Federal programs and our society (NIOSH, EEOC/ADA, ODEP, Social Security Disability, etc.)  I’ve already suggested a conference on this to the NIOSH people. In addition, we also need an even bigger term to cover ALL the preventable bad stuff that happens in so many domains of life  — and can turn what should have been a short-term hiccup in life into its ruination.   Here’s a laundry list of outcomes we want to avoid:  (a) preventable impairment and functional loss (due to inadequate or ineffective treatment), (b) preventable secondary medical conditions (such as obesity and depression); (c)  iatrogenic illness (such as opioid addiction and drug side effects); (d) over-disabling (due to false beliefs and lack of patient education), (e) avoidable job loss and withdrawal from the workforce, and (f) people leading purposeless lives of social isolation, economic dependency, and poverty who COULD be participating fully in human life!  These are the poison fruits of a system whose gaps and holes reflect a lack of commitment to assuring that the right things happen when a working person’s life is disrupted by injury or illness — no matter the cause.  So, we also need a big term to describe what we DO want to happen, and the better outcomes we want.

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June 8, 2015

Two worthwhile conferences in Chicago this week

Two conferences on worthy topics are going on simultaneously in Chicago this week.   One is a first-time event on a topic that deserves more attention:  the special workplace risks faced by workers with disabilities and their employer’s responsibilities under OSHA and the ADA.  The other is a 35th annual workers’ compensation and occupational medicine event that delivers high quality programs every year.  The profile of attendees at the two conferences also will probably be quite different.  Which one will expand your horizons and be most useful in your career or your service to clients?  Read on, learn more, and take your pick — if you can get to Chicago this week!

To my knowledge, a conference on Promoting Health & Safety for Workers with Disabilities being held on June 9 in Chicago may be the first of its kind.  It explores the implications of the Americans with Disabilities Act (as amended) for workplace safety and health programs.  I predict this will be the bottom line:  Individualized protection plans are a natural part of “reasonable accommodation” — and the need for them should be part of any template for the interactive process.

Beth Marks, RN, PhD, came up with the idea and is the main organizer of the event. Originally trained as a nurse, she believes that people with disabilities who are trying to lead full lives and work deserve support.  She also has personal familiarity with the kinds of unusual workplace hazards faced by workers with vulnerabilities.  Among her many roles, she is co-Director of the National Organization of Nurse with Disabilities (NOND.org)

This event is being hosted by the NIOSH-funded ERC and the NIDRR-funded RRTC at UIC.  It is being co-sponsored by a unique set of organizations:  unions, disability advocacy groups, medical centers and other ERCs,  (Pardon the acronyms:  To fully disclose who is hosting it: the Illinois Occupational and Environmental Health & Safety Education and Research Center funded by the National Institute of Occupational Safety and Health in the School of Public Health at the University of Illinois at Chicago  in collaboration with the Rehabilitation Research and Training Center on Developmental Disabilities and Health in the Department of Disability and Human Development in the College of Applied Sciences at the University of Illinois at Chicago.  Now, is that better? )

The second event is the 35th Annual SEAK Conference on Workers’ Compensation and Occupational Medicine.   Historically held on Cape Cod every summer, this SEAK meeting is being held in Chicago this year while the Massachusetts conference facility is being remodeled.   I have attended, spoken at, and conducted all-day workshops at this annual event many times.  It is an information-rich but not overly academic learning opportunity.  That’s because the focus is on practical application:  how to use information or how to do something important. (SEAK also offers other educational events on more specialized topics.)  The speakers come from a variety of disciplines (medicine, nursing — especially case management, law — including judges, and insurance).  They tend to have deep expertise in their topics, and the pace is lively.  The focus is mostly on the mechanics of workers’ compensation, with less emphasis on wellness, prevention, safety, large issues of social justice, etc.

If you decide to go to one of these events, please let me know which one you attended — and whether it was worth your while!

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June 5, 2015

A find! Free on-line course for patients with stress, pain & chronic illness

I spent hours yesterday on the web looking for some more self-development resources for our Maze-Masters clients.  By total chance, I fell upon a FREE ON-LINE VERSION of the famed 8 week Mindfulness Based Stress Reduction Program (MBSR) developed at the University of Massachusetts.  The developer is Dave Potter, a  generous psychotherapist from Idaho who is certified as a MBSR trainer by the UMass Center.     He had to make adaptations in going from a face to face classroom experience to an individual on-line one.   In so doing, he has compiled both the resources used in the course along with others — a rich array of videos and writings from some genuinely world-renowned experts.  They include Jon Kabat-Zinn who created the original UMass program, and many other teachers of mindfulness meditation, body awareness and yoga, and stress management.

As Dave says, MBSR does not “cure” serious medical conditions.  It is an evidence-based intervention.   A doctor can recommend it to a patient and formally “order” it as part of the medical treatment.  But the patient can just go get it themselves, too.   A large and growing body of research indicates the specific techniques taught in the program – when practiced regularly —  can have a significant therapeutic effect for those experiencing stress, anxiety, high blood pressure, depression, chronic pain, migraines, heart conditions, diabetes and other ailments.   Overall, participants say that they feel better:  their symptoms interfere less with their daily lives, and they feel more alive and more “in-tune” with themselves and others.

As the caption to Dave’s smiling photo says, “Even if you don’t intend to take the course, I hope you take advantage of some of the wonderful videos and articles offered freely on the free Palouse Mindfulness MBSR course website site.”

This discovery is GREAT from my point of view  because we have SO MUCH TROUBLE getting payers to shell out for books, videos and other instructional materials for our Maze-Masters clients.  These are out of pocket costs — on top of our time spent finding and getting the materials to the clients and talking with them to make sure they “got it.”   Have you noticed that at conferences, everyone TALKS piously about how important patient education is.  Well, baby, I’m here to tell you the payers AIN’T putting their money where their mouths are — yet!

By the way, in case you’re not aware, there are now established CPT codes that SHOULD allow providers to bill for (a) out of pocket costs paid for educational materials  and (b) delivering structured patient education programs.    In my limited personal experience, these are not yet being use routinely  — neither billed OR paid in the “real world”.  If you HAVE seen them in use, that’s EXCITING NEWS!  Please let me know who, what, where, when, why —  and under what circumstances!

 

 

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June 5, 2015

Why aren’t we saying and doing THESE THINGS about the ADA?

I’ve been listening to the prevailing conversation about the Americans with Disabilities Act, as amended (ADA), in workers’ comp and disability benefits circles. Most often it has a negative tone: the ADA imposes obligations and creates complicated legal dances that can get us in trouble unless we do things exactly right. I almost never hear ANYONE in these industries (other than disability rights advocates) talking about what we can do to FULFILL the social purposes for which that law was created!

I am also a member of the US Dept of Labor’s Stay-at-Work and Return-to-Work Policy Collaborative, As a result, I met the EEOC‘s Senior Legal Counsel Aaron Konopasky, PhD, JD.  He opened my eyes to the fact that the ADA now applies MUCH EARLIER and MORE FREQUENTLY in health-related employment disruptions (both workers’ compensation and short / long-disability benefits cases) than has traditionally been thought. (See the mini-white paper Aaron and I co-authored on this issue.)

Seems like one of the key purposes of workers’ comp and disability benefits programs SHOULD BE to help workers who get injured or sick or who lose functional ability over time to KEEP THEIR JOBS / LIVELIHOODS and if needed, FIND NEW WAYS TO EARN A LIVING appropriate for their changed capabilities so they can MAINTAIN THEIR ECONOMIC INDEPENDENCE.  If that is so, then it seems like EMPLOYMENT OUTCOMES should be included in the metrics by which effectiveness / success / value of these programs is measured.   (I don’t see this being done now — do you?)

Now let’s look at the flip side:  bad outcomes.  (more…)

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