May 13, 2020

Safer “Re-Opening” for High Risk Workers & Households

Here is my current thinking about the public health implications of focusing exclusively on protective practices at work to manage the threat of COVID-19 in the workplace. Return-to-work plans really must be individualized — and doing so will save lives. In fact, the plans should be stratified by level of risk in three areas:

  1. the risk of exposure to the coronavirus posed by each worker’s specific job tasks / work environment; and
  2. the worker’s individualized risk of COVID-related death if they get infected; and
  3. their whole household’s risk of death if they get infected — because workers who do acquire infection at work will take it home.

Protective measures such as altered work practices, personal protective equipment, and so on are unlikely to be 100% effective due to transmission of the virus by people without any signs of illness. (Think of the asymptomatic but infected White House staffers who exposed others — despite daily testing). Some infected but asymptomatic workers may spread the coronavirus at work. The workers who catch it may be young and healthy, developing only mild illness. But there may be vulnerable family members or caregivers in their homes for whom infection then proves fatal. Other workers may be at much higher risk for a poor outcome due to a personal vulnerability, becoming critically ill or even dying from COVID-19.

Can we all agree that one of our major goals is to minimize preventable COVID-19-related deaths? We should be encouraging, incentivizing, or even requiring employers to make accommodations based on each worker’s total level of risk (level of exposure + personal risk factors + household members’ risk factors). And ideally those accommodations will include NOT returning workers at high risk to the physical workplace until all the kinks have been worked out and enough time has passed to assure all parties that COVID-19 is not being passed around among the workers.

Many local governments are allowing business re-opening to proceed without much articulation of the PRINCIPLES that should guide the re-opening. In my opinion, they should be explicitly advocating for an approach that appropriately considers and balances FOUR THINGS:

  • The importance of an industry or type of business to the well-being of the community;
  • Risk of exposure for the public during business operations – the customers of the businesses;
  • Risks of exposure to workers due to the inherent nature of the tasks and/or the built work environment – which sometimes cannot be eliminated entirely;
  • The vastly different consequences of infection, especially variability in the likelihood of critical illness and death, among various subgroups of the workforce (and the population as a whole).

Let’s start with a recap: Why was everyone requested/required to shut their businesses, stay home, practice social distancing, and wear PPE or face coverings in the first place? I believe it was:

  • To prevent unnecessary and excessive deaths by reducing contagion at work OR via community spread — in an effort to avoid overwhelming the health care system, especially with critically-ill and ventilator dependent patients;
  • To give the “experts” enough time to study the behavior of the virus / illness / pandemic and learn essential facts to guide future action in a wise direction.

By making the decision to reopen society, powerful people have silently made the decision to allow community infection to spread — at a measured pace — as the only practical way to achieve the herd immunity required to end this pandemic and social paralysis in less than a year. I actually agree that this is the best alternative we have. A vaccine is unlikely to be available quickly enough or be sufficiently effective to do it.

However, we MUST do it in the least dangerous/destructive way. We should allow infection to spread among the low risk part of the population WHILE EFFECTIVELY PROTECTING the high risk segments. Once a sufficient number of low risk households have become immune, they then become the “herd” that surrounds and protects the vulnerable subset which has not yet aquired immunity.

Personally, I find totally repugnant the argument that “business necessity” allows government and employers to turn a blind eye to the reality that exposure of Mama or Daddy at work can lead to death to Grandma, Granddaddy, or the chronically ill child back at home.

Over the last few weeks, the stark disparity in level of risk of death by age decile has become more and more apparent. Likewise, the specific comorbidities that increase risk have been increasingly sharply defined. That means we NOW HAVE the INFORMATION needed to STRATIFY RISK and should act accordingly. Here’s some key data from the Massachusetts COVID-19 dashboard as of May 10. (See the charts on pages 12 and 13 – which are also pasted below.)

  • Low risk of death: From ages 0-29 the risk is ZERO per 100,000, between the ages of 30-30 is 2 / 100,000, and age 40-49 is 5 / 100,000
  • Higher risk of death: age 50-59 is 18 / 100,000; age 60-69 is 60 / 100,000
  • HIGH risk of death: age 70-79 is 236 / 100,000; age 80+ is 1070 / 100,000

Virtually all of the deaths in Massachusetts — 98.4% — have occurred in cases where there was a pre-existing underlying risk — at least one of the conditions associated with fatal outcomes, including age. This data is based only on deaths for which investigations have been completely — somewhat more than half.

The R0 (risk of spread) is highest within households, with a secondary attack rate of 10% to 19%. In fact, the majority of all COVID-19 cases have been due to household spread.

o https://wwwnc.cdc.gov/eid/article/26/8/20-1274_article
o https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa450/5821281
o https://www.contagionlive.com/news/spouses-adults-covid-19-infection-household-member
o https://www.medrxiv.org/content/10.1101/2020.03.03.20028423v1.full.pdf
o https://www.medrxiv.org/content/10.1101/2020.04.11.20056010v1

I’m not arguing that employers should make invasive and potentially illegal inquiries into each worker’s health status and living situation – but rather that employers should be making accommodations to protect workers who are in a high risk category either because of their own risks or those in their household. And workers should have the RIGHT to refuse to work if they or their family members are actually at high risk without fear of losing their jobs – sort of like the FMLA.

So, for example, how about instituting these THREE steps at the employer’s front door on Day 1: (1) temperature; (2) symptom inquiries / questionnaire; (3) a very short and confidential risk screening questionnaire.

“Yes” answers on the symptom and/or risk screening questionnaires would then require a confidential (onsite or virtual) interview by a professional with medical training, possibly followed by a request for corroborating medical records or other documentation. Some medical expertise is required to evaluate and determine whether the risk is legitimate/realistic and to provide appropriate counseling. If risk factors are confirmed, counseling would be done according to a protocol. In a voluntary program, the counseling would prepare the worker to make a fully informed choice whether to reveal the risk to the employer and request an accommodation if necessary. In a mandatory program, the medical person would send a simple note certifying that “extraordinary precautions or other accommodations are warranted” or similar.

During the large scale return-to-work processes now getting underway, a key group is without any protections: people who feel well enough to work at the moment but are at unusually high risk for death in the event they DO get sick or injured. They are going to fall between the cracks of the social systems designed to protect sick, injured and disabled workers and their households. Employers have NO DUTY under OSHA to protect worker’s families (“the public”) from harm when workers acquire contagious diseases at work. In addition, no job / income protection will be available via either workers’ compensation, or commercial disability insurance or FMLA — because an “at risk” employee has no diagnosis/ no illness keeping them from working (yet). Those protections only begin once the horse is out of the barn. A grieving family’s only recourse will be the tort system, and the Congress or state legislatures may well pass a law relieving the employers from even that liability. And I seriously doubt that being currently able to function but at high risk for death if infected with this particular virus would qualify one as a person with a disability.

I guess my real beef is with overly-simplistic thinking at all levels of our government with regard to plans for the re-opening phase. I hope that occupational medicine physicians who have the ear of the public health authorities in their states will raise this issue loudly. Everyone needs to sit around a table and figure out how to INTELLIGENTLY open business AND allow workers to protect themselves and their vulnerable family members at THE SAME TIME.

Surely, creative thinkers in combination with expert science communicators and practical program designers should be able to team up, figure out a good way to do this, then request a hearing with people in power — and proopse a comprehensive re-opening plan that makes good sense from BOTH a public health AND an economic perspective!

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May 10, 2020

Webinar: Strategic Approach to Large Scale RTW

I am moderating a panel of experts in a free ACOEM webinar on Wednesday May 13 entitled “COVID-19: Preparing for Large Scale Return to Work – A Strategic and Pro-Active Approach”.

The event begins at 12 noon Eastern, and is open to the public at no charge. It is intended especially for physicians and other professionals to whom workers and/or employers will turn for guidance. It will be recorded and accessible for later listening. This is the latest in a growing series of ACOEM webinars focused on various aspects of the pandemic.

The 5/13 webinar focuses on “the big picture” of re-opening. It will identify several predictable challenges — other than the obvious need for rational testing and personal protective practices — that are likely to arise for individual workers as well as their employers as large numbers of people are returning to work, more or less simultaneously.

The webinar will also highlight several specific issues that deserve careful consideration to determine the best course of action. Thinking ahead, clarifying priorities, and making detailed plans for how various aspects will go — as well as making some contingency plans “just in case” — will minimize needless distress, disruption, and illness, thus enabling the orderly return to work as well as to productivity and cash flow for everyone involved.

HERE ARE THE DETAILS:

Reserve Your Spot For This Free Webinar

COVID-19: Preparing for Large Scale Return to Work — A Strategic and Proactive Approach
Wednesday, May 13, 2020; 11:00 am CDT
60 minutes, plus optional bonus period of 30 minutes for additional Q&A

The discussion will focus on the planning and preparations required to: a) set up and manage practical, orderly re-entry procedures; b) manage predictable and reasonable human concerns; c) respond to mental distress and in appropriate behavior; and d) set realistic expectations for workers transitioning from inactivity back to full productivity.

As a result of attending this webinar, attendees will be able to alert workers and employers to predictable issues that may arise during the re-opening and simultaneous large scale return-to-work process and provide strategic guidance on how to manage those issues from their perspective. Attendees will also be prepared to counsel and empower both workers or employers to minimize distress and disruption by taking a positive pro-active approach to their own behavior and responsibilities during this period.

This webinar is co-sponsored by ACOEM’s Work Fitness & Disability and Behavioral Health Sections.

Moderator:
Jennifer Christian, MD, MPH, FACOEM
Chair, ACOEM Work Fitness & Disability Section
Occupational Medicine, Webility Corporation, Wayland, MA

Faculty:
Gaurava Agarwal, MD
Chair, ACOEM Behavioral Health Section
Director of Physician Well-Being, Northwestern Medical Group, Chicago, IL

Robert Orford, MD, MPH, MS, FACOEM
Preventive/Occupational Medicine, Mayo Clinic, Scottsdale, AZ

Elliot Rosenberg, MD, MPH
Public Health/Occupational Medicine, Ministry of Health, Government of Israel

Joel Axler, MD
Psychiatry, Strategic Benefit Advisors, Southborough, MA

Rana DeBoer, MS
Chief Culture Officer, City of Sioux Falls, SD

The deadline to register for this open-to-the-public webinar
is Tuesday, May 12, at 4:00 pm CDT

For more information, visit our website.

ACOEM | 847.818.1800 | custinfo@acoem.org | www.acoem.org

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April 17, 2020

Stop COVID-19: Get a mask on every face!

If you’d like to pitch in to help stop COVID-19, we’ve just launched a new website called Everyone Gets a Mask! that has all the stuff you need to do these things:

  1. Organize a team project to make and distribute large numbers of high quality homemade cloth masks to everyone in YOUR community* (in coordination with other local groups as necessary), OR ……
  2. Find and join an existing group doing something similar, OR ……
  3. Make a few masks for you and your family.

Q: Why is NOW the right time for you to take action?
A: It is now clear that COVID-19 is often spread by people who feel fine and don’t even know they are infected — and who are simply breathing, talking, laughing or singing! None of us want to be unwitting spreaders. On April 3, the US Centers for Disease Control (the CDC) recommended a step-up in protection in areas where there is COVID-19 activity: wearing cloth face coverings when out and about (in addition to social distancing, hand-washing, surface-cleaning, and covering coughs and sneezes).

Q: What needs to happen?
A: Over the next few weeks, our country needs to get cloth masks on the faces of almost everyone in every community* affected by COVID-19. Some people can’t wear masks, so we’ll never get to 100%. Experts predict that when 60% to 80% of us are wearing masks, as well as doing the other preventive practices, we will be able to slow or even stop the pandemic.

Q: Why cloth face masks?
A: Homemade cloth masks provide a lot better protection than none at all! As long as there is a shortage of manufactured surgical masks and N95 respirators, they must be saved for healthcare and emergency response workers. High quality cloth face masks filter much more effectively than poor quality ones. Everyone Gets a Mask! has technical specifications to guide you.

Q: Can masks do more than prevent infection?
A: Yes. They are a visible signal of unity and good will — concrete evidence that the wearer is caring for others in these hard times: “I am protecting you; you are protecting me.”

If you like these ideas, please check out the Everyone Gets a Mask! website then help this concept go viral by passing it along to people of good will – in your community* AND all around the country. The website was created as a gift to you, your family and friends, and your community* by a three-person team: Claudia Hix DO, David Siktberg MBA, and me, Jennifer Christian, MD.

* When we say your community, think of everyone in it:
• All the people in your family, neighborhood, company, club, congregation, civic organization, town or even county, including those who will be heading back to work in the next few weeks;
• Plus those who come to work in your area — especially those who provide essential services (who work in healthcare facilities, public safety and emergency response, grocery stores and pharmacies, delivery services, utilities, etc.), as well those who will be heading back to work;
• And the elderly or other individuals with risk factors that put them at higher risk of severe COVID-19 illness.

Remember: Over the next few weeks, our country needs to get cloth masks on the faces of almost everyone in every community affected by COVID-19. So please pass along this posting — or just the link (Everyone Gets a Mask! or www.webility.md/masks) — to as many colleagues, friends, family and organizations as possible in communities around the country. This applies – to those in areas that are experiencing the full fury of COVID-19, and those where the curve is clearly rising or may still rise.

And please tell us if you see something that could be clarified or improved – or share a story about what you have done with the website or the kit itself! We’ve already made a lot of changes based in input from others. Email us at masks@webility.md

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September 19, 2018

Over-dramatizing chronic pain isn’t helping much

The most recent MMWR report on the prevalence of chronic pain from the US Centers for Disease Control (CDC)  continues today’s unfortunate trend of over-dramatizing chronic pain and feeding the frenzy that sends the message “this is horrible; medical science has gotta DO something for these poor people!”   There are simply NOT 20 million people in the USA suffering constant agony from debilitating chronic pain.  There ARE a lot of people with chronic aches and pains, and most of them are coping with it just fine, thank you.

The two crude questions that the survey asked people to answer -– and the way their answers were interpreted, especially the way they defined “high impact pain” -– makes pain look like a bigger impediment to a good life than it actually is -– for most people.  And, more importantly, I believe the list of questions failed to identify the group that most desperately needs better help.

Information about pain was collected through responses to these two questions:

  1. “In the past six months, how often did you have pain? Would you say never, some days, most days, or every day?”
  2. “Over the past six months, how often did pain limit your life or work activities? Would you say never, some days, most days, or every day?”

Chronic pain was defined as pain on most days or every day in the past 6 months. High-impact chronic pain was defined as chronic pain that limited life or work activities on most days or every day during the past 6 months

Aches and pains, both short-lived and long-lasting are an unavoidable part of everyday life. Acute pains are the result of being out and about, being active, and using the body like it is designed to be used — exercising muscles harder than usual, dropping something on your toe, tripping over a curb, or getting a sore throat or a tension headache. Chronic pains are usually the residual of various kinds of accidents, illnesses, traumatic events and other untoward events in life — including the progress of aging.

To me, that means PAIN as well as LOSS — and adapting to them — are “natural” consequences of being alive. How many people who have lived a full and eventful life have no “scars” or “tricky joints” of any kind to show for it? How many old people have you met who DON’T have any aches and pains? The question is: how do we view our pain, how do we manage it, and how have we adapted to it?

I, for example, am old. And I meet the CDC’s criteria for chronic pain, and even for “high impact” chronic pain. I have some pain in the joints of my hands and feet due to age-related osteoarthritis — with maybe some extra wear and tear on my feet due to several years on tiptoe and in toe shoes as a dancer more 50 years ago!  My fingers and toes ache virtually every day, especially when I move them a certain way or use them a lot — or I part my hair on the wrong side 🙂

The range of motion in some of my fingers and toes is limited. Sometimes a nerve gets caught on something inside my foot — which suddenly creates a searing stabbing pain – which hurts like stink. My stiff, increasingly deformed, and chronically achy finger joints have certainly affected my ability to use my hands for forceful pinching and gripping. I have also had to adjust the kind of shoes I buy, and sometimes I have to avoid walking long distances — on those days when my feet really hurt. Sometimes, the numb, burning sensation in my forefoot forces me to limp. When it gets too bad, I have to stop walking and attempt to “readjust” the position of the structures inside my foot. A successful adjustment is accompanied by a clicking sensation and a sharp searing needle-like pain, and then complete and sudden relief.

However, I don’t believe I’ve ever taken an aspirin or tylenol because of my chronic joint pain. I have not gone to a doctor about it because my discomfort is quite tolerable, the extreme pain is very occasional, and I have no need to do a lot of physically-demanding walking or gripping. And I am certainly not interested in surgery – I see little point in allowing someone to muck around in the complex structures of an old arthritic foot that is going to continue to get MORE arthritic due to natural processes.

In short, I am quite able to work around my chronic pain. I have adapted to it, and quietly and without (much) whining made adjustments in what I do and how I live. Perhaps others would not approve of my personal adaptation strategy — I’m awfully sedentary — but it is working for me. My pain is NOT dominating my life, is NOT the main focus of my attention, and is NOT sucking the joy out of my existence. In fact, I am really enjoying my life as it is.

The people whose pain IS dominating their lives, IS the main focus of their attention, and IS sucking the joy out of their existence are the ones who most desperately need help. And maybe what they need most is a re-orientation – to make LIFE the point of their life and learn techniques for how to control their own symptoms and put pain on the back burner of their brain — instead of keeping it on the front burner as a blinking red bad and pressing problem that must be solved.

So, personally, I think we should stop talking about pain and loss as though they are terrible things that shouldn’t BE — and instead make it clear that the job in front of us is to learn how to (1) adapt to and cope successfully with the unavoidable and unpleasant things that happen while we are alive, AND (2) find ways to minimize their impact on our everyday experience by focusing our energies on creating a good life anyway.

Over the last several years, I have been following the science of pain treatment and collecting tools and resources that can help people learn how to achieve a victory over their chronic pain.  Among many other techniques, acceptance and commitment therapy (or ACT) seems to be a very promising technique in this regard.  So are several other techniques that help people who are stuck living with pain give up on being angry at it or trying to “get rid” of it.  That’s because our brains are arranged so that what we pay attention to stays on the front burner.  What we resist persists.

The American Chronic Pain Association’s website has a wide array of free and low cost resources for people living with chronic pain and who want to move “from patient to person” again.   Among my favorites are the ACPA’s Ten Steps From Patient to Person and the ACPA Resource Guide to Chronic Pain Management which begins with self-directed therapies.  The ACPA also has a network of chronic pain support groups in local areas.

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June 23, 2018

Don’t miss out! RETAIN grants are a big opportunity

RETAIN is a five year and $100 million Federal Grant program that state agencies must nominally lead.  However, the leadership team must be multi-stakeholder and include an organization that actually delivers hands-on medical care.  Moreover, the states will probably end up contracting for delivery of the many services by individuals or organizations in the private sector. Proposals are due in ONE MONTH – so if you’re tempted to get involved, join our list-serv now and learn what you need to do!  See more below.

RETAIN is the biggest opportunity for physicians who practice occupational medicine since the 1970’s — when NIOSH and OSHA were established. It’s also a huge opportunity for other professionals with expertise in preventing needless work disability during the early phase of the stay-at-work/return-to-work (SAW/RTW) process:  the first few weeks and months of an injury/illness episode.

RETAIN requires states to get involved VERY EARLY in new injury and illness episodes among workers they haven’t had on their radar — and arrange provision of several kinds of services with which these agencies have had little/no familiarity. Most of the state agencies that received the RFP (and must lead RETAIN in their state) have been confused and caught flat-footed by it. They really need professionals with expertise at the interface between healthcare and the workplace to pitch in at several levels:

– to help NOW with project design and proposal writing
– once the project launches, to help oversee, manage and tweak the project at the top level,
– in individual cases, to deliver specific services during the first weeks and months of work interruption. (In fact, eligibility for RETAIN program services ends after 6 months of work absence.)

I’ve set up a free list-serv for everyone who is interested in the possibility of getting involved with their state’s RETAIN project. My personal goal is to help as many states as possible to recruit appropriate leadership teams and write successful bids. The project is so unusual, I don’t think there will be many. The Feds plan to accept EIGHT bids (from eight states).

JOIN US — if you’re an occ doc or SAW/RTW professional who is willing to wade in, introduce yourself to strangers, and then join the small team that will be developing your state’s overall project design and writing its proposal (bid) between now and July 23. Once you join the list-serv, go to our website and read the small number of earlier and information-filled emails that will get you oriented and on the right track. You’ll find links to the RFP itself along with many other resources.

To join the RETAINers list-serv, go to https://groups.io/g/RETAINers and click on JOIN THIS GROUP

NOTE: Think big.  This is the beginning of an effort to knit together some holes in our social fabric to meet the needs of people who have been falling through the cracks.  The Feds are looking for proposals that will help workers with new health problems — regardless of what caused them.  The point is to help ANY worker for whom a new health condition is causing work interruption and, if the right things fail to happen, could threaten their job. Needlessly losing one’s livelihood and ending up on SSDI is a very poor outcome of a health condition — ESPECIALLY when it didn’t need to happen.

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May 22, 2018

If you’re interested in RETAIN, let ODEP know today!!

Please be a bumble bee and pass along this pollen information to your contacts at the large healthcare delivery organizations in your area/state that have an outside-facing occupational medicine department. This email is about a strategic opportunity for any occ med program that can also benefit the larger organization in which it sits – as well as hundreds or thousands of newly-injured/ill workers and their employers in their area!  It is a VERY TIME SENSITIVE opportunity, so if you know an organization to whom this might appeal, take action right away.

Any party with a potential interest in some aspect of the RETAIN demonstration projects described below needs to send an email to the Office of Disability Employment Policy (ODEP) in the US Department of Labor. The email address is SAW-RTW@dol.gov, and the phone number is (202) 693-7880. Tell ODEP you want to be put on the mailing list for the RFP (request for proposals) for RETAIN. It is expected to be released in the next week or so, and the deadline for responses will be short — because the money must actually be awarded by the end of September.

There is $67 million dollars in the Federal budget for RETAIN, which will be a five year project. In order for RETAIN to be successful, each state agency that is awarded the money (and will dispense it) will have to contract with – and develop a real working relationship/operational partnership with — one or more entities in the healthcare delivery sector. In Phase 1, the project budget will be roughly $2 million, and in Phase 2, roughly $18 million for each state that participates in the project. The Feds are hoping to award money to EIGHT states for Phase 1, and to FOUR states for Phase 2 – based on their success at getting themselves in position to deliver a successful demonstration.

A healthcare delivery organization you know might be an IDEAL setting for the new organization that will play a central role in the demonstration project. In Washington state, where this model was originally developed, tested, and proved successful, these new organizations are called Centers of Occupational Health & Education or COHEs. The purpose of these demonstration projects is to test a model of COHE-driven early intervention that delivers some simple and proven best practices known to help working people keep their jobs during recovery from an illness or injury that has recently disrupted their ability to work. The ultimate purpose is to reduce the number of rare and unusually poor outcomes: job loss with subsequent entry onto publicly-funded disability programs, especially Social Security Disability Insurance (SSDI). Studies have shown that the COHE program in Washington has improved almost every possible medical, claim, and employment outcome, including reducing inflow onto permanent disability programs by more than 25%.

I hope you will see the opportunity that RETAIN offers a local healthcare delivery system: to establish their organization as a highly visible and forward-thinking leader in occupational health – one that goes beyond delivering effective medical care for work-related injuries by ALSO minimizing some specific adverse secondary consequences of injuries and illnesses that today worsen outcomes and jeopardize too many working people’s lives and livelihoods! …..iIncluding (potentially) working people with non-occupational injuries and illnesses. More employers and workers are likely to choose to use an organization that enhances its services and thus its reputation for practical usefulness in this way.

A very brief description of RETAIN appears on page 6-7 of a Pre-Announcement of Upcoming Competitive Funding Opportunities which forecasts the release of several RFP’s (requests for proposals). I’ve also pasted the text about RETAIN from the Pre-Announcement below.

I’d LOVE to see YOUR state be one of the bidders, be selected, and then execute a resoundingly successful demonstration of this intervention model – because I see the need for it so clearly and trust the solid evidence that underpins it. You may already be aware that, as part of a Capitol Hill initiative to generate ideas for protecting SSDI, I led the development of a policy proposal that served as a source for this project. I was thrilled to tears when I got the phone call telling me it had become a Federal budget item, and have been following its evolution ever since. I am well known among some key players at the Federal level, since I was a member of the Stay-at-Work/Return-to-Work Collaborative sponsored by the Office of Disability Employment Policy (ODEP) at the US Department of Labor. ODEP will be administering/ overseeing the RETAIN demonstration project.

I can send you more detailed information now about the probable design of RETAIN if you’re interested. TIME IS OF THE ESSENCE if there’s ANY chance you or your colleagues or other organizations in your professional network or community might want to play. Send an email to the Office of Disability Employment Policy (ODEP) in the US Department of Labor at SAW-RTW@dol.gov, or call them at (202) 693-7880. Tell ODEP you want to be put on the mailing list for the RFP for the RETAIN demonstration projects.

And of course, if you’d like to toss around some ideas or I can help you in any way, give a shout.

US Department of Labor – Employment and Training Administration (ETA)
Upcoming ETA Competitive Funding Opportunities
Excerpt from pages 6-7

RETAIN Demonstration Projects ~ $63 million
Anticipated Publication: Summer 2018
Awards Made: Fall 2018

The Office of Disability Employment Policy (ODEP), in collaboration with the ETA  [US Dept of Labor’s Employment and Training Administration] and the Social Security Administration plan to award approximately $55,000,000 to $63,000,000 in cooperative agreement funds to plan and conduct pilot demonstration projects called RETAIN – Retaining Employment and Talent after Injury/Illness. RETAIN demonstrations will test the impact of early intervention projects on stay-at-work/return-to-work (SAW/RTW) outcomes. Central to these projects is the early coordination of health care and employment-related supports and services to help injured or ill workers remain in the workforce. To accomplish this, successful applicants will provide services through an integrated network of partners that include close collaboration between state and/or local workforce development entities, health care systems and/or health care provider networks, and other partners as appropriate.

The RETAIN Demonstration will be structured and funded in two phases. The initial period of performance (Phase 1) will be 18 months and will include planning and start-up activities, including the launch of a small pilot demonstration no later than month nine. We expect to provide approximately $2,166,000 each to an estimated six state workforce agencies in the form of cooperative agreements for Phase 1. At the conclusion of the initial period of performance, a subset of up to three Phase 1 awardees will be competitively awarded supplemental funding of up to $18,600,000 to implement the demonstration projects during Phase 2. Awardees will be required to participate in an evaluation, which will be designed in Phase 1 and conducted during Phase 2 by an external, independent contractor.

The following organizations are eligible to apply:
• State Departments of Labor, State Workforce Development Agencies, or an equivalent entity with responsibility for labor, employment, and/or workforce development; and
• Entities described in section 166(c) of WIOA relating to Indian and Native American programs. These entities include Indian tribes, tribal organizations, Alaska Native entities, Indian-controlled organizations serving Indians, or Native Hawaiian organizations. These applicants are not required to partner with Local Workforce Development Boards (LWDBs).

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January 24, 2018

Normal people in difficult health situations benefit from psychological services

Research has now shown how the liberal use of opioid medications in the post-surgical setting can lead to long-term dependency on these drugs as well as the development of persistent disabling (chronic) pain. Therefore, we must find new and better ways to manage acute and sub-acute pain (particularly post-surgical pain). Researchers are in hot pursuit of that goal. One group did a review of existing literature to identify psychological treatments that help relieve post-surgical pain– up to 12 weeks afterwards.  (See reference and link below.)

Short answer: Yes to CBT (cognitive behavioral therapy).  However, none of the papers that evaluated the impact of other types of psychological treatment met the authors’ inclusion criteria.  (Not meeting criteria is simply a sign the methodology or size of the studies wasn’t solid enough — the techniques may actually be effective, but a rigorous standard of proof hasn’t been met.)

Implications for ALL professionals who interact with ill and injured people: We must must MUST stop sending the message (with the way we speak and behave) that CBT and other effective psychological treatments are only for “screwed up people” with mental illness diagnoses!!!!

Background and Perspective:  Many people who are suddenly faced with UNUSUAL EVENTS have NORMAL HUMAN REACTIONS to them that lead them to make unwise decisions that lead to worse-than-necessary outcomes.  The list of normal human reactions includes things like confusion, uncertainty, worry, distrust, head-in-sand, false beliefs, and wrong-headed impulsive decisions.

A sensible and compassionate way to look at that kind of behavior is this: Some people are ill-equipped to deal well with what life serves up to them at a particular moment in time. They may simply lack the understanding, information, and effective tool/techniques that other people have. There is NOTHING WRONG with these people.  There is simply something MISSING that could make a positive difference if supplied.

I suggest we start thinking about people dealing with acute post-surgical pain (and other unfamiliar health-related life events) as people who need to be FULLY EQUIPPED or PREPARED to deal with whatever it is.  And we, as the professionals who are responding to their predicaments, are in a better position to know what it is they DO need and ensure they DO get it.

Two analogies:  The best analogy I know is prenatal care and childbirth education. There is NOTHING WRONG with a woman who hasn’t had a baby before being ignorant about pregnancy, labor, and delivery . The data is clear that prenatal care and childbirth education improve both patient experience and outcomes. We don’t stop to WONDER whether a pregnant woman “needs” that education. We KNOW she does – unless she’s already an “expert”!

Another excellent analogy is the palliative and hospice care that aid people who are preparing for their own death. Since we humans only die once, most of us are not experts at going through the wrapping up period of life.  There is NOTHING WRONG with being afraid and ignorant about what is coming and how to handle it.  Research long ago proved that the biopsychosocial approach used in palliative and hospice care improves quality of life for both patient and family. And more recently, the evidence is accumulating that hospice care actually prolongs life!

Among other things, “palliative care” involves educating patients and their caregivers — so they feel less powerless, so they put the emphasis in the right places, so they are prepared, so they have simple methods and techniques at their disposal for managing symptoms and relieving distress. All of this gives them a sense of SOME control – which is tremendously important to people dealing with a process that cannot be stopped and an inevitable end.

And we can’t assume that having a college degree means a woman knows anything about having a baby, or living with a terminal illness, or managing acute post-surgical pain.  General literacy is NOT a guarantee of health literacy – but low general literacy is pretty much a guarantee of low health literacy as well.  (A person with good health literacy is fully equipped and prepared to deal  appropriately and effectively with the health matters they are facing.)

Suggested action steps:  Decide to help people in difficult situations acquire the knowledge and skills they need to cope well with their current / future predicaments — so they get the best possible outcome.   Take a pro-active approach so that people are routinely offered assistance.  Your job is to make it clear you expect them to take advantage of and actively participate. Explain to them why and how doing this will help them.

Where there is a will, there is a way.   If you are creative, you will be able to figure out how to accomplish these things simply, at low cost, and effectively.  For example, CBT treatment often takes just a handful of face to face appointments.  Nurses and physical therapists have been successfully trained to do education and employ CBT techniques in specific situations. There are on-line versions of almost everything these days.  Use your existing staff to  provide oversight, structure, and reinforcement to ensure adherence.

1. For post-operative pain:  Since pain following surgery is entirely predictable, please start thinking about how you can ensure that patients get enough information and actual instruction in effective self-pain control techniques and methods, including psychological ones, so they too have a sense of SOME control and reduce their own suffering — during that difficult post-surgical recovery period?

2. For painful and disabling new injuries or illnesses that are disrupting jobs / livelihoods.  For working people whose ability to do their usual jobs has been affected by a painful injury or illness, please start thinking how you can ensure that they get enough useful information and practical instruction in BOTH self-care for pain and functional rehabilitation, including psychological techniques.  These tools will allow them to gain a sense of SOME control over their recovery and their future —  and thus will be more likely to have a good outcome.

Please let me know what you decide to do and how it goes.

REFERENCE AND LINK

Psychological treatments for the management of postsurgical pain: a systematic review of randomized controlled trials.  Judith L Nicholls,1 Muhammad A Azam,1,2 Lindsay C Burns,1,2 Marina Englesakis,3, Ainsley M Sutherland,1 Aliza Z Weinrib,1,2 Joel Katz,1,2,4 Hance Clarke,1,4   in Patient-Related Outcome Measures, 19 January 2018 Volume 2018:9 Pages 49—64.
DOI https://doi.org/10.2147/PROM.S121251

Authors:   1Pain Research Unit, Department of Anesthesia and Pain Medicine, Toronto General Hospital, 2Department of Psychology, York University, 3Library and Information Services, University Health Network, 4Department of Anesthesia, University of Toronto, Toronto, ON, Canada

ABSTRACT

Background: Inadequately managed pain is a risk factor for chronic postsurgical pain (CPSP), a growing public health challenge. Multidisciplinary pain-management programs with psychological approaches, including cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based psychotherapy, have shown efficacy as treatments for chronic pain, and show promise as timely interventions in the pre/perioperative periods for the management of PSP. We reviewed the literature to identify randomized controlled trials evaluating the efficacy of these psychotherapy approaches on pain-related surgical outcomes.

Materials and methods: We searched Medline, Medline-In-Process, Embase and Embase Classic, and PsycInfo to identify studies meeting our search criteria. After title and abstract review, selected articles were rated for risk of bias.

Results: Six papers based on five trials (four back surgery, one cardiac surgery) met our inclusion criteria. Four papers employed CBT and two CBT-physiotherapy variant; no ACT or mindfulness-based studies were identified. Considerable heterogeneity was observed in the timing and delivery of psychological interventions and length of follow-up (1 week to 2–3 years). Whereas pain-intensity reporting varied widely, pain disability was reported using consistent methods across papers. The majority of papers (four of six) reported reduced pain intensity, and all relevant papers (five of five) found improvements in pain disability. General limitations included lack of large-scale data and difficulties with blinding.

Conclusion: This systematic review provides preliminary evidence that CBT-based psychological interventions reduce PSP intensity and disability. Future research should further clarify the efficacy and optimal delivery of CBT and newer psychological approaches to PSP.

Keywords: postsurgical pain, CBT, acute pain, chronic pain, chronic postsurgical pain, multidisciplinary pain management

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January 5, 2018

More empathy for suffering improves patient experience

I just ran across the story of Rana Awdish and her sudden, near-fatal medical catastrophe — which put her in the critical care unit and resulted in the death of her near-term unborn baby.  She is a physician and was in specialty training for critical care medicine at the time.  The experience taught her a lot about the nature of suffering.  It also showed her that human caring and empathy is too often missing in hospital care today.  The story appeared on the NPR website yesterday, entitled Brush With Death Leads Doctor to Focus on Patient Perspective. She’s just published a book about the experience and what it taught her.  The title is In Shock.

I found an essay of hers published in the New England Journal of Medicine a year ago entitled “A View from the Edge – Creating a Culture of Caring”. In it, she provides more facts about what happened, especially the way the hospital medical staff and other employees treated her while she was in the hospital.  She clearly had intense emotional suffering at the same time her body systems were failing and she was near death.  Sadly, it is also clear that the people taking care of her did a much better job of attending to her medical problems than her human ones.

In her recounting of the facts, she highlighted specific careless and hurtful remarks that she had overheard or that her physician colleagues had said to her face.  She also highlighted some examples of tender caring others had demonstrated during her hospital stay.  In her new position as Medical Director for Care Experience at the hospital, she has used those specific examples to improve the training for all employees, from physicians to housekeeping staff.

Reading the three paragraphs below transformed the essay for me; it went from worthwhile to sublime.

“Through the training that was developed, participants learn to articulate their purpose as distinct from their job. Transporters hear how meaningful it was to me when one of their own — having seen me break down when questioned by someone in radiology — took it upon himself to warn the technicians performing various tests not to ask about the baby whose small pink wristband was still in my chart. He asked his colleagues to do the same. In an 800-bed hospital, the transporters had united to form a protective enclosure around one patient.

“Similarly, radiology technicians learn what a kindness it was that they stopped trying to awaken my exhausted husband to move him from my bedside for my portable x-ray, instead throwing a lead cover over him and letting him sleep. The power of these stories shows new employees that they have a purpose and that they are valued.

“In addition, new employees are taught to recognize different forms of suffering: avoidable and unavoidable. Our goal is to find ways to mitigate suffering by responding to the unavoidable kind with empathy and by improving our processes and procedures to avoid inflicting the avoidable kind whenever possible.”

I bet every single employee can find a way to share in a purpose like that.  From top to bottom on the hospital’s / corporation’s / our society’s pecking order of life, we have our humanity in common. We all have hearts and the innate ability to attune ourselves to notice another’s need or distress, and then to find a way to express caring for them.

There is an irony in the essay.  Most of the examples of uncaring comments came from highly trained healthcare professionals.  Most of the examples of compassionate behavior came from employees with more humble backgrounds and jobs.

Here’s another example of that, a YouTube video about Carolyn Collins, the janitor at Tucker High School.  The narrator says Carolyn has found her “true calling” — a purpose she finds deeply meaningful.  She maintains an extra “janitor’s closet” full of necessities for the 20 to 30 homeless students who attend that school.  She came up with the idea herself.  And she spends her own time and money to make sure that closet is fully stocked so those homeless kids always have access to free clothes, school supplies, snacks, and emergency food.

Notice again that this big-hearted person is a janitor.  As you listen to her talk on the video, imagine her own background, her educational level, and the size of her paycheck.  The narrator says Carolyn’s young son was killed in a home invasion.  I think Carolyn believes the person who killed her son was a desperate person.  As soon as she realized there were homeless kids attending Tucker High School, she was inspired to act.  She wants them to have what they need so they can go to school, and don’t need to steal or get in trouble — or kill someone.

I find the goodness of people heart-piercingly beautiful. And I’m the one who feels humble right now.

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November 28, 2017

Avoid “one-size-fits-all” thinking in evidence-based medicine

If you feel a duty to avoid “group think” and are not yet a subscriber, I recommend you take a look at this group and their blog:  Minimally Disruptive Medicine.   Today’s posting (What are the risks and benefits of adopting guideline-driven care?)  refers to a remarkable blind spot in thinking that has just begun to be revealed:   the faulty belief that one size fits all in treatment which is based on the assumption that mathematical averages are “good enough” to PRECISELY  describe the care a whole population should receive.   And there’s a link to a VERY COOL Air Force study about “average” pilots that led to a new approach to designing cockpits for them.

Interestingly, a neuroscience researcher brought up this exact problem of variability while discussing neuroplasticity and its application to rehabilitation after strokes in a YouTube I watched last night.    https://www.youtube.com/watch?v=LNHBMFCzznE.  She uses the phrase “personalized medicine”.    The genetics-oriented medical community uses the phrase “precision medicine.”   The bottom line:  people are not biologically identical at birth – and their life experiences after birth only INCREASE that variability.

The definition of evidence-based medicine (EBM) proposed by Dr. David Sackett, one of the original gurus who articulated the concept, DID include patient values and preferences.  (See diagram pasted below and this website:   http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036021.)

Note however that the Sackett definition FAILS to mention variations among patients – their biological idiosyncracies, other co-morbidities, or the context of the illness:  the patients’ life situations.   Technically, one could argue the nature and impact of those variations are all included in the box called Best Research Evidence.   BUT REALISTICALLY, as applied in practice and on the go, the “research” being brought to bear is usually mono-dimensional (the research on a particular test or treatment regimen).

A very bright and ambitious young Air Force physician told me last year that most of the fun is gone from medical practice for him due to EBM and EHRs (electronic health records).  By fun, he meant intellectual challenge and creativity.   In his world, going along with whatever the practice guideline says to do is the easy path.  There is neither encouragement nor reward for taking the extra mental step to consider whether there any reason why a patient might need something else –in addition or instead.   If he deviates from a guideline, he has to spend MANY more clicks and MUCH more  (bureaucratic) time documenting the reason for it.   He has already become cynical and is looking for an alternative to clinical practice.    Apparently the idea of mastering a “population approach” – seeing if he CAN consistently apply EBM across all of his panel of patients  – has little appeal for him.

Definitely a worthy bleeding edge of medical thought.    EBM conscientiously and consistently – but injudiciously – applied by clinical lemmings (imagine little white coats) may help many patients — but will definitely HARM some.

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September 27, 2017

Job loss due to medical care calendar vs. FMLA calendar

Extending medical leave beyond the FMLA period may be an UN-reasonable accommodation under the ADAAA, according to a recent decision of the US 7th Circuit Court of Appeals. The court wrote: “ADA is an anti-discrimination statue, not a medical-leave entitlement.” And it said that since the purpose of reasonable accommodation is to allow an employee to work, which a medical leave does not do, then a leave does not accomplish the law’s purpose. However, the EEOC opposes the position of the court, and is unlikely to change its view that a long-term leave IS a reasonable accommodation when it is: (a) of specific duration, (b) requested in advance, and (c) likely to result in the employee being able to perform essential job functions upon return.

ATTENTION ALL CLINICIANS and CLAIM PROFESSIONALS: Please notice this one key fact in the case before the court. A guy exhausted his 12 weeks of FMLA leave during the “conservative care” phase of treatment for his back pain. In fact, he had his back surgery on the LAST DAY of his FMLA leave — which was protecting his job!

We really have to think more about the intersection between the calendars of “evidence-based medical care” and job loss. For most of the common musculoskeletal problems (like straightforward back, knee, shoulder and ankle pain for example), the scientific evidence says that the doctor should begin by prescribing simple things like aspirin or motrin, ice packs, physical therapy, and exercise.  Unless there are clear signs of a potentially dangerous or progressive problem, the best thing is to wait for 6 weeks and give the patient’s body time to heal itself naturally.

But maybe we should be keeping our eye on the clock, and monitoring progress more actively during that 6 weeks.  When we see recovery not proceeding as hoped, we may need to ANTICIPATE the need for an orthopedic referral, make the appointment for that 6 week mark, and cancel it if things turn out better so it’s not needed.  If not, we may burn through several weeks before the specialist can be seen.

In my experience, it is more typical to see the initial treating clinician SLOWLY notice the passage of time and realize that conservative care hasn’t cut it.  Then they start talking to the patient about a referral to a specialist for consideration for surgery.  Then, when the surgeon sees the patient, they may talk about surgery and wait for the next appointment before requesting authorization from the payer.  They usually wait for a yes before scheduling the surgery — which is often some weeks in the future.   Maybe somebody ought to do a study of the weeks of time lost in this process.

Or maybe you have a better idea? How do we make sure that people’s FMLA clock doesn’t run out because of an ADMINISTRATIVE delays on OUR end, not medical ones on THEIR end? Our goal is to have them NOT lose their jobs – and right now I’m afraid we are really not paying enough attention to that critically important and NEGATIVE result of an injury/illness.

Read more about the 7th Circuit Court of Appeals decision here: https://www.natlawreview.com/article/ada-not-medical-leave-entitlement-seventh-circuit-declares

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