Category Archives: Articles, Publications, Research

June 22, 2016

Psychiatrist says we should use food to treat anxiety and depression

Dr. Drew Ramsey is a well-trained psychiatrist at Columbia in New York.  He grew up on a farm in Indiana.  When his patients weren’t getting well despite “evidence-based” psychotherapy and drugs, he starting wondering what was missing.  Then he started thinking about the link between what we eat and the health of our brains.  He figured out where all the latest nutrition research is pointing us, and started using food as part of his treatment plan for his patients — with good results.

Makes sense to me.  The brain consumes more energy than any other organ in the body. Obviously, a brain that isn’t getting what it needs in the way of nutrients will not function at its best.

So, one question to ask when we see someone who is not performing at their best mentally is:  are they eating right?   Which brings up another, much bigger question:  why are inquiries about nutrition not part of EVERY medical interview of sick people?  Why aren’t recommendations about foods that foster healing part of EVERY medical treatment plan?  Besides feeding the brain, nutrition is critical to healing injured tissues.

For years I’ve read about how doctors don’t learn nutrition.  It didn’t bother me because I DO know it.   My parents raised me to be a mother/wife and to be responsible for making sure I know how to feed my family well and keep them healthy.  I am also the main cook in our household.   But …. EVERY doctor should know what I know, and should keep it on the front burner.  And here’s the weird part.  Nutrition really ISN’T part of the medical culture.  Even though I’ve always known how important nutrition is, it hasn’t been part of what I talk about with people who are sick and need to get well.  Wow.  What a realization.  How stupid.

Dr. Ramsey has done at least two TedX talks, Brain Farmacy and Brain Food at the End of Your Fork.  He has a website, a blog, and three books.  Check it all out.  To me, his basic ideas make a lot of sense, and the nutrition stuff he’s saying is pretty solid, based on my own reading.  All in all, this seems like sensible stuff from the practical son of an Indiana farmer — who turned into a scientist, physician, psychiatrist and now educator.

(One concern: he may be getting swept up in the Dr. Oz fame whirl.  I hope he will avoid becoming faddish and commercial, pandering to the demands of TV fans who demand new woo woo immediate magic cures every day. So let’s go catch him now, in case he gets spoiled.)

I just ordered his Happiness Diet book to see if it’s a good patient education tool. Just THINK of all the people who are having trouble getting well.  Their medications aren’t working, they can’t tolerate their medications; therapy isn’t working, they don’t like their therapist.  I wonder how many could help heal themselves by thinking of food as therapy– and start making their brains healthier by eating nutritious (and delicious) food!

Do tell me what you think after you look at all of this stuff.

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June 9, 2016

Interview with Val Lougheed about recovery and her book Be Still

I recently asked Val Lougheed some questions about her book Be Still and her experience recovering from major trauma.  I have summarized our dialogue for you below.

At the time of the head-on automobile collision that nearly cost her life in 2003, Val was the owner and president of a successful rehabilitation company then called Northern Lights Canada, with a large staff in Ontario.  The accident caused a significant head injury, internal injuries, and multiple broken bones. She made a remarkable recovery and was left with subtle limitations. If you want to see Val in action, here’s a brief 4 minute YouTube video of her speaking at a conference. She was able to return to her company, and then found a new calling as a speaker and author on head injury and recovery.   Her book Be Still is a very personal set of vignettes from her hospitalization, her recovery and rehabilitation — and her reinvention of herself.

Val and I met in person a few years ago.  She has been a longtime valued contributor to the multi-disciplinary Work Fitness & Disability Roundtable email discussion group I run.  I recently read Be Still and recommend it to you.  Her book offers a very personal glimpse into the inner experience and outer realities of someone bound and determined to heal from devastating injuries.  She has been working on a second book to be released later this year.

DR J:     Why and when did you decide to write your book, Be Still?
VAL:      It was serendipity.  At the time of my accident, I had almost finished a Master’s Degree in Community Rehabilitation and Disability Studies at the University of Calgary. My advisor knew I had kept a journal while I was in the hospitals, and suggested that I write a narrative about my recovery for my thesis. She encouraged me to write only about my personal experience – no research, no literature references, no nothing. She said to write it so that when someone read it they would feel like they were going through the experience with me. As I analyzed my journals, the particular themes that stood out were trauma, pain, depression, acquired brain injury, narcotic pain killers, and methods of helping. Writing that paper was sort of like an exercise in do-it-yourself narrative therapy. I believe it augmented my recovery. And then I realized I could self-publish it as a book.

DR J:  What did you want your book to accomplish?
VAL:     I wrote it in hopes that it would provide some useful insights into the following questions:
1.    What does it mean to recover?
2.    What can I do, myself, to recover and return to a life that includes work?
3.    What can we do — as practitioners, as family, as friends — to aid recovery and  return to work?

I have realized that the meaning of my accident for me comes from writing, studying and speaking about recovery. So every time I speak, I feel like I owe my life to the people who are listening. Every time someone reads my book, it’s the same – I owe my life to them. To my complete delight, people respond to my talks with the same amount of passion (and tears) that I have in giving them. I am driven by the hope that my work can, in some small way, lead to the development of a more sensitive, effective and in-tune system within which practitioners and patients/clients can work together to achieve successful returns to life and work.

DR J:   You have some very personal experiences to share with us — but before we go there, do you have any advice for people now trying to recover in the “system”?
VAL:     Of course!  Here are my six best suggestions.

  1. Play your own game. Don’t fall into the trap of believing you are disabled and can’t work, or that you don’t want to work/be functional.
  2. Be curious about your recovery. Try to learn and understand everything about all aspects of your recovery. Read, talk to people, write a journal – whatever you like to do. This helps to put the ‘problems’ outside of you so you can look at them with some distance between you and them. This helps to preserve your inner self from being consumed by your problems.
  3. Functionality is everything. Be clear about what a functional life for you looks like, and work towards that. Don’t get sidetracked with standardized measurements and pronouncements, or with the need to prove that you are disabled. For sure, do whatever you have to do to get the money and help you need to recover — and play the game if necessary. But always continue working towards your own vision of personal functionality.
  4. Get good psychological help. If you can afford it, or convince the insurer to pay for it, find a good psychologist or counsellor who can support you in your efforts to recover. My preference is narrative therapy, for a couple of reasons. First of all, it helps you to separate yourself from your impairments/illnesses/problems and work on them from a distance, so that you don’t drown in them. Secondly, it helps you to re-story yourself and your life, which is so important when you are going through a ‘re-organization of self’.
  5. Look for ‘angels’. There are some people out there who are truly angels. They are the ones who are prepared to listen to you, respect you, understand you and even love you. If you find one, spend time with them, listen to them, and let them help you.
  6. Stand up for what you know you need. You will be called all sorts of names (malingerer, non-compliant, unmotivated, etc, etc). Do not listen to this. Be clear about what you need and then search out people who can help you in this regard.
  7. Never, ever, ever give up!

DR J:   What have you learned about how recovery really happens?
VAL:    I know now how recovery happens on different levels. There is the outside recovery – the physical aspect of it. That part can be measured, quantified and standardized (e.g., how long does it take a broken collar bone to heal and what will it look like?). Healthcare professionals assess and fix this kind of stuff.

But then there is the inside recovery, which I found to be a deeply personal experience. In reality, there is no difference between the physiological and the psychological – no split between the mind and the body. The combined whole person can’t be standardized, measured, quantified or partitioned (which is very frustrating for a disability benefits system based on those things).

Shortly after I woke up after the accident I realized that I had lost myself. By ‘myself’ I mean my spirit, my soul, my energy – whatever it was inside of me that was ‘me’ was gone. I realized that I was becoming someone else, but I had no control over the process. Very scary – like all of a sudden not knowing who or where you are….like floating with no ground under you and no net to catch you. In clinical terms, I would call it an ‘existential crisis’.

In Judith Herman’s excellent book, Trauma and Recovery, she contends traumatic life events can shatter the sense of self.   Since an event is traumatic if the involved person perceives it to be traumatic, there must a lot of people out there with shattered selves!  And typically, it’s not exclusively the doctors and other healthcare professionals who help put the inner person back together – it might be social workers, friends, family, a minister, a nun, or maybe even just a comment from a person in passing.

Beyond this, a good recovery requires an alignment of the stars so to speak, in terms of the presence of positive family and social support along with other facilitating factors (a safe place to live, relatively good general physical and mental health, enough money to manage, and so on) to realize progress.

DR J:   How did the knitting back together of Val, the whole person occur?
VAL:     Here’s one little story:  About four months after the accident, I was talking to Sister Brenda, a nun at St. John’s Rehab Hospital in Toronto where I was a patient.  I shared with her my sense of loss of self.  By virtue of her amazing listening and empathy skills, I suddenly found myself.  My “me” was all rolled up in a little ball in my stomach!  I thought back to the accident, and suddenly it made sense to me why that was where it was.  As the other car approached, I must have realized that I was not going to be able to escape a collision — so the me that is ‘me’ hid away. As soon as I found where “me” was, I knew that was the start of true recovery.  I believe this experience of a ‘split’ between the mind and the body is the result of trauma.

Coming back to life required major internal change, a re-organization of myself on a grand scale. It required me to have a strong sense of personal control, personal power, and raw courage to follow through with necessary (and often painful) treatments and rehabilitation activities.I needed to be around people an practitioners who could help me with these things.  In his amazing book, The Upside of Down Thomas Homer-Dixon describes the process of ‘”coming back” as a “novel and unpredictable recombination of elements”.  That is exactly what it felt like for me.

Jon Kabat-Zinn has my favourite definition of what rehabilitation is really all about. He says that “rehabilitation is the learning to live inside not only one’s body, however it is after an injury or illness, but inside one’s very being”.  That quote really resonates with me.

DR J:   Who and what helped or hindered your rehabilitation?
VAL:     When I think of who helped me most to come back to life, there was of course a literal village of wonderful doctors, nurses, physios, OT’s, psychologists, etc. etc. who helped put my body and my head back together.  But specific people and particular moments — both bad and good — stand out in my mind.

I felt very vulnerable all the time during my recovery – physically obviously, but also emotionally. I felt that anyone could hurt me so easily that it was very hard to trust anybody.  This issue of trust is a huge one, in my opinion, in terms of facilitating recovery. If I trusted someone, I loved them and would try my hardest to do whatever they asked. If I did not trust someone, I hated them because I felt like my life was being threatened by them, and I would do whatever I could to get away from them. This led me to define what trust meant for me…..

I trust (love, feel safe with, will try hard for) people who:
•    Listen to me
•    Understand me
•    Respect me
•    Are competent.

In terms of being a client in the disability benefits system, when trust, positive regard, respect, and so on were absent, I could sense it – like an animal instinct. If someone treated me like this, I would feel threatened, and become REALLY uncooperative (I couldn’t help myself!), and do everything in my power to get away from that person. This is a good example of what’s called avoidance behaviour in the world of neuroscience (Rock, 2008).  I think it is often mis-labeled as non-compliant, malingering, unmotivated, etc. etc. in the system.

When my personal experience of impairment was not taken into consideration, when my recovery was measured against published norms that did not reflect exactly where I was in time and space, when I was not trusted, when I was not understood or respected, I not only lost my physical and cognitive ability to function, I also lost my will to recover.

But on the other hand – I definitely needed the money that I got from the insurance company to support me and to pay for necessary therapies when I could not work. And of course, in order to secure such monies, I had to continually prove that I was still disabled, with on-going health care assessments.

But frankly, it’s hard to recover when you are having to prove you are disabled in order to get help. It casts you in a crazy world of damned if you are recovering (because then you lose your benefits) and damned if you aren’t (because then you lose your functional life). The contentious, confrontational and distrustful atmosphere within which this plays out only serves to make it all so very much worse.  This is the reality of the disability paradox that plagues the current system adn that is what I’m researching and writing about now.

DR J:   Thank you, Val Lougheed, for sharing your personal experience of a difficult but successful recovery with us.
VAL:     Thank you for the opportunity.

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May 18, 2016

It’s time to establish accountability for job loss

My report on Establishing Accountability to Reduce Job Loss After Injury or Illness (commissioned by the US Department of Labor’s Office of Disability Employment Policy) was originally conceived as a simple effort to lay out the rationale for adding work and participation in life to the list of positive health outcomes.  (I suspect that I was asked to write it because they thought a physician like me would focus on medical practitioners and the healthcare delivery system.)

Almost immediately, it became obvious to me that in order to make a solid contribution to the on-going public dialogue about health outcomes, the paper would have to explore the meaty issues of explicit expectations, accountability, metrics, credible data, rewards for best practices, and incentives for both participation and performance.

Soon after that, the absurdity of discussing expectations and accountability for the healthcare system alone became obvious —because organizations in other sectors of society play a role in the SAW/RTW process, each of which has enough discretionary power to support or thwart it.

Thus, over time, the purpose of the paper shifted to answering this question:  What has to happen in order to engage the professionals at the front-line  — the ones who work directly with affected individuals and make discretionary decisions about how much effort to make and for what purpose — so they start making a real effort to help people stay employed?

Who are those front-line professionals?

(1) Healthcare professionals.  Most of us view our purpose as making accurate diagnoses and providing appropriate treatment.   We are generally not trained to assess work capacity and prevent work disability.  Yet our opinions about work have considerable weight under law, regulations, insurance policies and traditional business practices.  We generally don’t spend much time and energy thinking about issues outside the exam room.

(2) Workplace supervisors or HR professionals.  Their focus is the business of the organization, producing its goods or delivering its services,as well as abiding by company policies and applicable laws. They can decide how much effort to make to help the employee stay at work and keep their job.  With rare exceptions, they are neither aware of the preventable nature of most work disability, nor are they trained how to negotiate and arrange stay at work or return to work plans, identify alternative temporary tasks or reasonable accommodations.  And they are not incentivized to do so.

(3) Claims/benefits administrators.  Their focus is administering the benefit programs correctly, establishing eligibility, compensability, meeting deadlines, making payments, and other requirements. In between these duties, they decide how much effort to make to help the beneficiary/claimant. Like the workplace professionals, with only rare exceptions, they are neither aware of the preventable nature of most work disability, nor are they trained how to negotiate and arrange stay at work or return to work plans, identify alternative temporary tasks or reasonable accommodations.  And they are not incentivized to do so.

Job loss is the third worst outcome of an injury or illness

As I thought about these players and those who influence their behavior, the biggest realization dawned more slowly:  job loss is a potentially devastating secondary consequence of a health-related employment disruption or a failed SAW/RTW process — because it often leads to permanent withdrawal from the workforce.  In fact it is the third worst outcome of a health condition, the other two being death and loss of limb or core functions like sight and hearing.

Yet we have not seen it that way.  Unlike death and serious injury, job loss is generally not noticed.  It’s actually a hidden outcome.  The frequency with which it occurs can only be estimated indirectly — because it is untracked and thus invisible.  When someone loses their job due to long-lasting illness or injury, they often end up leaving leave the workforce permanently, becoming dependent on public benefits programs like SSDI.

Some years ago, a senior Social Security Administration official commented to me that SSDI is the largest insurance fund IN THE WORLD and yet it has no risk management program, no loss prevention program.  Private sector insurance companies view these as core functions of their organizations.  They know they must identify and take steps to reduce risks and mitigate losses in order to meet their responsibilities and stay solvent.

In my view, government should be likewise obligated to take steps to protect SSDI (and the taxpayers who fund it) from the economic consequences of the dysfunctions, inadequacies and gaps in the upstream social structures and programs — because their failures end up on public benefit programs.

Government will make a major contribution to reducing demand on SSDI by:
(1) establishing policy that job loss/withdrawal from the workforce is a very unfortunate outcome of a health problem and should be avoided whenever possible,
(2) enabling all parties to see more clearly when it happens by requiring reporting of these events; and
(3) establishing consequences of some sort when involved organizations are non-responsive (negative incentives such as financial penalties, loss of privileges, or public exposure) or do take appropriate action (positive incentives such as credits, privileges, or favorable publicity).

This combination of outcomes visibility and accountability should then start to shift how parties in the private marketplace choose vendors and suppliers.

How will things look different when there IS real accountability for job loss?  

Implementing the broad range of actions recommended in the Establishing Accountability report will require a significant long-term effort because of their comprehensive, complex, and varied nature.  Taken as a whole, these actions have the potential to create truly transformational change.

Success will mean that more workers living with adult-onset chronic conditions and impairments (acquired disabilities) will be able to stay fully and productively engaged in their own personal, family, and community life; protect their household’s standard of living; remain economically self-sufficient contributors to their local area economy; and avoid dependency on government programs—which will in turn protect their future health and well-being and improve their children’s future prospects.  At the national level, success has the potential to stem the tide of declining labor force participation, lighten taxpayer burdens, and bolster the nation’s social fabric and the vitality of the economy.  All in all, the initiatives proposed make good use of limited government resources.

The ultimate success of the initiative will hinge on the ability of Federal policy leaders and supporters to create and sustain real multi-stakeholder buy-in and enthusiasm for achieving the future vision described in the paper.   A good next step is for the federal and state governments to decide whether and where to start.  It will take time and effort to achieve consensus among key stakeholders that this kind of initiative is necessary, timely, and deserves priority for person-power and funding.  Once that preliminary groundwork is laid, more detailed planning work can get underway.

Whoever you are, I hope you read the Establishing Accountability paper and agree that change and action is needed.  If my suggested recommendations spur you on to creative thinking, you do NOT need to wait for the government to act.  You can start factoring these issues into your decisions about who to collaborate with now.

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May 16, 2016

New study: adherence to guidelines leads to better outcomes

One of the issues raised at the multi-stakeholder Work Comp Summit I attended in Dallas last week (more on that later), was this question:  “Are Treatment Protocols and Evidence-Based Guidelines a Benefit or a Burden?”  Evidence-based medicine (EBM for short) and evidence-based treatment guidelines have been controversial in some quarters, especially when they don’t support popular (and lucrative) treatments.  Skeptics have pointed to the lack of “real world” proof that following these guidelines actually does produce better outcomes.

As a near-miraculous coincidence, we have HARD FACTS to contribute to that discussion as of today. A landmark paper has just been published that will / should attract wide attention — particularly in the regulatory and commercial marketplaces.  The new study says it is describing the development of a methodology for assessing the impact of treatment guidelines — but in so doing it has produced the first tidbits of hard evidence that adhering to EBM treatment guidelines significantly improves outcomes of work-related injury claims, in terms of both medical cost and duration.

There’s an easy-to-read article about it entitled Study Supports Benefits of Evidence-Based Medicine in this week’s on-line Workers’ Comp Forum published by Risk & Insurance.  According to that article, the researchers believe this is the first scientific proof that consistently applied treatment guidelines are more effective in treating injured workers — when compared to non-evidence-based care. If you’re a details type, read the original article entitled A New Method of Assessing the Impact of Evidence-Based Medicine on Claim Outcomes.  It’s in this month’s issue of the Journal of Occupational & Environmental Medicine.

To the methodologists and kvetchers among us – any comments on this merits of the methodology they used?  Do we have an opportunity to IMPROVE the methodology?  And just in case there are any advocates of EBM among us, anyone want to yell YAHOOOOOOO? I do!

The study was supported in part by AF Group, formerly Accident Fund Holdings Inc which owns a family of workers’ compensation companies and is itself a for-profit subsidiary of Blue Cross Blue Shield of Michigan.  It was AF Group’s workers’ comp claim data that was analyzed using ODG’s treatment guidelines.

ACOEM membership includes a subscription to JOEM, so if you know an ACOEM member, ask them to get the article for you.   It may be simpler to purchase your own copy on JOEM’s website.    The authors are Hunt, Dan L. DO; Tower, Jack MS; Artuso, Ryan D. PhD; White, Jeffrey A. MS; Bilinski, Craig MS; Rademacher, James BA; Tao, Xuguang MD, PhD; Bernacki, Edward J. MD, MPH.   Dr. Bernacki works at both the University of Texas and Johns Hopkins University, and has done some superior research in the past on questions of real practical interest.  The full citation is JOEM: May 2016 – Volume 58 – Issue 5 – p 519–524 doi: 10.1097/JOM.0000000000000718.

I sure wish this study had been done based on ACOEM’s Occupational Medicine Practice Guidelines which are the clearly superior product from my (informed) point of view.  That’s the NEXT study that should be done.

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May 8, 2016

Key but hard-to-find esoterica in evidence-based medicine

Mother’s Day Brunch is over, and I am feeling appreciated and loved, though a bit bored and lonely now that the “kids” have left for home.   So I’m catching up on stuff.

I went back to finish reviewing a draft practice guideline via an on-line questionnaire.  The authors wrote that I was selected to participate because of my particular field of expertise.  I started but didn’t finish the questionnaire last month.  When I logged in again today, the software jumped me straight to a question that asked whether I agree with a statement that begins: “There is OCEBM Grade C supporting evidence that ……”

This terminology was only semi-famliar to me, so I Googled OCEBM which wasn’t much help.   I still haven’t found the criteria for Grade C (which implies there exists criteria for Grade A, B, and maybe other grades beyond that too).    More Googling will probably help.  But to be truthful, I decided to give up on this effort.   When the researchers asked me to participate, they didn’t tell me the survey has SIXTY FIVE questions each of which seems to require a whole lotta cognitive work including evaluating a set of brief descriptions of the scientific literature pertaining to the subject of each question.   I am NEITHER an academic type nor a methodologist (a person who critiques the experimental design and analytical methods used in research).

HOWEVER, while Googling around I did find a document  entitled “Understanding GRADE: An Introduction” that MAY BE USEFUL to you.  It was for me.  It succinctly describes  (in LESS than 1,500 words) the steps that developers of systematic reviews and practice guidelines should use to assess and rank the quality and strength of evidence supporting a particular practice or treatment.  This method is widely used in appraising scientific studies.  Worth a read – particularly if you are confused by competing guidelines.

Methodology is KING in evidence based medicine — if the scientific quality of a study sucks, you shouldn’t view the results as reliable/valid/believable — no matter how much you love them.  So if you’re like me and not a methodologist yourself, you need to make sure that the committee that produces an “evidence-based guidelines” has members who really do know that stuff.

In theory, I like the idea of wide participation of experts in development and review of practice guidelines.  But based on my (limited) experience with development of the ACOEM practice guidelines for occupational medicine, the work is so hard, detailed, and time-consuming that it tends to be done by a small group of committed experts who put in a TON of hours, and then send their finished product out for comment.  Part of the reason why I felt so uncomfortable reviewing the practice guideline today is that there was so little background information and context provided to me as a reviewer.  Like:  (a)  what were the 65 questions going to be like; (b) how long would it take me; (c) where are they in the development process, and (d) what use is going to be made of the on-line reviewers’ input?

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March 7, 2016

Manifesto – Preventing Needless Work Disability (DRAFT)

I’ve tried to squeeze all the main ideas of the work disability prevention (WDP) model into one page (see below). The model has matured over the last several years as key dynamics have become more apparent.  I’m curious to hear your reaction to this new version.

After promoting the WDP model in the private sector for a long time, I started introducing it to the Federal / State disability sector in 2011.  Now seems like the right time to get a compelling and very succinct document circulating so it gets in front of many more eyes  – for example, lots of eyes on Capitol Hill and in regulation-creating / law-making (sausage making) circles.

The members of the Work Fitness & Disability Roundtable are also helping me craft a 3 or 4 bullet “sound bite.”  However, in my view it will take more than that to get influencers and decision-makers to decide to explore these issues further. They need a quick summary of WHAT the problem is, WHY things look the way they do, and WHAT might be possible instead — but just a bit.  Thus, this one-pager.

I’m not yet clear what to do with this draft – other than to post it here and solicit your comments.   Am also hoping to get your ideas for the best organization to issue and disseminate a manifesto like this — so it has the maximum impact.  What are the chances of it going viral?  Please leave a comment below or email me your ideas and suggested revisions.

Work Disability Prevention Manifesto (DRAFT)

  • Preserving people’s ability to function and participate fully in everyday human affairs, including work, is a valuable health care outcome, second only to avoiding loss of life, limb, and essential bodily functions.
  • Loss of livelihood due to medical problems is a poor health outcome because worklessness is harmful to people’s health as well as their personal, family, social, and economic well-being.
  • A new medical problem that threatens the ability to continue earning a living is a big challenge – a life crisis that must be addressed. Most people are unprepared, never having faced this double-headed predicament before. It can overwhelm their coping abilities.
  • When medical conditions occur or worsen, especially common health problems, most people are able to stay at or return to work without difficulty because the right things tend to happen during the first few days or weeks.
  • However, many of the prolonged work disability cases in both private and public sector sickness programs, disability benefits, and workers’ compensation programs began as very common health problems (for example musculo-skeletal pain, depression, and anxiety) but had unusually poor outcomes.
  • Unusually poor outcomes are frequently due to the interplay of sub-optimal health care and non-medical factors. Without a team focused on helping them get their lives back on track, people can get lost in the healthcare and benefits systems. Remediable issues in the situation are overlooked and not addressed. Incentive alignment among the involved parties is poor.
  • Medical conditions by themselves rarely require prolonged work absence, but it can look that way. And with every passing day away from work, the odds are worsening that people will ever return to work. After a while, they start to see themselves as too disabled to work.
  • Unlucky people lose their job and do not find a new one. They leave the workforce and eke by on disability benefits, in poverty, and vulnerable to its detrimental effects.
  • Today, most professionals typically involved in these situations (healthcare professionals, employers, and benefits handlers) do not feel responsible for avoiding job loss.
  • Good scientific evidence exists about how unusually poor outcomes are created, how to avoid them, and the health care and other services that can optimize function and protect jobs.
  • When work disruption begins, it is both effective and cost-beneficial to have a coordinator assist the individual, their treating physician, and their employer with communications, as well as focus everyone’s attention on restoring function, accommodating irrevocable losses, and making plans for how to keep working, return to work, or quickly find a more appropriate job.
  • Urgent priority should be given to establishing accountability for work disability and job loss as well as building nationwide capacity to consistently deliver services that help people stay at work or return to work – just in time, when needed.
  • Helping more people with medical problems to keep their jobs or find new ones in a timely manner will benefit them and their families, and will benefit our society as a whole.

March 7, 2016

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November 18, 2015

Our proposal for “upstream” services to reduce “downstream” inflow onto SSDI

Kim Burton, Tom Wickizer, and I have a good idea for how to reduce the inflow onto Social Security Disability Insurance.  Ours was among only twelve proposals selected for further development during a “competition of ideas” held by the SSDI Solutions Initiative sponsored by the Committee for a Responsible Federal Budget.

Once selected, we fleshed out the proposal in a written report.  It recommends the development, testing, refinement and launch of a nationwide Health & Work Service (HWS) that would assist workers who have recently developed potentially disabling conditions to maximize their functional recovery, stay at or return to work — and either KEEP their jobs or FIND new ones!  Our report describes why the service is needed and how it would work.  It includes many literature citations that provide a solid foundation for our proposal as a whole as well as specific design features of the HWS.

SSDI Solutions Initiative

The full reports have just been released to the public.   You can find all 12 of them here:   http://ssdisolutions.org/selected-papers.

And you can find ours here:  http://ssdisolutions.org/sites/default/files/christianwickizerburton.pdf  There is a main report and 3 (juicy) appendices.  One oddity is that the editors removed all biographical or organizational info about the 3 authors.  We could be 3 dogcatchers or 3 priests or 3 unemployed hula dancers for all the readers will ever know.  Here’s info about me and my co-authors:  Jennifer Christian, Thomas Wickizer and Kim Burton.

I verbally presented our idea in just 6 MINUTES at the SSDI Solutions conference on August 4, 2015.   Here’s a video of the entire event.  (My presentation starts about minute 36).

Do you happen to know any professionals who would LOVE to be part of a national effort to help people mitigate the impact of illness and injury on their lives and futures — and prevent needless work disability?  I do!!!  Among them are many of my physician and psychology colleagues in the American College of Occupational & Environmental Medicine, the many professional members in a wide variety of disciplines on the Work Fitness & Disability Roundtable — and most especially the 100 Founding and Charter members of the nascent but still unfunded Praxis Partners Consortium.

Hey, I have an idea!  If you like the idea of a HWS service, why not get in touch with the people at the Committee for a Responsible Federal Budget and tell them so!   Here’s a link to their “contact us” page:  http://ssdisolutions.org/contact/ssdi

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October 30, 2015

Turning private tragedies into a public concern: job loss after injury or illness

Do you realize that NO professional feels responsible when a working person loses his or her job because of a health problem — neither the doctor, nor the employer, nor the person handling the claim for healthcare, disability, or workers’ compensation benefits?  At most, the professionals may say “that’s a shame” assuming they are even aware it’s happened.  Job loss is often invisible; the person just drops off the radar.  The government insists that employers track workplace injuries and illnesses, hospitalizations and fatalities — but no-one is tracking job loss.  Among the public purposes of the Americans with Disabilities Act is promoting employment of people with disabilities.  The millions of workers now silently disappearing from the workforce due to newly-acquired disabilities deserve more visibility — and more help.

An estimated 2.5 million people leave the workforce each year for health reasons, most frequently due to things like low back pain and other common musculoskeletal conditions, as well as the most common mood disorders of depression and anxiety.  And none of the professionals who are called on to respond when those individuals start having difficulty are being held accountable for making an active effort to help them keep their jobs. Obviously, some people really can’t continue to work (for example those who have a terminal illness or have suffered an incapacitating injury).  But some of those lost jobs COULD have been averted if any of those three professionals had devoted more of their skill and discretionary effort to finding a better solution.

In my opinion, this hole in our social fabric through which people with newly-acquired disabilities are falling has been invisible until now — and is unacceptable.

To put this in perspective, as Western societies have evolved over the centuries, other kinds of private tragedies have become public concerns.   Do you realize that until roughly the 19th century, no one felt responsible when a pregnant woman died in childbirth, or her newborn infant did — which was very common?  “That’s a shame,” people said.  It was each family’s private tragedy.   Today,  several professions, many hospitals, and whole departments within public health agencies in every single state focus on keeping pregnant women healthy, providing prenatal care, assuring a safe childbirth, and proper care of newborns.  Maternal and infant mortality rates are now considered basic indicators of the health of a country’s entire population  — and the adequacy of its public health / health care systems.  In the developed countries, maternal and infant deaths are 50 to a 100 times lower than the rates in still-developing countries.  Here is data from the CIA’s World Factbook.

Pic of Mat Infant Mortality rates 2015-10-30

Wouldn’t it be interesting to see a comparable table showing job loss rates for the countries?  What do you think it would show?   I bet the developing countries are doing less well by comparison — because their social safety nets tend to be weaker.  And I doubt workers that in the US are a 100-fold better off.   I’ve heard that European countries make it much harder to “throw away” unwanted workers.  It is not only important for workers and their families to stay employed.  Every time a worker loses his or her footing in the world of work, our society takes a DOUBLE hit:  we lose an economic contributor AND at the same time we gain another person dependent on taxpayer funded benefits.

I’ve been part of a two-year effort to start thinking seriously about ways to reduce job loss due to illness and injury among U.S. workers while serving as a member of the US Department of Labor’s Stay-at-Work/Return-to-Work (SAW/RTW) Policy Collaborative. This year three of us (economists (David Stapleton,  Kevin Hollenbeck, and I) were asked to develop policy papers, each on a specific aspect of the issue.

My task was to think about how to establish accountability for job loss among the professionals who have the best opportunity to influence the outcome.  I felt so LUCKY to be PAID to take the time to explore this topic in depth — it was really fun to put my “thinkatorium” into high gear.  Stimulating conversations with more than 30 experts in various fields and sectors of society helped shape my thinking (thank you all — their names are listed in the report).  The final product is three main recommendations and a set of specific suggestions for action — how to accomplish the recommendations.  I hope you will read my paper to see where this line of inquiry leads you.  I bet you will be surprised — because I was.

On October 22, the U.S. Department of Labor’s Office of Disability Employment Policy (ODEP) and Mathematica’s Center for Studying Disability Policy (CSDP) hosted a policy forum to introduce the three policy papers and all of their recommendations. You can view the 90 minute video of the event here.  It includes some very good questions from the audience and subsequent dialogue. All three policy papers are available on Mathematica’s website.

Please consider joining me in transforming these 2.4 million hidden and all-too-private tragedies per year into a public challenge for change.

And before you go — did you notice that the data I cited on maternal and child death rates came from the US Central Intelligence Agency’s INFORMATION WEBSITE???  Who knew?  I just stumbled on it.

Photo announcing policy rec - video of event 2015-10-29

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October 10, 2015

Some specifics: Our proposal for a Health & Work Service

In our August 2015 proposal to the SSDI Solutions Initiative sponsored by the Committee for a Responsible Federal Budget on Capitol Hill, we recommended that a community-focused Health & Work Service (HWS) be established.  The services to be provided by the HWS are generally not available in our country today, particularly to lower-wage workers and those who work for small firms.This service would be dedicated to responding rapidly to new episodes of health-related work absence among working people in order to help them:

— Minimize life disruption and get things back to normal as quickly as it is medically safe to do so
— Focus attention on treatments and services to restore ability to function at home and at work
— Understand and navigate through the healthcare and benefits programs and systems
— Avoid being abandoned; learn how to be a squeaky wheel and get their needs met
— Communicate with all parties to expedite both medical care and the return to work process, including resolving non-medical obstacles to recovery and return to work, making temporary adjustments or arranging reasonable accommodation when appropriate.
— Keep their jobs or promptly find new ones if that is necessary.

(The material below summarizes our written proposal.  If you’re interested in the scientific research that underlies these ideas, the 30+ pages and 3 appendices of our “real deal” formal report support all key assertions with literature citations and an extensive bibliography.  Along with the 12 other proposals commissioned by the SSDI Solutions Initiative group, it is scheduled to be published electronically in late October, and in print in January 2016.)

The first few days and weeks after onset are an especially critical period during which the likelihood of a good long-term outcome is being influenced, either favorably or unfavorably, by some simple things that either do or do not happen during that interval. It is the optimal window of opportunity to improve outcomes by simultaneously attending to the worker’s basic needs and concerns as well as coordinating the medical, functional restoration, and occupational aspects of the situation in a coordinated fashion.

The best opportunity for basic intervention appears to last about 12 weeks or three months, although some data shows it ending by 6 months.  Many studies have show that a modest set of simple services—that embody an immediate, systematic, pro-active, integrated, and multidimensional approach—can mitigate the potentially destructive impact of common injuries, illnesses, and chronic conditions on quality of life among the working population.

In the USA today, a large and growing fraction of Social Security Disability Insurance (SSDI) awards are being made to people deemed totally unable to work due to conditions that are among the most common health problems in America and the world, but which only rarely cause permanent withdrawal from the workforce. Low back pain and other chronic musculoskeletal conditions (MSK), and common mood disorders (CMD) —particularly depression and anxiety—are the most prominent conditions in this category.

Near-immediate assistance from a community-focused Health & Work Service will allow people with these kinds of common conditions to avoid the kind of adverse secondary consequences they too often experience today. Those consequences are usually not obvious until months or years later, after unfortunate things have happened. The unlucky ones have received sub-optimal health care, been left with under-treated or iatrogenic impairment,  become dependent on opioids, found themselves socially isolated, lost their jobs, withdrawn from the workforce, lost economic independence, and ended up on long-term disability benefits programs or SSDI in order to survive. Anticipatory programs that ensure the right things happen from the start and include early identification of those needing extra support are the simplest and most effective way to prevent later adverse secondary consequences of these conditions.

As we envision it, the HWS will build strong collaborative relationships with referral sources in local communities: treating physicians, employers, and benefits payers. Service delivery in individual cases can be largely telephonic and internet-based because these technologies are proving to be as or more effective than face-to-face care delivery. The quadruple goal is to maximize service quality, optimize outcomes, minimize logistical challenges, and control costs. The HWS service will:

(a) — get its referrals from affected individuals, local treating physicians, employers, benefits payers and others when work absence has lasted or is expected to last more than four weeks;

(b) — champion the stay-at-work and return-to-work (SAW/RTW) process from the time of referral through the end of the immediate response period (usually 12 weeks post onset);

(c) —  quickly evaluate the individual’s situation, screen for known risks for poor outcomes, help them make a SAW/RTW plan and support them in carrying it out;

(d) —  facilitate communications among all involved parties as needed to get everyone on the same page and driving towards the best possible outcome.;

(e) — expedite and coordinate external medical, rehabilitative and other kinds of helping services, including referrals for specialized services as needed to address remediable obstacles in a variety of life domains;

(f) — take a problem-solving approach in collaboration with affected individuals, their treating physicians, employers, and payers.

Of course, developing the HWS will first require a commitment to funding, either by the government or by a foundation that is committed to system change. Once that has been obtained, the initiative will unfold in a series of steps including design, prototyping, development, and field-testing in different geographies, followed by a large randomized controlled trial.  After that, the HWS can gradually roll out across large geographic areas.

What does this mean for you?   First, if you like the idea of working people getting the kind of support they need and deserve — and when it is most likely to make a difference,  please support this idea in whatever way you can.  Why not call or email your Congressman?  Second, if you are a professional with the expertise and passion required to help people get “right back on the horse” — and are now stymied and frustrated by the current system’s inadequacies / dysfunctions, you have probably realized that the HWS service might create a lot of fulfilling and satisfying jobs for specialists like you.  If so…. that’s another reason to call or email your Congressman!

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October 9, 2015

A Health & Work Service could prevent or reduce impairment/disability

 

There is definitely an opportunity to make a positive difference BIG ENOUGH to make the expense and effort of developing, launching and delivering a nationwide community-focused Health & Work Service (HWS) worth it — in my opinion.   (Our proposal for establishing the HWS was among 12 ideas selected for development as part of the Committee for a Responsible Federal Budget‘s SSDI Solutions Initiative on Capitol Hill.)  There are two main reasons why this opportunity exists.

First reason:  Years of research have shown that some of the unfortunate secondary consequences of illness and injury — certain kinds of impairment and work disability — CAN sometimes be prevented or reduced.  This is particularly true in people with the most common chronic musculoskeletal conditions (MSK) especially low back pain, and the most common mental disorders (CMD) like depression and anxiety.  And research has also shown that intervening early in the unfolding of an injury or illness episode can have a very favorable impact on the long-term outcome.

Second reason:  Millions of workers in America fall through the cracks in our society because they have no access to services or expertise that might protect them against job loss after injury or illness, or they experience service failures.  Many of them work for employers that do not offer health or disability insurance, or that are excluded from the requirement to buy workers’ compensation insurance.  Many work for small companies that are exempted from the Family Medical Leave Act which protects jobs for 12 weeks when employees have health problems, or the Americans with Disabilities Act which requires employers to make reasonable accommodations for employees with disabilities.  In addition, there are many people who are the victims of neglect or poor decision-making by those with authority over some aspect of their situation.  Sub-par employees headed for termination exist among the administrative staff, professionals, supervisors, and managers in every organization, including every medical care facility, workplace, and benefits claims administration organization.  Before leaving, each of these sub-par employees has probably had an impact on hundreds of vulnerable workers.

Therefore, it is not correct to assume that all of the people who are now on SSDI due to these common health problems had the worst (most severe) form of their particular MSK or CMD from a biological/pathological perspective, and that nothing could have prevented their entry into SSDI.  While undoubtedly true in many cases, it is also likely that a sizable number of them lost their footing in the world of work and ended up on SSDI because of events that occurred in response to their health condition—not the condition itself. Their lives fell apart due to a cascade of adverse secondary consequences of the initial medical problem, and after a time SSDI became the best option for survival.

Remediable or Avoidable Reasons for Poor Outcomes

At the moment when the common health problems of this subgroup of SSDI recipients first started, these people would often have looked very similar to other patients with the same diagnosis and objective clinical findings—but who then experienced good recoveries.  This is because the factors that predict poor outcomes (serious impairment and prolonged work disability) as a consequence of MSK, especially low back pain, are not tightly related to either the specific diagnosis or the extent of the pathology. Although less research has been done on factors that predict poor outcomes in CMD, and diagnosis does play a more significant role, there are other important non-medical factors.

Some of the factors that predict poor outcomes are immutable (such as age, past medical history, work history, and geographic location). But other factors are potentially remediable such as elapsed time out of work, uncertainty and distrust due to lack of communication or information, uncoordinated or inappropriate medical care and advice, low expectations of recovery, excessive vigilance, catastrophic thinking, false beliefs, fear of movement, self-limitation, perceived injustice, and lack of employer support. Today, those who handle these situations do not typically look for any of these remediable problems and address them.  And none of the professionals involved has been trained to feel responsible for driving the situation forwards towards a good outcome .

The standard medical care process is simply inadequate to help people in these situations avoid poor life outcomes. What is needed is coordinated activity during a fleeting opportunity to address and resolve a set of pivotal issues (both medical and non-medical) around the time the condition starts interfering with work—issues that will set the situation off onto the right or wrong path.

The first few days and weeks after onset are an especially critical period during which the likelihood of a good long-term outcome is being influenced, either favorably or unfavorably, by some simple things that either do or do not happen during that interval. It is the optimal window of opportunity to improve outcomes by simultaneously attending to the worker’s basic needs and concerns as well as coordinating the medical, functional restoration, and occupational aspects of the situation in a coordinated fashion.

The best opportunity for basic intervention appears to last about 12 weeks or three months, although some data shows it ending by 6 months.  Many studies have show that a modest set of simple services—that embody an immediate, systematic, pro-active, integrated, and multidimensional approach—can mitigate the potentially destructive impact of common injuries, illnesses, and chronic conditions on quality of life among the working population.

In summary, the way a health-related episode that disrupts work unfolds over time in all dimensions—biological, psychological, social, and economic—can have a big impact on the outcome. Events that occur can either mitigate or aggravate existing risk factors in the situation, leading to better or worse outcomes. There are usually many opportunities to actively influence the course of events immediately after onset of a health problem (and many fewer opportunities later on), but today there are few resources devoted to finding and exercising these opportunities. Most of the current attempts to steer situations to a better outcome are made long after the best opportunities have passed by.

If you’d like the references for the research mentioned above, get a copy of our full report when it is published by the CFRB later this month (electronically) or in January (in print).

Bottom line:   If you agree that the USA needs a community-focused Health & Work Service, contact your Congressional representative, tell them you like our proposal and recommend that it be included in the 2016 SSDI reform legislation package.  Or even better yet, take a grass-roots approach.  Team up with other like-minded people to see if a local charity or foundation will fund your efforts start a HWS in your own community!

 

 

 

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