Category Archives: Musings

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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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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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 26, 2016

Two faulty beliefs about IMEs & impartial physicians

Patients and their advocates tend to be skeptical about independent medical opinions.   There are legitimate reasons to be concerned.  However, I want to point out two common but faulty beliefs that create UNNECESSARY distrust in this aspect of disability benefits and workers’ compensation claim management systems.  First, despite patients’ faith in their own doctors, treating physicians as a group are NOT a reliable source of accurate and unbiased information.  Second, although justice IS even-handed, impartial physicians should not find for both sides equally.

Based on my experience leading teams on three consulting projects that audited the quality of more than 1400 reports of independent medical evaluations and file reviews I definitely share MANY other concerns about the quality of the reports, the process by which they are procured, and the physicians and other healthcare professionals who provide them.  But these two particular issues are not among them. Read on to find out why.

FACT:  As a group, treating physicians are NOT a reliable source of accurate and unbiased information

First is the incorrect belief that the treating physician is the BEST place to turn for an “independent” opinion because they are highly trained professionals who are familiar with the patient’s case.   There are two main reasons why this is incorrect:

(a) There is considerable variability in the appropriateness and effectiveness of the care delivered by practicing physicians, and patients are not in a good position to assess it.  Evaluating appropriateness and effectiveness is admittedly a difficult and imperfect process, but the best way we know to do it is through the eyes of another physician who is equally or more expert in the matter at hand — and has no axe to grind and no financial stake in the outcome:  neither a friendly colleague nor a competitor.

(b) In medical school and residency, physicians are often told they should be “patient advocates” — but that instruction may not include a definition of advocating. (True for me and many others in physician audiences when I have asked about it.)  Patient advocacy sometimes turns into doing or saying exactly what the patient wants, not what is actually in the best interest of the patients’ long term health and well-being.  (I call this being a McDoctor.)  Particularly in today’s world with fierce competition between medical groups for patients and the use of “patient satisfaction scores” in calculating physician bonuses, that is true.  The data is clear:  treating physicians provide unnecessary antibiotics, pain medications, inappropriate treatments and are even willing to even shade the truth on reports in order to keep their patients happy.

The reason why arms-length or “third party” physicians are preferred as the source of opinions is to protect patients from harm from EITHER the “first party” (treating physician) OR the “second party” (the payer — which has an OBVIOUS business interest in controlling cost).  Judges, public policy people, and I get uncomfortable when the WAY the arms length physician is SELECTED is distorted by the interests of either the first party or second party.

FACT:   Impartial physicians’ opinions should not find for both sides equally

Second is the belief that “truly” impartial physicians should come down on the side of the patient vs. insurer half the time.  Or call it 50:50 for plaintiff vs. defense.  This belief is WRONG because cases selected for review or IME have been pre-selected by claims managers and case managers.   These professionals may not be healthcare professionals but because they see thousands of cases and become very familiar with the medical landscape, they ARE often more experienced OBSERVERS of the process of care than many physicians. They learn to recognize patterns of care that fit normal patterns, and care that is unusual.  These days, they are often expected to use evidence-based guidelines to identify outlier cases.  Those who focus on specific geographical areas come to see which doctors get patients better and which ones don’t.

The VAST MAJORITY of the time, there is no need / no reason to refer a case for independent review.  The treating physician IS doing the right thing;  the diagnoses, prescribed treatment, and causation determination (if work-related) DO appear reasonable and appropriate.   If the claims managers/ case managers see no problems or have no questions, they don’t refer the case for outside review.  If it aint busted, why fix it?

So as a rule of thumb, you can assume that some feature or another in ALMOST EVERY case being sent to review has RAISED QUESTIONS in the mind of an experienced observer of the care process.  The reason WHY the case is REFERRED is because that observer has only a very superficial knowledge of medicine.  They need an adviser — an impartial and expert physician who can evaluate the clinical facts and context and then either CONFIRM that the treating physician is doing the right thing or VALIDATE the claims/case manager’s concerns.

When claims/case managers are doing a good job selecting cases for referral, we SHOULD expect that MOST of the decisions will favor the insurer / defense. The more expert the claim/case managers are, the MORE LIKELY the independent physicians will agree — because the claims/case managers are accurately detecting real problems and concerns.

(By the way, a similar ratio seems to apply in the court system.   A judge once told me that MOST defendants ARE guilty – because the prosecutors don’t want to waste their time and public funds bringing cases to trial if they think the defendant is innocent – or if they simply think they will lose.    A perfect example  of this pragmatism is the FBI’s recent decision not to prosecute Hillary Clinton.  The Director made it clear that they didn’t want to waste the taxpayers’ money on a case in which they wouldn’t be able to convince a jury “beyond a reasonable doubt.”)

Consider this:  If you are a treating physician who FREQUENTLY ends up with your care plans rejected by claims managers and utilization review, consider the possibility that YOU stick out.  Your care patterns may be more unusual than you realize.  Your outcomes may be worse than your colleagues’.

Sadly, some physicians discredit input from independent experts in front of patients.  They THINK they are advocating for their patient — on a social justice crusade, but end up harming their patient instead — by teaching them they have been wronged, are a victim of “the system,” and a helpless pawn.  This message:

  • increases distrust, resentment and anger (which in turn worsens symptoms);
  • encourages passivity rather than problem-solving (which in turn increases the likelihood of job loss, permanent withdrawal from the workforce, and a future of poverty on disability benefits).

A former president of the Oregon Medical Association said he counsels patients this way:  “Your two most important treasures are your health and your job. And  I am here to help you protect both of them.”  Healthcare practitioners really ought to do everything they can help their patients find a successful way out of these predicaments, instead of allowing them to believe they are trapped.  The “system” is not designed to solve their life predicament for them — they may have to do it themselves.  The physicians’ care plans should consist of those treatments known to restore function and work ability most rapidly.  Physicians should encourage their patients to tell their employer they want find a way to stay productive and keep their jobs.  And if the employer won’t support them, physicians should counsel their patients to try to find a new job quickly — even if it’s temporary or they have to make a change to the kind of work they do.

Adapting to loss is a key part of recovery.   When I was treating patients, I could tell they were going to be OK when they said with pride “I’ve figured out how to work around it, and life is getting back on track.”

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September 9, 2016

Pithy 4-min Video & 1-page Manifesto for you to use

Mathematica just released a 4-minute video of me pointing out why the work disability prevention model is important — in plain language.  The video was made at the request of the US Department of Labor’s Office of Disability Employment Policy (ODEP).  The main messages in the video are:

  1. MILLIONS of Americans lose their jobs every year due to injury and illness;
  2. Worklessness and job loss have been shown to harm physical and mental health as well as personal, family, social, and economic well-being;
  3. Worklessness and job loss should therefore be considered poor healthcare outcomes;
  4. Unexpectedly poor outcomes can often be prevented and there is good research evidence about how to do that;
  5. Changes need to be made so that vulnerable people get what they need at the time when they need it — and as a result are able to have the best possible life outcome, stay in the workforce, and keep earning their own living.

In addition, the video also explains WHY and HOW some people have unexpectedly poor outcomes of conditions that do not normally cause significant work disruption and job loss.  Unless you’re in my line of work, it is hard to understand why things turn out badly in some cases and not in others — especially if they looked exactly the same at the beginning.

The video is loosely based on a one-page Work Disability Prevention Manifesto I wrote.  I put a draft of it on this blog last spring and got many useful comments.  After many revision cycles, it is now as succinct and compelling as I know how to make it.  ODEP had no hand in the Manifesto; it’s my independent work.

I’m glad I can now share these two items with you because the WORLD needs to know more about these issues—and most PEOPLE in the world have a very short attention span and no interest in the topic to begin with.   I hope you will pass this stuff along to the people whose thinking you want to change or whose buy in you need. Then maybe THEY will pass it along to others as well.  Social norms ONLY SHIFT when people share powerful mind-opening ideas with one another.

Lastly, let’s all stop speaking ABOUT these problems.  It is time for us all to start speaking FOR action and FOR changes.

WORK DISABILITY PREVENTION MANIFESTO
©Jennifer Christian, MD, MPH August 2016

Preventable job loss demands our attention

  • Millions of American workers lose their jobs each year due to injury, illness or a change in a chronic condition.
  • Preserving people’s ability to function and participate fully in everyday human affairs, including work, is a valuable health care outcome, second only to preserving life, limb, and essential bodily functions.
  • A new medical problem that simultaneously threatens one’s ability to earn a living creates a life crisis that must be addressed rapidly and wisely. Most people are unprepared for this double-headed predicament. It can overwhelm their coping abilities.
  • When medical conditions occur or worsen, especially common ones, most people are able to stay at or return to work without difficulty. However, many prolonged work disability cases covered by private- and public-sector benefits programs began as very common health problems (for example, musculoskeletal pain, depression, and anxiety) but had unexpectedly poor outcomes including job loss.
  • Loss of livelihood due to medical problems is a poor health outcome. Worklessness is harmful to people’s health, as well as to their family, social, and economic well-being.

Why do such poor outcomes occur?

  • Medical conditions by themselves rarely require prolonged work absence, but it can look that way. Both treatment and time off work are sometimes considered benefits to be maximized, rather than tools to be used judiciously.
  • Professionals typically involved in these situations (health care providers, employers, and benefits administrators) do not feel responsible for avoiding job loss.
  • Unexpectedly poor outcomes are frequently due to a mix of medical and nonmedical factors. Diagnosed conditions are inappropriately treated; others (especially psychiatric conditions) are unacknowledged and untreated. The employer, medical office, and insurance company (if there is one) operate in isolation, with little incentive to collaborate.
  • Without the support of a team focused on helping them get their lives back on track, people can get lost in the health care and benefits systems. With every passing day away from work, the odds worsen that they will ever return. After a while, they start to redefine themselves as too sick or disabled to work.
  • When people lose their jobs and do not find new ones, they barely get by on disability benefits and are vulnerable to other detrimental effects.

How can we fix this problem?

  • Good scientific evidence exists about how unexpectedly poor outcomes are created, how to avoid them, and how health care and other services can protect jobs.
  • Health-related work disruption should be viewed as a life emergency. Productive activity should be a part of treatment regimens.
  • When work disruption begins, it can be both effective and cost-beneficial to have a coordinator help the individual, treating physician, and employer communicate and focus everyone’s attention on maximizing recovery, restoring function, accommodating irreversible losses, and making plans for how the individual can keep working, return to work, or quickly find a more appropriate job.
  • We must urgently establish accountability for work disability and job loss in our workforce, health care, and disability benefits systems and build nationwide capacity to consistently deliver services—just in time, when needed—that help people stay at work or return to work.
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July 19, 2016

Overcoming fear of sharing our work with others

It’s scary to make a suggestion or share a work sample on a social networking site or a list serv in an effort to help less expert colleagues.  There’s a risk that an even-more-expert colleague will point out the flaws, or even make belittling comments.  If they’re kind, the expert will do it in private.  If not, there is the possibility of gossip behind one’s back, or public humiliation.

A colleague I deeply respect recently took that chance — not because he’s the world’s expert on a particular topic, but because he has a commitment to generously sharing what he does know for the benefit of others.  His goal in sharing his work product was to upgrade the way a particular issue is usually handled across the country.  That’s why I admire my colleague.  He offered a very concrete work product for others to use if they would like.

Fear of humiliation and being incompetent lie one millimeter beneath my skin. That fear, which is pretty common among humans, runs rampant in physicians.  It was intensified by our severe socialization during medical school and internship.  I hesitate every time I put any of my own thoughts or work “out there” for all to see.

I’m not alone in having this fear of being upstaged by someone more expert. For example, a doctor recently unsubscribed from the ACOEM Work Fitness & Disability Section list-serv with this comment:   “I joined the WFD section because I presumptuously (perhaps arrogantly) thought that given my decades of trying to navigate the rocky coastlines of fitness for duty and disability management I might actually have something of value to offer the newbies who might post questions.  So I responded to couple of posts and …… Well, let me tell you, I may be a big fish expert in my insular little pond, but soon recognized that the WFD Section is replete with knowledgeable, articulate, and fluent experts.  I really didn’t have much of anything new to offer. It was kind of like the experience of being at or near the top of your class in a suburban  high school then getting into a competitive college in the big city where everyone is as smart as you or smarter. So you folks don’t need me; you’ve got it covered. And I’m not fishing for compliments or encouragement either (which you couldn’t offer anyway since you don’t know me), just keeping it real.”

Got any ideas for how to solve this cultural problem?  I don’t — other than to point out these three aphorisms which seem relevant:

  • “Don’t let the excellent drive out the good.”
  • “You may need to lower your standards in order to improve your performance.”
  • “In the land of the blind, the one-eyed is king”

Fear of sharing stifles collaboration and innovation — so it inhibits any community’s ability to upgrade its current prevailing level of quality — “what typically happens”.  There’s something wonderful about people contributing what they DO KNOW.  There’s something wrong about being made to feel bad if it turns out someone else is EVEN MORE expert or wise.  So, perhaps we need to ponder, in the “land of the blind”:
— how a kind and respectful person with binocular vision (“the nation’s top expert at seeing”) should behave towards blind and the (rare) one-eyed people?
— how one-eyed people could best respond to input from the (very rare) binocular individuals?
— how blind people should differentiate between the (rare) one-eyed individuals and the (very rare) binocular people?

In the meanwhile, here is what happened with my colleague.   I received feedback that there were some inadequacies in his work product.  I sent that feedback along (anonymously by request) to him.  I ended my email with this:  “On behalf of all of those who are less well organized and systematic than you are, and for whom your tool provides a concrete model of what ‘good looks like’ — thank you for this contribution.   And, please, if you have the time, use the feedback to go take it up a notch!”

His response: “I’m very open to discussions on ways to improve this document.  I look forward to input of all sorts.”   He also plans to teach a session on how to use the “new & improved version” at our professional development conference next year.   THIS is the kind of professional behavior I DEEPLY ADMIRE.

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July 6, 2016

Where does working age end? Who is too old to work?

I’ve been trying to draw more attention to the special healthcare needs of the working age population since they power the engine of the economy.  The healthcare industry needs to expand its focus beyond symptoms and select treatments that rapidly restore the ability to function in this group  — to help them recover faster and more completely, to keep their jobs and livelihoods, and avoid the negative consequences of prolonged worklessness for them and their family!  Doctors and other healthcare professionals often don’t really THINK ENOUGH about the impact of their treatment regimens on working people’s lives outside the office.

But as I advocate, I’ve begun pondering that definition: “working age”.  It seems safe to use 18 as the low end of the range (even though kids younger than that do work, most of them are still in school).  But what about the top end?  At what age should we stop seeing work as the norm?  Stop expecting anyone to work?   Start thinking it’s silly to insist on working?  What term should we use to describe those who have lived for a really long time but are still very active and working?  What term should we use to describe people who are the exact same age but the press of years has made them too feeble to work anymore, even though they are “healthy”?  We all know people in both of these categories.  Simply calling them both old seems inaccurate.

I found a thoughtful article from the World Health Organization (WHO) exploring how to define “old” or “elderly” — in Africa!   Have you noticed how often we notice oddities about our own culture when we look outside it?  That’s when we notice the automatic assumptions and blind spots we’ve been living with.

I think you’ll enjoy reading the excerpts I’ve pasted below from the full WHO article.  I have colored in red the parts I found most eye-opening.  They are a breath of realistic and straight-spoken fresh air about how humans age.

Bottom line as I see it:  In developing societies where the administrative and legal fictions of retirement and pensions do not exist, the people tend to define old and elderly straightforwardly and on a case by case basis depending on the actual circumstances of humans as they accumulate years (and as younger generations come behind).  Old age begins when one assumes the social role of an elder, when one withdraws from social roles either because it is time for someone younger to take over or because of decline in physical / mental capability.  And finally, when it is no longer possible to actively contribute, one is definitely well into old age.

By that reasoning, if you are still able to play the roles and carry the same load of a person a decade younger, you are not old yet.  I still don’t know what to call you though.  Or, more truthfully, I don’t know what to call myself.  I am still in there pitching though I turn 70 years old this year.  I did recently give up one of my roles to make room for a younger person who deserved her day in the sun.  Didn’t want to hog it and hold her back.

Proposed Working Definition of an Older Person in Africa for the MDS Project

Most developed world countries have accepted the chronological age of 65 years as a definition of ‘elderly’ or older person, but like many westernized concepts, this does not adapt well to the situation in Africa. While this definition is somewhat arbitrary, it is many times associated with the age at which one can begin to receive pension benefits.

Although there are commonly used definitions of old age, there is no general agreement on the age at which a person becomes old. The common use of a calendar age to mark the threshold of old age assumes equivalence with biological age, yet at the same time, it is generally accepted that these two are not necessarily synonymous.

As far back as 1875, in Britain, the Friendly Societies Act, enacted the definition of old age as, “any age after 50”, yet pension schemes mostly used age 60 or 65 years for eligibility. (Roebuck, 1979). The UN has not adopted a standard criterion, but generally use 60+ years to refer to the older population (personal correspondence, 2001).

The more traditional African definitions of an elder or ‘elderly’ person correlate with the chronological ages of 50 to 65 years, depending on the setting, the region and the country. ….. In addition, chronological or “official” definitions of ageing can differ widely from traditional or community definitions of when a person is older.  Lacking an accepted and acceptable definition, in many instances the age at which a person became eligible for statutory and occupational retirement pensions has become the default definition. ….

Defining old
“The ageing process is of course a biological reality which has its own dynamic, largely beyond human control. However, it is also subject to the constructions by which each society makes sense of old age. In the developed world, chronological time plays a paramount role. The age of 60 or 65, roughly equivalent to retirement ages in most developed countries, is said to be the beginning of old age.

In many parts of the developing world, chronological time has little or no importance in the meaning of old age. Other socially constructed meanings of age are more significant such as the roles assigned to older people; in some cases it is the loss of roles accompanying physical decline which is significant in defining old age. Thus, in contrast to the chronological milestones which mark life stages in the developed world, old age in many developing countries is seen to begin at the point when active contribution is no longer possible.” (Gorman, 2000)

Categories of definitions
When attention was drawn to older populations in many developing countries, the definition of old age many times followed the same path as that in more developed countries, that is, the government sets the definition by stating a retirement age. Considering that a majority of old persons in sub-Saharan Africa live in rural areas and work outside the formal sector, and thus expect no formal retirement or retirement benefits, this imported logic seems quite illogical. Further, when this definition is applied to regions where relative life expectancy is much lower and size of older populations is much smaller, the utility of this definition becomes even more limited.

Study results published in 1980 provides a basis for a definition of old age in developing countries (Glascock, 1980). This international anthropological study was conducted in the late 1970’s and included multiple areas in Africa. Definitions fell into three main categories: 1) chronology; 2) change in social role (i.e. change in work patterns, adult status of children and menopause); and 3) change in capabilities (i.e. invalid status, senility and change in physical characteristics). Results from this cultural analysis of old age suggested that change in social role is the predominant means of defining old age. When the preferred definition was chronological, it was most often accompanied by an additional definition.

…… If one considers the self-definition of old age, that is old people defining old age, as people enter older ages it seems their self-definitions of old age become decreasingly multifaceted and increasingly related to health status (Brubaker, 1975, Johnson, 1976 and Freund, 1997).

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June 12, 2016

Almost embarrassed to mention my near miss with “disfigurement”

It’s almost embarrassing to mention my own personal experience with my birthmark, because it is so trivial.  But when I think about why my birthmark has NOT had much impact on my life, I see clearly the impact of the messages that kids get from their parents and the world around them.  I feel lucky and grateful — and more aware of the ways that the lives of others with the same or more substantial “imperfections” and “impairments” may have been changed by the reactions of their parents and the world around them.

There was a defining moment in my life when I had a near miss with defining myself as “disfigured”  Had that moment gone another way, I might have carried myself  differently, dealt with other people differently, and adjusted my view of the future that was possible, given my situation.

I do have a red birthmark on my cheek — roughly 2″ in diameter.  It has grown darker with the passage of time.  It was pale red in my youth.  In my mind, it has never been a big thing — but over the years I have come to realize that everyone doesn’t agree with that assessment.

My life would have been very different if my parents had taught me to see myself as disfigured. Daddy was a pediatrician, and approached every parenting issue from this point of view:  “What will create the best adult out of this kid?”

While I was in elementary school there must have been a specific day when I asked a question about my birthmark — because I remember what happened next.   They pointed out that everyone has “imperfections”.  In fact,  we (the four kids) then took turns combing over each other’s bodies until we did find some kind of mark on all of us.  Theirs were QUITE subtle: a pale brown “café au lait” spot on an arm, a patch of unusually thick and hairy skin.  Nothing on the face.   But as far as I was concerned, that proved the truth of my parents’ statement.

They also claimed that during Colonial times, people thought the best way to tell who was a witch was to look for an imperfection — because witches look perfect and real human beings don’t.  Later, with no apparent awareness of any philosophical contradiction, my parents also pointed out that only God is perfect. Overall, their explanations answered my questions, met my needs, reassured me, and settled the issue. I didn’t sense that anything was “wrong” with my birthmark, my face, or my appearance. I decided I was fine in that department.  And in fact, my parents indirectly told me I was pretty by constantly reminding me that  “beauty is only skin deep” and focusing their energy on molding and developing my “insides”.

So I grew up feeling pretty “normal” and reasonably confident — without any belief that I had any appearance problems beyond the ones that most kids have (pimples, hair, etc.).  No thoughts about my birthmark at all, really.  I wasn’t afraid of other people’s reactions to it.   In fact, I was only rarely asked about it, and then I would simply answer “it’s a birthmark.”   I was never ever teased about it or bullied — nor even called names.  A few years ago I realized that my maiden name (Harting) would have made a great rhyme with farting!  As things turned out, I was quite a popular kid, elected Homecoming and Junior-Senior Prom Princess two years in a row, etc — all the while feeling the usual terrible insecurities and desires of adolescence. Using my mother as my role model, I never wore any make up at all unless it was a dress-up occasion.  That’s still true now, except I wear cover-up for presentations as well as fancy parties.

It wasn’t until I was in my mid-30’s and went to a cosmetics counter to ask for cover-up makeup that the salesperson’s reaction taught me my attitude was unusual.  She said most women in my situation WHISPER when they approach to ask her for cover-up.  A few months later, a woman my mother’s age (with whom I had gotten quite close) asked why I didn’t cover my birthmark.   I acted surprised and said it just didn’t seem necessary.  She then shared her theory: she had decided my coping strategy was to be defiant and “flaunt it.”  I was stunned. I had had no inkling she thought my birthmark WAS a big deal.

She did get me to thinking though.  I realized that if other people notice the birthmark, I can use it.  So now when I arrange to meet people I’ve never seen before, I sometimes remember to say I have a birthmark on my right cheek.  It’s useful as an “identifying mark” as the cops would say!

What a gift my parents gave me!   Imagine how different my perception of myself and the way the world was looking at me — and thus my interactions with the world — could have been. All because of a little 2″ square red mark on the skin, that affects no function at all.  I suspect that my outgoing and dominant temperament / personality and social skills have also been a help.  The fact I never experienced bullying of any kind (until I was in medical school) indicates to me that I am by nature near the top of the human version of the hen house pecking order.

I sat next to a guy on a plane recently with a facial birthmark like mine–a hemangioma.  His was BIG.  It covered half his face and neck.  In some places, dark blue-red skin hung in folds, almost like a turkey.  It really was disfiguring — from my vantage point, one side of his face didn’t look like a “regular” face at all.  The guy was SUPER chatty, outgoing, and engaging.  He was almost so “in your face” as to be socially odd.  But after a minute or two, the net result was that he put everyone at ease because our focus shifted to the topic of conversation instead of his appearance.  Turns out he is a specialist in some sort of technological field (forget exactly what) and is on the road constantly.  That means being out in public and meeting new people in new situations is his everyday reality.  I decided that his extreme extroversion is the way he has responded to his predicament — the way he copes with the outside world’s reaction to his appearance.  Rather than shrink away, ashamed, in an attempt to be invisible and thus sidelining himself, he has INSISTED on his right to participate fully in life by INSERTING himself in the middle of it.  I wonder what HIS parents told him as a child…….

I guess you could say that guy on the plane and I have ended up in similar places — with an approach sort of like the puppy in The Present video.  If you don’t SEE yourself as disfigured / disabled, and/or if you don’t even CARE that you are, life is a lot bigger and more fun.

Which makes me wonder:  why do we insist that people define themselves as “disabled” in order to be eligible for “reasonable accommodations” that would let them get or keep a job?  Why can’t we just ask them to explain what they cannot do without the accommodation — instead of insisting that they label themselves?

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