Category Archives: Tools, Techniques, Methods & Money

October 19, 2015

WHY would I want to live to 101?

I am a bit upset and depressed because I just learned my life expectancy is 101 — according to the electronic calculator that analyzed my answers on the Health Age Questionnaire.  I found it on the website of the American College of Lifestyle Medicine.  It seems like a good organization aimed mostly at doctors who prevent chronic disease by prescribing and teaching healthy lifestyles.  However, they had better come up with a better argument for lifestyle change than this:   “Wow, if you do everything we recommend, you get to live until you’re entirely useless, helpless, and bored out of your mind.”

After I got the 101 prediction, I redid the questionnaire, this time shading several answers to the “sad” side instead of the “happy” side — and the darned thing STILL says I’m going to live to 94.  Phooey!  Who the heck WANTS to live that long?  NOT ME!   I can clearly imagine my quality of life is likely to be by then. By the time Americans get over the age of 90-something, the VAST majority are demented, frail, and unable to live independently — and I might add have become totally irrelevant in the eyes of the rest of American society, with a status more similar to pets or babies than adults.

That was my dad’s fate.   He died just a few days before he turned 89 — after refusing medical care for a heart attack because he had been WAITING for a way to die.  Before that day, his medical problems were basically age-related degeneration.

A Harvard College, Harvard Medical School grad, former Director of one of the National Institutes of Health, my dad re-invented himself and his career at least three times.   Originally trained as a pediatrician, he spent most of his career focused on child and maternal health, family planning, and other services to facilitate optimal development and health of the population.  At about age 50, he left the pressure of Washington DC, gave up on a difficult marriage to my mother, and moved to the Eastern Shore of Maryland.  He became a county health officer, developed a wide circle of friends and got involved in community affairs.  He was always a kind, optimistic, creative, and positive person, even though he didn’t have much of a sense of humor.  But his fun-loving second wife put him up to a lot of innocent mischief.  We have a photo of him in Florida wearing a lei on his head, a bra made of coconut shells and a hula skirt — and a HUGE SMILE (while stone sober, I may add).

Around about age 80 he “retired” from medicine.  And then, with some partners, he started a Sylvan Learning Center franchise and founded the Delmarva Education Foundation.  He was still in there pitching, though clearly slowing down.

Shirley, his beloved second wife died in May of 2006, the year he turned 84.   A few days after that, he commented to me “I’ll never be the center of anyone’s life ever again.” His zest for life was gone because she was.  She had cherished him and nurtured him — and vice versa.  He was lonely, sad after that, and grew increasingly bitter.  He had zero interest in finding a new companion or keeping up his social life. Treatment for “depression” had no effect.  My sister who lived nearby did yeoman work to be family and provide companionship to him — and do the practical work required to keep him in the housing complex for independent elders where he lives.   By the time she gave up and moved him to assisted living, there were FOUR part-time workers supporting him — plus her.  However, Daddy was right, of course — he never was the center of anyone’s life again.

He had already given me his healthcare power of attorney.  We had explicitly discussed his wish that I protect him from “the medical juggernaut” in case he was unable to do it himself.  He also did done some exploring of ways to exit gracefully.  I sent him an article from the New England Journal about what dying is like for patients with terminal conditions who refuse food and drink as they near the end of life.  But when my dad in Maryland discussed this with his psychologist, the psychologist pronounced the method both a sin and against the law — so Daddy resigned himself to sticking around.   In February of 2008, almost two years after Shirley’s death, Daddy (who could no longer write because of a worsening tremor) dictated this to his psychologist:

Because of my many disabilities – vision, hearing, etc. – I am happy to take advantage of the first opportunity that the Lord provides to join my wife Shirley in heaven.  My daughter Jennifer holds the medical power of attorney for me.  As a physician, she has the knowledge to determine what conditions are most likely to result in death, or result in disability that I would have to live with.  In the former case, I would like medical care withheld if my condition would ordinarily result in death, and would like for hospice to provide palliative care.  In the latter case, I will just ‘grin and bear it’.   I have made peace with the Lord in this decision, and ask that all my children support the decision that I have made.

As he neared 90, the burdens of age had became even heavier.  He still had no “terminal” conditions other than age.  He was deaf, could no longer read or see the computer screen due to macular degeneration, had a tremor, chronic pain due to joint degeneration, and was very weak.   He had lost all of his curiosity and most of his mental power.  At one point, he was on 14 different medications,  most of them with no discernible effect.  I asked his doctors to stop as many as possible because nothing could reverse the progress of aging.

In the end, Daddy handled his exit firmly and gracefully, by himself, when he developed severe chest pain.  He obviously recognized it for what it was — a potential way out.   He told the ER doctor:  “I’m just here to check and make sure it IS a heart attack.  If so, all I want is morphine, no treatment.”   The ER doctor, luckily, had her wits about her and suggested hospice.  He immediately said yes.  He lived less than a month — long enough to have one last Christmas Dinner with his kids and grandkids.  Then he let go and left this earth.

More than twenty years earlier, Daddy and I had completed a multi-scenario medical decision-making worksheet.  It was designed to make us think about and decide what we wanted our caregivers to do in various medical scenarios if we became unable to express our wishes. Surprisingly, that conversation wasn’t a downer at all.  In fact it was the best conversation I think I EVER had with him because we talked frankly and intimately about what made life worth living for each of us personally — and when it wouldn’t be worth continuing.   At the time, he said he wanted to be kept alive until he couldn’t enjoy the day anymore.   Yet as things turned out, he was forced to live four years after he had stopped being able to enjoy the day.  .

We humans have invented ways that are KEEPING people alive longer, but we haven’t yet invented ways to safely and humanely allow those who HAVE BEEN kept alive past the time when they find quality of life tolerable to say they have “had enough, thank you” and move on to the next realm.

I don’t want to share my Dad’s fate.  The idea of being sidelined, trying to think up “ways to pass the time” because I’ve become too deaf and blind to read or interact with others or do anything useful, beset with the chronic aches and pains of aging bones and joints makes me feel YUCK, or more accurately, DREAD.

Even if I were a “hale and hearty” 90 year old, I can’t think of a PURPOSE that I personally would find exciting enough to make life worth living when I’ve been alive that long.  “Smelling the roses” doesn’t do it for me — because I am already starting to feel like I’ve had my fill of a lot of things.  Been there, done that.  Been THERE and done THAT, too.

For the foreseeable future, my current purpose for living are these:
1)  Devote my energy and talents to leaving the campground of life better than I found it.
2)  Enjoy everyday life with my husband, family, and friends — and the outdoor world.
3)  Seek beauty and truth, especially in music, opera, theatre, dance, the visual arts, and spiritual practice.
4)  Grow in wisdom and kindness.  A VERY COOL thing is that personal growth & development in these two areas are available to all ages, including the very old (ahem, until dementia sets in).

What does this mean for you — if anything?   Maybe you could think about what makes life worth living for you.  It will make you feel STRONG and GOOD to do it.    Fill out a Five Wishes living will from Aging with Dignity that gives your caregivers instructions for how to care for you in case you can’t tell them yourself at a critical moment.   And, do think about what you want the quality of your life to be like and how long you DO want to live.   Do YOU really WANT to live to 101 or to 120?  Why?  What FOR?

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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 8, 2015

Dan Siegel says I can use my mind to reshape my brain — or YOURS!

I’m in the middle of taking an on-line course by Daniel Siegel, MD.  I hope you do, too.   It’s called “Practicing Mindsight” — 6 hours consisting of 32 video mini-lectures delivered live to an audience of about 240 mental health professionals, physicians, educators, as well as organizational behavior and social policy wonks.   (I’ve also  heard a great TED talk by this guy).  He’s a famous psychiatrist, trained at Harvard Medical School and UCLA, now clinical professor of psychiatry at UCLA, an award-winning educator – and expert researcher in the emerging field of “interpersonal neurobiology”.

It’s on a website called www.Udemy.com.  I’ve listened to the first 9 mini-lectures so far.  He began by asking how many of the professionals in the audience think the mind is important in everyday affairs — and in their practices/organizations.  All hands went up.  Then he asked how many had any instruction on what the mind is?   Five percent raised their hands.   He says that the proportion has been similar in 85,000 professionals he has asked.   He  says the purpose of the course is:  How to see the mind and make it stronger.    I say the course is focused on STRATEGIES for changing the STRUCTURE of the brain (one’s own and that of one’s patients/clients) by using the mind.   Think of that:  USING the mind as a tool to INTENTIONALLY remodel circuits in the brain.

Here are three big points I have heard in his lectures so far:

(a) Key definition:   The mind is a PROCESS not a thing.  It REGULATES (monitors and directs) the flow of energy and information both within an individual and between people.  (Energy is roughly defined as stuff that makes things happen.  Information is both data and meaning or story.)  As part of his grant-funded work, he had put together a group of 40 researchers in a wide variety of fields who were all (eventually) able to agree on this definition.

(b) “Attention” – which is where the mind focuses, what it is paying attention to  – is what CREATES new neural pathways, and STRENGTHENS either existing or new ones by reinforcing the pathway.  As the saying goes: “neurons that fire together wire together”.  For example, the more we pay attention to our pain (assessing it, worrying about it, “fighting” it), the deeper we are carving that channel.  Common sense, grandmothers, and “New Agers” have been telling us for years to focus on what we DO want instead of what we DON’T want  — and now science is confirming it.

(c) Humans are genetically programmed to AUTOMATICALLY create internal experiences and capabilities that mirror or incorporate things they see or feel during interactions with others.  As we watch someone else raise a glass of water to his lips, the cells in our brains that move our own arms light up.  We sense his intention to drink, we may experience thirst, or the sensation of water or of refreshment.  We feel sad when someone cries, and are happy at their joy.  Others’ brains shape what goes on in ours —  what circuits are firing and being reinforced — and vice versa.  Simultaneous mutual (interpersonal) experience is a KEY part of the “social” in our “social species”.

So I got this:  The techniques we use to SHIFT our attention (or another person’s attention) away from bad stuff and towards more productive ways of thinking are actually MODULATING neural circuitry in the brain (which is neuroplasticity in action).  This has now been confirmed by rigorous research on techniques such as mindfulness, CBT, etc.   (I personally remember reading a study which showed that SIMILAR changes in the brain can be observed after either medication OR “talk therapy”.  In that TED talk by Siegel that I watched, he asserts that much of the circuitry in our frontal lobe is created and shaped by everyday INTERPERSONAL INTERACTIONS which DEVELOP it – and of course it is our frontal lobes which make us uniquely human.)

The takeaway for us as physicians in tangible organ-system-focused specialties is there is POWER TO HEAL in our words —  and in the human quality of our interpersonal interactions.  We have an opportunity to INTENTIONALLY HARNESS that power and explicitly add it to our therapeutic armamentarium.

Although the mental health professions already are aware of the power of words and relationships, physicians are on the front-line dealing with patients with PHYSICAL complaints and distress.  We are in the best position to use the power of words and relationships to start relieving those symptoms and easing that distress — even if all we do is alert the patient to the healing power of the mind and persuade them to accept help from a mental health professional.  Apparently, the only specialty these days that requires training in patient communication is family practice.  Thus, this appears to be a neglected skill area in all of the other medical specialties.

Those of us who have accepted the idea that sickness and disability are the COMBINED product of bio-psycho-socio-economic factors, and who are setting out to reduce the disruptive/destructive impact of injury/illness on quality of the patient’s everyday life and future – especially in at risk cases and “heartsink patients” — MUST master this stuff.  We need to practice the SCIENTIFIC ART of empathic therapeutic interaction.  We must learn how to effectively redirect the patient’s attention into more appropriate channels so they develop their own capability to adapt to / cope effectively with their own situations.

The tuition for the Siegel Practicing Mindsight course is usually $137, but if you follow the directions below, you may be able to get a $39 special rate.  It supposedly ends TODAY — although it supposedly ended yesterday, too.  Some people don’t seem to be able to find the $39 offer.  There’s probably a glitch of some kind that is making it show up only when you wend your way through the electrons a particular way.

Here’s how I found it again just now:  I use Firefox.  I entered  “daniel siegel mindsight” in the search box, then I clicked on the link for an Udemy ADVERTISEMENT that appeared in the top left corner of the search results.  The website that appears says the rate is $39 again today (coupon valid until October 8).   But when I went STRAIGHT to the udemy site, the cost is $137.

Go for it — fool around, and then REGISTER!   But bring your brain AND appreciation for quirkiness with you.   This is  fascinating material taught by a deep and independent thinker, serious expert and experienced researcher.  And, Siegel is a character with really colorful personal stories:  so far we’ve heard tales of misfittery in medical school, salmon fishery, dance, nudity in Greece, etc.

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August 12, 2015

Who will address working people’s reasonable concerns when illness or injury disrupt their lives?

What do working people wonder and worry about when their lives (and work) have just been disrupted by a new illness, injury, or a change in a chronic condition?

While creating a course to train doctors how to meet their patient’s needs, we realized we had to know what those needs were.  It seemed obvious that patients would want to know what is wrong with them and what kind of medical care they need.  But beyond those things, we came up with a list of predictable and totally reasonable issues:

How long am I going to be laid up (out of commission)?
How long do I have to take it easy?
When I can go back to doing my usual stuff?
In the meanwhile, what can I still do? What shouldn’t I do?
What can I do to speed my recovery?
If I can’t work, how will we pay our bills next month?
When will life be back to normal? …..if ever?
What does this mean about me?   My future?
What is this going to do to my livelihood?  What will this do to us financially?
Who will help me?  Who can I trust?  Who has my best interests at heart?

I often show this list when I am speaking to groups about how to improve outcomes for people with common health conditions like back pain.  It always rings true with the audience.  After one presentation, an influential executive (in a wheelchair with quadriplegia) told me that she had had all of those concerns immediately upon awakening after her accident.

Here’s my question:   How are people getting these questions and concerns answered — when and by whom?  The standard design of a medical visit (memorized by all physicians during our medical training) DOES NOT include a time for doing it.  There is no sub-heading in our report format called:  Patient Education,  Instruction, and Guidance.  If it is happening, it is spotty at best.

So if most doctors are not answering these questions, who is?   Which of the other professionals who are responsible for responding to life & work disruption in working people IS going to address them?   Unless one of these “experts” does so, the people will have to come up with their own answers.  Yet how many are prepared to do that?   They will come up with their own best guesses (which may be wacky) or may turn to their family, friends, co-worker, neighbor, union steward, or a lawyer for answers (who may or may not give them a bum steer).

What does this mean for you?  If you are committed to better service (and/or want to avoid the trouble caused by bad advice), figure out a way to meet people’s totally reasonable needs for information and advice.   If you are a treating clinician, consider making a revision to your standard visit protocol and report templates by adding that missing section:  Patient Education, Instruction & Guidance.

Another simple idea for healthcare providers, employers or insurers is to create a standard operating procedure to mail out or hand out a brochure.  The 60 Summits Project developed a fact sheet for employees whose health conditions have just started to disrupt their work — and a fact sheet for supervisors on how to manage the situation in the workplace..  Feel free to use these sheets as is, or remove the 60 Summits logo and revise them to suit yourself.  But please do SOMETHING!

 

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July 20, 2015

My “mini-manifesto” to reduce spine disability

You may be interested in the “mini-manifesto” I delivered this past Saturday 7/18 at the Spine 10×25 Research Summit in Chicago hosted by the North American Spine Foundation.  They have declared a worthy and very ambitious goal:  to reduce spine disability by 10 percent by the year 2025.  Thus the name: Spine 10×25. Pronounce it like you’re buying lumber – “10 by 25”.

(You can see the video and listen to my talk —  or even the ENTIRE 8 hour event because it was live-streamed and recorded.  Click here to do so.  Advance the recording by moving the blue dot along the horizontal line.  My talk starts at 5:31:50 and goes until 5:51:30.)

Do you know of any other medical group that has drawn a bold line in the sand like that?  I don’t.  It had never occurred to me that a professional society would set out to measurably move the needle.  They just don’t take on that type of project.  Most healthcare professional associations content themselves with pontificating:  being experts and telling other people what to do and how to do it.

My own professional society (ACOEM – the American College of Occupational & Environmental Medicine) has made many significant contributions to society.  In particular, our evidence-based treatment guidelines are very well regarded and in use by several states.   ACOEM has produced many other useful publications that have had a positive impact.  In fact, some of them were developed under my leadership.  But, in the end, they all amount to pontification.

In 2006, I told ACOEM I didn’t want one of those documents to just sit on an electronic shelf. We had developed it in order to introduce the work disability prevention paradigm and shift the way all stakeholders think about work disability.  Entitled “Preventing Needless Work Disability By Helping People Stay Employed“, that report needed to go out into the world.  Thus, the 60 Summits Project was born to carry it into the 50 US states and 10 Canadian provinces of North America.  We created groups of volunteer professionals who planned and held 20 multi-stakeholder summit-type conferences in 12 states and 2 provinces.  We invited the attendees to consider ACOEM’s 16 recommendations for improving the stay-at-work and return-to-work process.  We asked them to decide if they liked each recommendation, and if so, to make a plan for how they were going to carry it out in their own business, community, and jurisdiction. (60 Summits eventually ran out of money and was mothballed.)

Then last month, the boldness of the Spine 10x 25 initiative made me realize that even The 60 Summits Project had a pontification angle to it.  Propagating a new way of thinking and discussing a set of recommendations for change is not the same thing as CARRYING them OUT.  I felt compelled to go and check out these NASF people and participate in their Spine 10×25 Research Summit.

My assigned topic was “Precedents and Prospects for Success” in a 15 minute time slot that got expanded to 20.  It seemed important to speak straight and share my ideas about what needs to be true in order for their goal to be realized.  I offered the audience a (draft) conceptual foundation to use as a context for change, as well a summary-level vision of the way things will look in the future WHEN things have ACTUALLY changed and spine disability is BEING REDUCED by 10%.  View it here. Remember to advance the recording to 5:31:50.

I may expand a bit on some of the main points of that mini-manifesto in later posts.  I developed all of those slides at the conference in order to take into account what the speakers said who had gone before me!  Luckily, I also had some time at lunch.  The tight time limit meant a few big ideas got short shrift.

 

 

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July 7, 2015

Free on-line CBT course helps Australians living with pain feel better

An Australian study in the journal Pain reports that a FREE on-line course that employs CBT techniques has worked well in helping patients with chronic pain reduce both distress and other symptoms  — no matter how much contact the patients had with a clinician during the several week course – and it clearly outperformed “usual care.”

The Pain Course was developed by psychologists as part of a non-profit initiative of the Centre for Emotional Health, part of Macquarie University in Sydney, Australia.  Their tagline reads:  “Developing effective, accessible and free psychological treatments …”   Before you get TOO excited, this particular course and the other on-line offerings of ecentreclinic.org which developed it are only open to residents of Australia.

Here’s a bit more about this group from their website:   “We comprise a team of psychologists, psychiatrists, and research staff….The eCentreClinic is a specialised research clinic that develops and tests state-of-the-art free online treatment Courses for people with symptoms of worry, panic, social anxiety, OCD, PTSD, stress, depression, low mood and other health conditions including chronic pain. We built the eCentreClinic because millions of Australian adults suffer with these symptoms and conditions each year. But, most do not seek help or see a mental health professional. We believe that people have a right to helpful information and to know about practical, proven, skills that help. We hope that by providing this information and supporting people to learn these skills via the internet more people will learn to master their symptoms and conditions. By doing this we hope they will also improve their quality of life and that of their families and communities.

Here’s a link to the abstract.   It is is an open access (free) article, so you can also download a pdf of the entire article here.

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July 6, 2015

Why Put People Who Don’t Care in Charge of Timing?

I just realized that there are two short little sentences that are causing BIG PROBLEMS.   They are:

1.   “We can’t start looking for transitional duty for him  (or, we can’t start the reasonable accommodation process) until we get specific work restrictions from the doctor,” says the employer.

2.   “She will be eligible for job training only after her condition is declared to be medically stable (at MMI or P&S) and permanent work restrictions for all body parts are known,” says the benefits administrator.

These two sentences reveal that the speaker is in a REACTIVE posture, refusing to make an effort to get out ahead of the ball.  They are passively waiting for a PHYSICIAN or the POLICY/LAW to determine the timing of an important event  — an event which could have a huge impact on the outcome.   The problem is:  neither the physician nor the insurance policy/law are watching time slip away.

I hear these two sentences frequently during the part of my week when I serve as a physician adviser to a multi-disciplinary care management team.  Since many of the standard techniques to manage claims have previously been tried, I often suggest non-standard things.  I tend to hear those sentences AFTER  I suggest doing something pro-active in a case that’s stalled out and headed towards a predictably poor outcome.  For example, I may recommend that INSTEAD OF WAITING, we approach the doctor with an proposal for a return to work plan and some potential transitional tasks.  Or I may recommend that we acknowledge the obvious handwriting on the wall — which says the person is never going to go back to the original employer — and offer the worker some psychological or vocational counseling to help them start focusing on the future and figure out what kind of work they want to do and how to find a new job.

The PHYSICIAN doesn’t know that the longer employed people are absent from work due to a health condition, the more likely it is that they will lose their jobs, never get another one, and end up on as a long-term disability claimant.    And with a conventional medical education, the doctor doesn’t feel responsible for helping patients stay employed.

So WHY is the employer WAITING for the doctor?   WHY can’t the employer ANTICIPATE the general nature of the limits/restrictions?   If the shoulder has been affected, it’s obvious the restrictions will involve lifting and reaching!   If it’s the right foot, it’s obvious there will be limitations on walking and standing!   If you’re uncertain what workers can do, ASK them!  (The Americans with Disabilities Act expects you to do so.)   If the employer and the employee propose a plan to the doctor that they both agree on — what are the odds the doctor will say no?  VERY LOW!

The POLICY or LAW describes outer limits, not the best path.  The law usually dictates the earliest or the latest date when something must occur —  not the optimal timing of it.  So WHY is the benefits handler WAITING for the formal declaration of MMI / P&S?  This too is not part of conventional medical training.  Most doctors don’t see it as a milestone and are unaware they’re supposed to make a formal statement.  I suspect that benefits handlers are so worried about violating rules and regulations that they think they HAVE to wait to start helping a person move on and find a new job until the LAW MANDATES it.  Why can’ t that benefit handler VOLUNTARILY make a move earlier?

Seems to me that determining the OPTIMAL timing for events, and deciding whether to offer BETTER assistance than the minimum specified in the law lies within the discretionary authority of the benefits handler.  In fact, aren’t we supposed to be paying them to use their judgement?

[CAVEAT: This has been true where I have worked, but maybe in some jurisdictions or policies, I’m wrong.  If you are more expert on these matters than me, please tell me why I’m incorrect.]

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June 18, 2015

Pain-free without surgery — despite horrible-looking MRI

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

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

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

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June 17, 2015

Communications Clarity Dept: Useful distinctions

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

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

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

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

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

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

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

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

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

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June 5, 2015

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

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

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

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

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

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

 

 

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