Tag Archives: intervention

May 22, 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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January 24, 2018

Normal people in difficult health situations benefit from psychological services

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

REFERENCE AND LINK

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

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

ABSTRACT

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

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

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

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

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

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October 31, 2016

Social Security Administration seeks input from YOU

I hope you will read — and respond — to this Request for Information issued by the U.S. Social Security Administration.  SSA is looking for input in order to decide whether to undertake a demonstration project (at the community level) for early intervention in musculoskeletal (MSK) conditions – in the first few weeks (<12) after onset of work disruption.

I’m sure SSA will really pay attention to thoughtful input they get from “front line” professionals and researchers / practitioners with expertise in this field — and from patients who have personal experience with the gaps and holes in our systems today that push them towards disability and job loss.

SSA will ONLY proceed with this demonstration project idea if they think it WILL decrease job loss, workforce withdrawal, and eventual applications for SSDI — by reducing needless impairment and disability while preserving livelihoods among the workers.   At this stage, SSA is asking basic questions about the level of evidence supporting the efficacy of early intervention, what the interventions should consist of, as well as the wisdom, practicalities, and potential efficacy of such an effort.

The deadline for responses is November 18.   There is a real possibility this demonstration will actually happen.  The President’s proposed 2017 budget has $200 million allocated for demonstration projects by SSA.    Whether or not that money will ever actually be appropriated will depend on many factors, including which candidate is elected President and the composition of the Congress.

While I was scanning the RFI to find the response date, I was stunned and delighted to see my name listed in one of the 3 references cited at the end!  SSA listed the concept proposal for a Community-Focused Health & Work Service that Tom Wickizer, Kim Burton and I contributed to the SSDI Solutions Initiative sponsored by the Committee for a Responsible Federal Budget.  All of the proposals, including ours, are available here: SSDI Solutions: Ideas to Strengthen the Social Security Disability Insurance Program .Maybe our work has actually made some difference – at the very least, SSA is now interested enough to seriously explore our ideas!

Now it’s YOUR turn to make a difference — by reading and responding to SSA’s RFI.

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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 28, 2016

Video on tools & techniques to aid recovery & RTW

You may like watching the video of a group discussion on Tools to Aid Recovery and Return to Work that was presented (and recorded) via Blab yesterday.  It was a stimulating exchange of ideas about both tools AND techniques with my colleagues Les Kertay, PhD and Chris Brigham, MD — as we each sat in our own offices.  Each of us were visible in our own little boxes on the screen.

The session was aimed at professionals in any discipline who want to hone their skills at working with individuals who are having trouble getting back on their feet.  It was sponsored by R3 Continuum and hosted by John Cloonan, their Marketing Director.

The video is now available on You Tube.  There are a few static-y and jumpy spots in the video, but I believe you will find the 60 minute conversation is worth your time.
Here’s the link to the YouTube version:  https://www.youtube.com/watch?v=jAwJFMD0hBo

Afterwards I talked to John Cloonan about Blab.  Apparently it has a built-in link to Twitter, so Twitter users can watch the live Blab video using Twitter’s Periscope capabilities.  Comments from Twitter users are fed to the Blab screen and are visible to presenters, which enables audience participation.  In addition, John was able to simultaneously link the live video to Facebook.   So while we were talking among ourselves, an unknown number of people were watching our discussion via R3 Continuum’s website, Facebook AND Twitter.   If you go any of those places, you can still find it.

Wow, talk about the ability to extend one’s reach and connect with many audiences!   Looks like John Cloonan (as a marketing guy who wants to disseminate messages far and wide) is drawn to Blab because it is possible to attach such a big social media megaphone to it!

As is typical with new technology, there are more challenges than are obvious at first glance.  For example, Blab works much better with a high-speed wired connection.  Some users may find their firewall is blocking it and have to figure out how to unblock it, etc. etc.  I had to restart my silly computer to get the microphone to work.  So having a “tech rehearsal” ahead of time was absolutely essential.

Les, Chris and I are all members of the Praxis Partners Consortium, by the way.

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November 19, 2015

Early EVENTS influence outcomes: You have power to make good things happen!

Few people realize how important early EVENTS are in determining the eventual outcome of a work disruption due to a health problem, particularly the most common kinds of conditions:   low back pain and other kinds of muscle and joint sprains and strains, depression, and anxiety.

Let’s call this a poor outcome:  a failed medical recovery that results in over-impairment and excessive “disability” accompanied by work absence and loss of employment that could have been avoided.  And let’s call this a good outcome:  the fullest possible medical recovery with the least possible physical or mental impairment and the smallest possible impact on the rhythm of everyday life, including minimal lost work time and continued employment.   Do you agree?

Here’s the exciting “so what” about this news that EVENTS influence outcomes:  all three of the professionals who respond to an individual CAN influence what some of those EVENTS are going to be.  Those three professionals are:  the treating doctor, the workplace supervisor, and the benefit claims handler.  This news means that each of them actually has some POWER to nudge things in a good or bad direction!!

See below for a brief description of why early events are so important, and how the experience of  people destined for lucky or unlucky outcomes differs.  In fact, these ideas are some of the main concepts of the work disability prevention model.  (NOTE:  The scientific articles that support the  evidence-based concepts are briefly noted in parentheses.  Their full literature citations appear in the list of References in our report that recommends the establishment of a nationwide Health & Work Service.)

When a working person’s life is disrupted by a new or changed illness or injury, the first few days and weeks after onset are an especially critical period.  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 (Bowling 2000; Cornelius et al. 2011; Franklin et al. 2013; Loisel and Anema 2013; Nicholas et al. 2011; Shaw et al. 2013; Waddell and  Burton  2004; Waddell,  Burton,  and  Main  2001).  It  is  the  optimal  window  of  opportunity  to improve outcomes by simultaneously attending to the worker’s basic needs and concerns (Shaw et al. 2013)  as  well  as  by coordinating  the  medical,  functional  restoration,  and  occupational  aspects  of  the situation in a coordinated fashion (Wickizer et al. 2011).

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

The best opportunity for basic intervention appears to last about 12 weeks or three months (DeWitt 1995; Franklin et al. 2013; Hashemi et al. 1997; Johnson and Fry 2002; Loisel and Anema 2013; Turner et  al.  2008)  although  some  data  shows  it  ending  by  6  months  (Rumack  1987;  Waddell  and  Burton 2004). 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 (Burton et al. 2013; Hill et al. 2010; Iles, Wyatt, and Pransky 2012; Kendall et al. 2009; Lagerveld et al. 2012; Loisel and Anema  2013;  McLaren,  Reville,  and  Seabury  2010;  Mitchell  2012;  Nicholas  et  al.  2011;  Shaw  et  al. 2013; Sullivan et al. 2005; Turner et al. 2008; Waddell and Burton 2004; Wickizer et al. 2011).

This new approach will allow people to avoid the kind of adverse secondary consequences of medical conditions that they too often experience today (Institute of Medicine 2001; Dartmouth 2008; Franklin and  Mueller  2015).  Those  consequences  are  not  usually  obvious  until  months  or  years  later,  after unfortunate things have happened. The unlucky ones have received sub-optimal health care, been left with undertreated 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 (Darlow 2011; Franklin et al. 2008; Franklin et al. 2014; Franklin and Mueller 2015; Habeck, Hunt, and VanTol 1998; Nguyen et al.)

CLARIFYING KEY TERMS

Figuring out where the opportunity to improve outcomes actually lies will be easier if we first clarify some terms that are often used carelessly or that mean different things to various audiences.

Work Disability vs. Disability
In the world of employment and commercial insurance, the word  “disability” is carelessly used.  In this world, the correct term is often “work disability” –which means absence from or lack of work attributed to a health condition.

According to the ADA, disabilities are impairments affecting major life functions (such as work).  Having a disability need not result in work disability.  This is a core concept embodied in the Americans with Disabilities Act. Similarly, having symptoms or a diagnosis need not (and usually does not) result in work disability.

Medical Recovery vs. Functional Restoration
Medical recovery refers to the resolution (disappearance or remission) of the underlying pathological process. Functional restoration refers to reestablishing the usual rhythm of participation in everyday life including 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 often accompanies medical recovery, but not always.  Even when medical recovery is not possible, restoration of function often is.   In some cases, it may require separate and specific professional attention.  Functional restoration may include rehabilitation (broadly defined), the successful use of assistive technology, adaptive equipment, and/or reasonable accommodation in the workplace.

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. A professional needs to provide the following services throughout the immediate response period (which typically ends with stable RTW or 12 weeks post onset).  These services are not generally available today, especially to lower-wage workers and those who work for small firms:

  • oversee and champion the affected individual’s stay-at-work and return-to-work (SAW/RTW) process until it is successful.
  • conduct a quick initial assessment and planning session that considers the individual’s entire situation, screens for known risks for poor outcomes, helps the individual and/or employer make a  SAW/RTW plan and  support them  in  carrying  it  out;
  • drive towards the best outcome by:
    — expediting and coordinating 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;
    — facilitating communications among all involved parties, ensuring they get the information they need so everyone has a shared picture of the situation and the goal;
    — taking a problem-solving approach with affected individuals, treating physicians, employers, and payers.

If RTW has not occurred by the time the 12 week period has ended, that should trigger a hand-off  to another professional with broader expertise for a deeper assessment which is likely to reveal the need for a different strategy, revised goals, a new approach, or the involvement of other disciplines.

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October 26, 2015

Medical “red herrings” lead to over-treatment & leave patients suffering

When I give a presentation, my goal is to give a gift to the listeners — some new information, perspective, or insight they might not have had before.  I spend time beforehand, imagining how they see the topic now, what they might be thinking, and how I should structure my talk to take them from “here” to “there.”

It’s very gratifying when they send signals that they “got it.”   The funnest [sic] part about public speaking is seeing people’s eyes light up or heads nod as I speak, or having them come up all excited to talk to me afterwards, or when they send an email — or when they write about what they heard.  It’s particularly graifying when the article a reporter writes matches up with what I hoped they would notice.  All those things were true last week when Keith Rosenblum (a senior risk consultant from Lockton), Dr. David Ross (a neurologist and developer of the NP3 diagnostic testing method) and I gave a presentation at the SIIA (Self-Insurance Institute of America) conference last week.  Our audience was a small group of professionals who work for companies (employers) that are self-insured for workers’ compensation.  Our topic was “How Medical Red Herrings Drive Poor Outcomes and Big Losses— and What You Can Do to Stop Them” .

And in particular, here’s a shout-out to reporter Robert Teachout (wow, a rhyme!) for really GETTING what we were trying to get across in our session.   Robert’s article appeared last Friday in HR Compliance Expert.

Dr. Ross taught the audience about the latest definition from pain experts on the essential nature of pain:  it is an EXPERIENCE put together by the brain after it analyzes and interprets many things.  Pain is NOT a sensation in the body.  He also described why and how “objective findings” on MRI often lead doctors to over-diagnose structural spine problems and provide over-aggressive treatments — because the actual source of the pain lies in soft tissues or the brain itself.

My job in the session was to point out this obvious but often overlooked fact:  doing surgery on the wrong problem is not going to make the patient’s pain and distress go away.  And I introduced the audience to the idea that there are other very common causes of prolonged back pain, distress and disability (summarized as biopsychosocioeconomic (BPSE – bipsee) factors) that may mimic or worsen noxious sensations coming from the spine.  Screening for and dealing with easy-to-treat BPSE factors BEFORE resorting to aggressive testing and treatment makes more sense than waiting until AFTER you’ve subjected the patient to those potentially harmful things.  That’s because MRIs, opioids, injections, and surgeries increase the patient’s certainty that their problem is in their spine while at the same time failing to relieve their pain AND causing side-effects and additional problems.    Keith recommended that employers / claim organizations start screening for the presence of a variety of BPSE factors — and get them addressed — BEFORE aggressive, potentially destructive and definitely expensive treatment even begins.  Screening methods can include simple things like questionnaires, or fancy things like the NP3 testing methods.

In addition, even when surgery IS needed, it makes sense to screen for complicating BPSE issues and address them BEFORE surgery as well as during recuperation — because having clear indications for surgery and being a good surgical candidate doesn’t mean a person is free of the kind of BPSE issues that reduce the likelihood of a good recovery.

I sent Robert, the reporter, a compliment via email that read:  “Robert, you did a remarkable job of capturing the salient facts, important implications, and key take home messages from our session.”  I hope you will read his article — and that you’ll send him a note if you found it informative or helpful

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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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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 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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