Monday, August 18, 2008
Dr. Adams’ Case Management Update (Since 1999)
This is the 505th Weekly Issue
This Week's Topic:
"The Too Common Apology"
Question:
"Have you ever tried
to differentiate between those injured workers who hire a lawyer and those
who do not?"
Dr. Adams replies:
"I
recently viewed an event in which a toddler who was not supervised by his
father, ran from a store and then briefly caught his fingers in the closing
door.
There was no tissue damage, but the child wailed. He wailed loudly.
The father of the screaming child then yelled at another patron who was entering
the store at that moment as if it were the patron's fault simply because he was
there.
I had watched this child sitting at a table with his father, thrashing about
prior to the accident, attention-demanding, and chiefly ignored by his dad.
The store manager came forward to try to soothe the father and the boy. The
father would not accept the verbal support, and, rather than remove the child
from the environment, he allowed the child's cries to continue to escalate.
An employee came forward with ice which father and son also refused. The volume
level of the child's screaming increased.
Another patron witnessing this, and having his wife and children with him, came
to assist, offered the child ice cream and tried to console the father. He tried
to reassure the father after looking at the boy's hand. Again, all was refused
as the situation grew in magnitude.
I then saw the child's hand. It was red, neither bleeding nor (as yet) swollen.
Had the father removed his child from the store, he would have been providing
what is called a "Type One Cure." When someone is traumatized in a setting,
remove them from that setting and do little to remind them of the setting they
have just left.
I am certain that I was not the only person there believing that the father was
looking at legal/financial recourse for an event that was purely accidental. and
if anyone were responsible, it was the father's, for being inattentive, and the
child's, for being disobedient.
We have a blameful society. When ill-fate befalls us, it is never just an
accident. It is almost always "someone's fault, and they are going to pay."
For explicable, but not necessarily optimistic reasons, we have evolved into a
society that has ceased to suck it up, tough it out and, instead, feel that we
have recourse to the law...rather than responsibility for ourselves.
Many (most?) patients, because of the nature of American culture, believe that
they must be compensated even for their own carelessness but especially if
someone else makes a mistake.
However, we worsen that situation. Unlike the manager in this store and other
patrons in the store, when someone is injured at work, they are repeatedly
frustrated by lack of access to timely care, abandonment by coworkers and
friends, and are most often left with no advocate. It is then that they turn to
attorneys, and many will apologize for having no choice but to do so."
Monday, August 11, 2008
Dr. Adams’ Case Management Update (Since 1999)
This is the 504th Weekly Issue
This Week's Topic:
"Sights of Surgery"
Question:
"Do you ever wonder how a
patient without education sees surgery?"
Dr. Adams replies:
"I'll
discuss the exceptions in a moment, but for the average injured worker, surgery
is a mixture of hope, fear, confusion, concern, and desperation. Few
industrially injured workers, those with high school education and less,
understand what their surgery will entail.
For better
(although I believe for worse), their concerns are dismissed, or, at best,
minimized when they ask questions or admit to fear. They are told that "there is
nothing to worry about" and "this procedure is done all the time" and certainly
"it is no big deal."
To the patient, it is.
Recently, a patient of mine, injured four years ago, and having hip surgery two
years ago, was told that he now needs lumbar surgery. He does not understand the
procedure. He is pessimistic that it will be of benefit. He is fearful of going
under anesthesia, and, unquestionably, he dreads the entire experience. His last
surgery was fraught with complications including re-admission for post-surgical
infection, inadequate orders for pain medication and a dismissive attitude from
both surgeon and hospital staff.
In brief, it was, for this particular patient, a truly horrific experience.
Now here he is being told that he has no option but to have additional surgery.
His concerns are dismissed if not derogated. If he could avoid surgery, he
certainly would, but he is certain that there is no choice.
So imagine what that would feel like: dreading, fearing, and not trusting a
procedure and being told that you must proceed regardless of your emotional
response.
For this particular patient, he is in psychological care and has a venue in
which he can de-burden himself of these fears, understand and confront them and
move forward. But most patients do not have that option. They battle for
authorization for a procedure, that they clearly do not want; fighting for
something that they actually dread is certainly a miserable emotional conflict.
Managing the fear of impending surgery is not an easy task, and for many. it is
not a task that can be completed without assistance."
Monday, August 4, 2008
Dr. Adams’ Case Management Update (Since 1999)
This is the 503rd Weekly Issue
This Week's Topic:
"The Great Entrenchment"
Question:
"A a lecture, you
referred to the "great entrenchement." What exactly is that, and is it
something we need to avoid...and how do we do that?"
Dr. Adams replies:
"Entrenchment
is not a good thing. Its true definition comes from the military where it is a
type of fortification created by digging.
In the case
of personal injury, the patient becomes entrenched (dug in) to their complaints,
their care and their own perceptions of disability, and they fortify (or resist)
so that they cannot be moved forward.
This quite
often happens when they fall into the hands (practice) of a clinician (primary
doctor) who continues to treat despite making no progress in resolving the
patient's complaints. The doctor becomes unwilling to release or refer the
patient, and the patient begins to believe that only this doctor can be of
help...even though the patient has shown little or no benefit to remaining in
the care of this doctor.
This is
entrenchment. And the patient often becomes a staunch supporter of the doctor
even though no one else involved in the case feels that the doctor is helping
the patient.
The patient
begins to feel that he must protect the doctor from the outside criticism. The
patient fights to remain in the car although months, and sometimes years, have
elapsed without improvement.
The doctor
becomes dependent upon the patient, either emotionally and/or financially, and
cannot act upon the reality that he has provided little of lasting benefit to
the patient.
The best
solution, as always, is prevention; look for too frequent visits, unproved
treatment approaches, struggles to maintain control of the patient as well as
indication in notes that the doctor believes that he has to protect the patient
from malevolent sources including employer, insurer and even the patient's
family."
Monday, July 28, 2008
Dr. Adams’ Case Management Update (Since 1999)
This is the 502nd Weekly Issue
This Week's Topic:
"Beware of the Darkness"
Question:
"Do you feel that
posttraumatic stress disorder (PTSD) is overdiagnosed?"
Dr. Adams replies:
"It is
over-diagnosed and also inaccurately/inappropriately diagnosed. It is arguably
one of the most misdiagnosed psychological disorders. It is often applied
to someone who is depressed, angry and/or simply withdrawn after injury.
True PTSD is an impressive disorder to observe.
It arises from being the victim of, or witnessing, an injury that threatens a
life or bodily integrity of an individual. The patient with the disorder is truly
miserable. In the midst of their daily activities, scenes of the trauma
suddenly appear before them as though they were back in the situation.
They awaken with alarm if not panic from sleep having had nightmares (called "parasomnias")
of the original trauma or nightmares of very similar events. Even watching
movies or television programs, reading books or newspapers or hearing reports on
the radio of similar events, can trigger the feelings evoked by the original
injury.
The patient fears
that the event will recur or, in the case of an assault, that the perpetrator
will seek them out and assault them again. They become fearful
of the time of day, season of the year, location of the original trauma and even
smells and sounds which trigger memories of the event (called "redintegration").
They believe that they have no control over their thoughts or emotions. They
see these symptoms as merely a continuation of the trauma itself as though there
will never be a separation between the incident and them.
Nonetheless,
as with many diagnoses, it is quite often inappropriately applied to those with
lesser symptoms or other disorders. It can also be unskillfully treated,
resulting in the symptoms worsening and becoming chronic and refractory to
change.
Patients
that are inaccurately diagnosed, and then told that they have PTSD, will cling to the diagnosis as though it defines
and determines their future. It is not a difficult diagnosis to make, and,
yet, instances abound of it being inaccurately diagnosed."
Monday, July 21, 2008
Dr. Adams’ Case Management Update (Since 1999)
This is the 501st Weekly Issue
This Week's Topic:
"How much effort is wasted"
Question:
"It takes a
considerable amount of time to gather all the medical information regarding
an injury before we can determine how best to return an individual to work."
Dr. Adams replies:
"Well, perhaps that is true, but not necessarily. Those physical data are, of
course, extremely important, but they only establish physical capacity, not the
underlying human "will" and motivation.
I designed this very quickly administered diagnostic tool that, among other
things, tells me if the patient feels that the injury “ruined my life”, if the
patient “deeply resent(s) this injury," sees it as having been “preventable” and
is now strongly blameful of others.
More importantly, among other information, this tool addresses the role of the
job itself in the scheme of the patient’s life. Was the job “solely for the
money” and devoid of any emotional investment?
Administering this before I meet the patient enables me to target the patient’s
goal for care in my, or any, office. It also tells me whether there is a stark
contrast between being released to return to work versus true intent of doing
so. That contrast is very common.
An impressive amount of time is spent finding objective data regarding the true
extent of the physical injury. While those physical data are unquestionably
important, it is essential to establish what the patient believes about the
injury and plans to do as a result of those beliefs."
Monday, July 14, 2008
Dr. Adams’ Case Management Update (Since 1999)
This is the 500th Weekly Issue
This Week's Topic:
"The Baggage Claim"
This is the
500th consecutive Case Management Update...five hundred weeks of responding to
individual questions.
Whew, that
is approaching ten years. I could have purchased a bass boat and gone fishing.
Well, except that I do not know how to fish nor drive a boat, and they have fish
at Kroger.
In either
case, to commemorate this milestone, I want to provide you a very concise
summary as to what you were supposed to have learned about events before and
after injury, regardless of injury and regardless of the State in which the
injury occurs.
Every worker
lives in a state of denial. My 15 year old daughter would tell you that
"denial is the name of a big river in Africa." That's another story.
In order to
function in any job, especially those which have risk, the worker cannot
continually process dangers, and how he/she would respond to an injury (or in
some cases, an assault) if it occurred at work. The workers must live in denial.
When injury
occurs, therefore, that denial gives way to the trauma. The initial stages of
trauma include shock, recoil and disbelief.
Regardless
of the degree of physical damage, the worker believes that care will be timely
and effective; that all will be resolved in short order.
As reality
sets in, the worker finds that he/she will return to work in short order or
perhaps after several weeks of recovery or possibly after many months of care
and, in some cases, that return simply will not occur.
It is rare,
at the onset of the injury, for patient, employer, physician or insurer to know
with certainty when return to productivity will occur.
But there is
a greater complication that pre-dates all injuries, every single one, and that
is the amount of baggage that the patient carries into the accident.
As we have discussed, this can range from legal and financial problems to
marital and family problems to other health problems, educational deficits,
intellectual limitations and varying degrees of motivation to fight against
obstacles. Everyone has baggage.
And guess
what: the injury creates its own degree of baggage...anger, resentment,
dependencies, fears, isolation, frustrations, and arguably all human emotions.
...and a few which are not so human.
It is not
possible to determine the amount of baggage through physical examination and
treatment of the patient. Simply put, patients are rarely truthful. They are
often in denial of their problems or unquestionably embarrassed by them. They
are not forthcoming.
Patients
will use their injuries, whether deliberately or unconsciously, to address the
baggage that they carry.
Those
treating the patient falsely believe that injured tissue can be treated, and the
baggage can be ignored.
This does
not work, and the unclaimed baggage increases.
Those
authorizing tests, those paying the bills, and those interfacing with the
patient, all live in their own denial, both of the patient’s baggage and their
own. They believe that they can sidestep all of this baggage without tripping.
They cannot.
It is this
baggage about which I have written for five hundred weeks. It is this baggage
that directs the course of care and recovery. And interestingly, this baggage
always seems to make it past the security checks."
Monday, July 7, 2008
Dr. Adams’ Case Management Update (Since 1999)
This is the 499th Weekly Issue
This Week's Topic:
"...Lies and Videotapes"
Question:
"We have caught more than
a few claimants working after injury and claiming that they could not.
I think that you will agree that the level of deception among these people
is remarkable."
Dr. Adams replies:
There is a line in a Bob Dylan
song that goes "Money doesn't talk...it swears." And there is no doubt that
malingering and corruption is a significant concern.
However, there are two extremely important areas that you need to seriously
consider:
If video surveillance demonstrates that the patient is working beyond the limits
set forth by the authorized treating physician, why is the patient doing this?
A. Is the patient forcing himself to work beyond physical limits to keep from
being nonproductive and bored? Is the patient extending himself as an attempt to
participate in his own work-strengthening? Has the patient been encouraged to
attempt some productivity every day, despite pain?
B. Or, as you appear to suspect, is the patient clearly demonstrating a
functional capacity far beyond what his physician believes it to be.
C. Is someone advising the patient to appear as though his limitations are more
severe than they truly are? Is someone recommending to the patient that he
remain in his residence, not venture out, and be on guard for investigators
documenting his every behavior?
Injured workers receive a large amount of misinformation and disinformation that
results in their making poor decisions. They are often told some behaviors will
enhance the "value" of their injury and other behaviors may compromise that
value.
Such advice most often comes from within and outside the family from those who are truly ill-informed as to
what a person needs in life, beyond finances. This advice springs from the naive
position that all of life's ills are resolved financially and that the patient's
self-image and self-worth have a monetary rather than emotional value.
What an injured worker needs to know is that "you may have permanent limitations
and chronic pain despite any care that is provided. While you are being told
that there is a financial value to this suffering, in fact, there is none. Any
money will eventually be depleted, and you will continue in your life with your
symptoms. What you need are activities that make you feel productive, more
complete, and a value to yourself and others. You need to be encouraged to do as
much as you can, to extend beyond your limits, and to establish a post-injury
life that offers some degree of fulfillment."
