Reliably Determining Occupational Causation April 21, 2010 Dan Rafael Azar MD MPH QME Medical Director Alliance Occupational Medicine Santa Clara & Milpitas 1
Identifying Causation is Critical • Impacts claim management • Impacts source of medical treatment • Impacts employee health • Impacts liability for treatment • Impacts future costs • Impacts profitability • Impacts morale Make the right decision as early as possible 2
Evaluation and Treatment is a Partnership – Employee-Patients – Employers – Carriers (adjusters) – Utilization Review – Medical Case Managers – Attorneys – WCAB judges – Legislature 3
Evaluation and Treatment is a Partnership • We share goals (some of us) – Get the EE • as well as possible • as quickly as possible • for the lowest cost – Goal: MMI (maximal medical improvement) – Goal: P&S (Permanent & Stationary) 4
Why use an Occ. Med. Clinic? • Measure our success by case management – – Causation determination Disability management Claims management Cost effectiveness • Responsible for quality of ancillary services • In-house specialists are held to higher standard • Personalize treatment for local employer • Typically best choice for initial treatment 5
First Visit “Basics” 1. Diagnosis 2. Causation 3. Treatment 6
Treatment Philosophy • Attitude of provider – – Neutral in mind Positive in attitude Not pro-EE Not pro-ER • Thorough history taking – Fact finder – Active listener • Thorough exam • Thorough documentation – Fact organizer • Synthesize treatment plan • Lead, Communicate and Coordinate to Implement Plan – – “It takes a team” Define roles Problem solve Educate stakeholders generously 7
Treatment Philosophy • Always strive to do the “right thing” = Speak the truth – WC serves a specific purpose – WC is not a safety net – Treating a non-occupational illness under WC is not “doing the EE a favor” • Establish causation as AOE/COE – Arising Out of Employment – (occurring in the) Course Of Employment • Probable cause – Not just “a possible cause” • Significant contributor – Not trivial • No patient-physician relationship exists until causation is resolved and treatment is started 8
First Visit • Goal: put together a unbiased narrative that tells a believable story • Fact collecting and organizing • Develop a relationship with patient • Dispel bias against “company doc” – Reflect comprehension – Express compassion 9
Thoroughness at First Visit Includes Reviewing All Available Information • • • Authorization form from employer Patient description of injury mechanism Anatomic illustration of injured areas Basic current and past work history Clarify prior relevant medical history 10
History: Establishing Diagnosis, Causation and Pre-Injury Baseline § § § § What happened? No problems before then? What makes it worse? Ask for specific responses. Ask questions until it makes sense Check for non-occupational contributors Check for consistency of causation: ü Worse at End of Day? Week? ü How does it feel on weekends, vacation? § Organize a time line for current injury – Include treatment received since onset of sx’s 11
History: Why now? It Should Make Sense: • What changed in this EE’s life (at work or home) to trigger this injury? – – – Increased work volume? Increased work hours (OT)? Increased work pace? Coworker laid off? Coworker maternity/disability leave? Relocating offices without correct ergonomics? • Is there a clear causative relationship? § If it doesn’t “make sense” its non-occupational until proven otherwise 12
Identify Non-Industrial Contributors? • Personal Medical Illnesses (diabetes, thyroid, degenerative) • Hobbies: knitting, sewing • Gardening / Home Projects / Remodeling • Sports • Family / Small Children / Dependent Adults • School / Second Job • Over-committed – – Just too much Many working mothers & homemakers Unrealistic personal expectations Poor interpersonal boundaries, 13
During History Listen for • • • Anger Blaming Self pity Passive attitude Poor coping High perceived stress • Poor boundaries (at work and home) – Excessive sense of responsibility – Inadequate rest and recovery – Life out of balance Poor self-care – Lack of regular exercise – Smoking – Diet • 14 (Skip to Slide 23)
Establish Impact on Function • • • Activities of Daily Living (ADL’s) Impact on Work Duties? Clarify work functions These are additional clues to causation Look for association between painful activities and causation • “What were you doing when you first noticed symptoms? ” 15
History > Subjective Section of DFR / Report • • What? When? Where? Injury-relevant medical history – Prior treatment history – What worked? – Rate of recovery • How is work impacted by injury? • How is injury impacted by work? • Contemplate – Differential Diagnoses – Causation & Apportionment – Treatment Plan • Set stage for upcoming physical examination 16
Physical Examination: Confirm Diagnoses • Define physical boundaries of injury • Thinking: Differential Diagnoses = “Probable and Possible Dx’s” • Identify medical red flags – Expedite care – Contact ER/Adjustor, ED, PMD, Specialist) • Identify case management red flags: – Exam doesn’t fit history/mechanism – Exam suggests non-occupational pathology – Exam suggests supra-tentorial amplification 17
Objective / Examination • Visual Observation during history – Pain with movement – Movement to relieve pain – Signs of excessive anxiety • Active Range of Motion (AROM) • Visualize painful area – Discoloration – Edema – Asymmetry • Palpation – Tenderness – Bogginess (edema) – Fibrosis • Provocative Testing – – – Tinel’s Phalen’s Impingement test Signs of malingering Symptom Exaggeration (conscious vs. unconscious) 18
During Examination Look for: • Lack of aerobic fitness • Lack of muscular development • Advancing age – likelihood of injury increases as capacity and rate of healing decreases • Poor general health 19
A = Assessment = Diagnoses Identify: • Pathology (what’s wrong? ) • Extent of problem (define anatomic areas involved) • Severity (mild, moderate, severe) – based on exam findings & impact on function • Chronicity (acute, cumulative, pre-existing) • Cause (non-occupational, degenerative) 20
Plan = Discussion & Treatment • Discussion: – Describe how I arrived at diagnoses – Synthesis of Subjective and Objective – Differential Diagnosis – Differential Causation – Explain pathology and relationship to most reasonable mechanism of injury – Acknowledge all relevant diagnoses – Acknowledge impact of non-occupational dx’s – “What it isn’t” (e. g. not CTS, not C-radiculopathy) 21
Causation: Entirely Non-Occupational • “You need to see your own doctor; I cannot treat you under WC” • “Friendly” first aid advice • End on positive note – Less conflict with me – Less disruption for employer at workplace • Document on Work Status – Non-Industrial – See Own MD 22
Treatment Plan: Plan Ahead • Plan A • On recheck… – If it works…typically finish Plan A – If it doesn’t work initiate Plan B • • Check for non-compliance with plan A Consider alternative diagnoses Consider Diagnostics – if they will impact care Discuss injection or alternative treatment • Where ever possible use MTUS/ACOEM Guidelines for treatment 23
Treatment Plan: Patient-Centric Goals • • Actively listen to patient’s concerns Define most disruptive diagnoses “I get it and I’m competent “ “I can help with your injury and the problems its causing you – trust me” 24
Treatment Plan: Educate the Patient • • • Anatomic posters Explain biomechanics and provocative test results Demonstrate knowledge and credibility Answer questions Dispel common disbeliefs Reinforce with printed handouts – Pathology – Basic exercises • Reassure you will communicate with employer – Work recommendations – To follow restrictions as written – Injury is “real” 25
Treatment Plan: Talk to the Patient • Explain multi-pronged treatment approach • Expectation: – “Its your job to get better” – Outcome depends on patient effort – “No change = no gain” • Outcome depends on severity of illness • Outcome depends on delay in seeking care • Reassure: – think positive – take action – be realistic • Make yourself available to patient 26
Specific Treatment Plan for an Acute Injury • Mild / Minimal Injury: – First Aid Only (OSHA – not labor code) – Non-Rx meds if sufficient – No Physical Therapy • Or option of “instruction only” by therapist • No modalities or procedures – Full Duty (if safe) – Depends on severity 27
Treatment Plan for an Moderate to Severe Acute Injury • Start Physical Therapy ASAP • Recheck 2 – 7 days • Restrictions if medically necessary – – Only if necessary Specific to injury Specific to job duties Safety driven • Prescription meds if medically necessary – Avoid narcotics or muscle relaxants where possible – Use OTC’s or topicals – Limits pain or sedation as an excuse for not working 28
Goals of Physical Therapy • Recover full function • Establish healthy habits • Minimize risk of recurrence 29
Physical Therapy During early phase of treatment: • Decrease pain & inflammation – – – TENS Ultrasound Phonophoresis/Iontophoresis Myofascial release Teach proper use of ice and heat • Improve active range of motion (AROM) • Reduce injury-related anxiety – Educate about pathology – Encourage movement • Teach proper technique 30
Physical Therapy Late Phase of Treatment: • Focus on increased flexibility, strength & endurance • Teach self-care and personal responsibility • Provide home exercise equipment (if needed) and instruction – – • • Theraputty Theraband Home exercise ball Foam Roll Limit TENS unit to specific cases for pain management Limit home traction unit to radicular cases Prescribe one month trial Re-evaluate for demonstrated use and benefit before refill 31
Cumulative Trauma Injury • Defined by mechanism – not anatomy. • Work Related Musculo Skeletal Disorders (WRMSD’s) Includes many different tendinopathies, myofascial pain syndrome and sometimes peripheral nerve entrapment (CTS) • Identify specific diagnosis – Extensor tendinitis bilateral wrist (R>L) – Lateral epicondylitis R elbow – mild, chronic 32
4 Major Causes of Cumulative Trauma Injury • • Excessive force Awkward positions Static muscular tension Insufficient conditioning for job requirement 33
Cumulative Trauma Injury Challenges: • • • Gradual onset Delay in seeking care Multifactorial cause Prone to “Injury Creep” Typical treatment guidelines geared to single, acute conditions under ideal conditions • High risk of recurrence 34
Cumulative Trauma Injury Challenges • Milder cases: an absence of objective symptoms • Subjective symptoms such as pain influenced by mood, attitude and job/life satisfaction • Response to treatment impacted by personality – The mis-educated and over-educated – Fear, anxiety and frustration 35
CTI: Treatment Plan • Ergonomics - evaluate & adjust • Self-care – Microbreaks hourly? – HEP: flexibility, strength, endurance and reduce pain • Technique at work and home • Splints? • Work Habits (hours, pace, days, location) 36
Call Designated Employer Representative (DER) • • • Diagnoses Why I consider it occupational Treatment plan Establish Communication Early intervention if there are discrepancies in history Insider information – back story – pre-claim conflict – workplace issues • Re-examination of causation 37
Case Management at MD Recheck • Before you walk in… – Always check previous note and if needed DFR – Always check PTx flow sheet for # of visits and exercise compliance – Stay on track with treatment plan – Check for new reports, diagnostics, consults, correspondence and status of certification • Reinforce patient-physician relationship 38
Case Management at MD Recheck: • “How is it going? ” • Get specific about injury – Patients wants to talk about pain – I want to talk about function – Get specific about functional capacity • Check compliance – Home Exercises / Microbreaks – Meds – Splints 39
Case Management at MD Recheck: Reinforce: • To change outcome we need a change in behavior • Monitor for passivity, blaming noncompliance, sabotage, inconsistencies “The Lecture”: “Ultimately this is going to be your problem if… • Restrictions become permanent • Fact: Impairment / Disability ratings have changed • Chronic pain is chronic and can ruin your life 40
Case Management (cont. ) • If responding to PTx/HEP consider 2 nd Rx if – Not ready for independent self care – Not ready for trial of full duty • If not responding consider – – Certified Hand Therapy (CHT) Chiropractic Acupuncture Myofascial release • Discuss treatment options with patient – Placebo effect – Sense of control – Not appropriate for all patients 41
Especially Challenging Cases • Low Back Pain from prolonged sitting • Depression/Anxiety from work (“Stress claim”) • Depression from chronic pain, etc. • Sick Building Syndrome / Chemical Sensitivity • Noncompliance with treatment plan 42
Low Back Pain From Prolonged Sitting • • • History Look for prior injury or alternate causation Check Ergonomics Check Work Volume Thorough examination “The talk”: – The human body and prolonged static posture – Microbreaks – Overall fitness / balance • Poor Job Fit : this is your problem 43
Stress Claim / Psych. Claim • “So how did you get hurt? ” • Basic history about circumstances – Relationships – Work volume • Doesn’t meet >50% occupational causation: – See your own MD – Call employer and advise • Strong case for legitimate claim: – Make referral for psych. referral – Continue care through personal health plan until claim accepted (we are not mental health specialists) 44
Depression • Pre-existing? • Identify early because this will impact coping and recovery. • Refer to personal MD for treatment because not occupational causation. 45
Depression “due to injury” • Chronic Pain • Disability • Financial Impact • Impairment Reassure – • “Normal” response to consequences of any illness or disability • Depression is situational and will resolve with physical recovery or emotional adjustment 46
Depression “due to injury” • Recommend patient see PMD • WC not designed to manage depression • Patient probably predisposed to depression/anxiety – check history • Do not automatically accept as secondary to original injury • If denies prior hx of depression consider psych. consult • PTP cannot ignore patient psych complaints associated with injury • While consult being certified (? ) refer back to PMD. 47
Sick Building Syndrome Chemical Sensitivity Syndrome • History, history • Investigate thoroughly before accepting claim • Review MSDS (if applicable) • Discuss with DER or Safety Manager • Review Industrial Hygiene report • Toxic response must make sense • Causation is EE’s duty to establish • Toxicology consult if highly plausible/probable Chemical Sensitivity is ultimately a job fit problem 48
Problematic Patients • • Passive / Depressive / Anxious personality Borderline personality Type A personality Never feel ready for trial of full duty – Proceed with trial of full duty – Call employer • If fails trial of full duty: – – Mis-diagnosis? Consult? Diagnostics? Work Capacity Evaluation (WCE)? 49
Other Problematic Patients • I don’t ever want my case “closed” – “It might come back” – “What if I need to find another job” – “I won’t continue to treat you if…” • you are not responding to care, or • stable and don’t need regular medical care. – Reassure and describe Future Medical • “I got laid off…” – Often a secondary gain issue – If on full duty see above – If on modified duty request WCE • Figure out what is blocking MMI 50
Closing Cases as P&S Depends on outcome: • Cured? • Residual symptoms? • Residual impairment? • Residual disability? • Permanent work restrictions? 51
Other Issues to be Resolved at P&S • AMA Guides Whole Person Impairment Rating • Causation: Is residual WPI Occupational? • Apportionment: Is the WPI of mixed causation? • Future Medical: What? How much? How specific about type? Indefinite? • Permanent Work Restrictions? 52
Common WCE Results • Most IW’s are “full duty capable” despite pain and behaviors • Many identified as having inadequate “Chronic Pain Coping Skills” • Very sore after testing strongly suggests non-compliance with HEP 53
Thank You Alliance Occupational Medicine 315 South Abbott Ave. , Milpitas 2737 Walsh Ave. , Santa Clara Please visit us at www. Alliance. Occ. Med. com 54
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