Good morning. I'm Garson Caruso. I'm an occupational physician and consultant in Harrisburg, Pennsylvania. My colleague is Les Curte, who is a clinical psychologist and consultant in Chattanooga, Tennessee. We're going to talk this morning about evaluating post-COVID conditions. This talk grew out of a paper that we published last year in the AMA Guide's newsletter on the same topic. And we wrote that paper because we were concerned about some of the things that we were seeing in workers' comp and disability evaluation in our practices. So this morning, we're going to try to give you an update on that and maybe give you some other things to think about. Post-COVID conditions are really challenging for clinicians, particularly the disconnect between the number of subjective symptoms and complaints that people have and the relative lack of objective findings. These are a little bit different from the classical syndromic illnesses like fibromyalgia and chronic fatigue syndrome, because we do have some reasonably good evidence for physiologic substrates in COVID. So we are going to propose both a humanistic and a scientific approach to sufferers from COVID-19, but we're going to advise caution in adopting attributions for causation, explanations, and management strategies, and particularly for assigning disability. As I said, I'm an independent medical consultant. Les is a senior vice president for behavioral health for Axiom Medical and an industry consultant. Les also receives humongous royalties from the American Medical Association for his role as an editor. Most recently, I figured I was up to about 25 cents an hour. The AMA Guides to Navigating Disability Benefit Systems. Neither of us has any conflicts of interest to report. Please hold your questions until the end of the presentation. We did allot some time for questions, and we will be here afterward if you have questions. The slides have changed somewhat from what you have in your handout, so please email me and I'll send you an updated copy of the slides and particularly the reference list. We have a little over 200 references that you might find useful. So this morning, we're going to talk a little bit about history, definitions of post-COVID, and terminology. We're going to look at common symptoms and some of the current incidence and prevalence numbers. We're briefly going to review potential pathologic mechanisms. Then we're going to talk about evaluation and management and some of the specific concerns that we have. Okay. Post-infectious symptoms include things like cognitive dysfunction, cardiac and pulmonary disorders, diffuse arthralgia and myalgia, fatigue, and some behavioral health concerns like anxiety and depressed mood. This current pandemic is not the first time these have been seen. These were documented as far back as the end of the 19th century after the Russian flu pandemics of 1889 and 1992. Then again after the influenza pandemic in 1918. Then after the SARS pandemic in 2003, the MERS pandemic in 2012, and even after the Ebola scare in 2016. The World Health Organization provides a case definition for post-COVID conditions. It really has three components. The first is a history of probable or confirmed SARS-CoV-2 infection. The second one is a time component, which they allow a month for acute symptoms and then persistence of symptoms for an additional two months. They really stipulate that post-COVID conditions start at the end of the third month. The third condition is that they cannot be explained by any other diagnosis, which is kind of similar to complex regional pain syndrome. To our knowledge, there's still no widely accepted clinical diagnostic criteria for post-COVID conditions. There are, I think, 85 symptoms that have been documented, so there's really no pathognomonic syndrome that you can look at. In September 2020, the International Classification of Diseases adopted code U09.9 for unspecified post-COVID conditions, but they stipulate that you want to also put other findings like chronic respiratory distress or anosmia and dysgeusia. The terminology has evolved. We started out back in 2020 with long-term effects or late sequelae of COVID-19, then chronic COVID-19. The term long or long-haul COVID-19 seems to have come about in 2020, and this is credited to an Italian physician by the name of Elise Perigo, who you actually use it in a hashtag to describe her own condition, and it kind of stuck and became a very common usage. Then we segued into the post-acute variants, post-acute COVID-19, post-acute COVID syndrome or PACS, post-acute sequelae of SARS-CoV-2 infection or PASC, which came from the NIH, and we're going to use the term that the CDC uses, which is post-COVID conditions or PCCs. All right. There we go. So the most common symptoms you can see here, cardiopulmonary, gastrointestinal, mental health, metabolic, profound fatigue. Fatigue and respiratory symptoms seem to be overall the most common, but there's really quite a wide variety. There are significant headaches, neuromuscular disorders, lots of nervous system conditions, and then there are complaints about cognition, and we'll be talking about that as we go along a little bit. There's this comment from Soriano, and I think this is generally being accepted, and we'll raise some questions about this, but they generally have an impact on everyday functioning, including ADLs and IADLs, and I think we'll raise some questions about that statement. One thing that's very clear is that symptom report is really high. This is not an eye test. You can look at it more closely, and there's the reference for it, but this was kind of a fairly early meta-analysis. Overall, the history of any symptom at 60 days post-acute was 72%, which is really quite staggering when you come right down to it. The most commonly reported symptoms in this analysis, and this has been pretty consistent as we've looked at things, is fatigue, respiratory, ongoing respiratory distress. Cognitive symptoms, complaints go up and down. We'll come back to that again, and pretty much all of these are generally speaking they're below 25% of the time, with the exception of these ones that are most commonly reported. There's a different way of looking at it. If you looked at, Taquette did another meta-analysis, and the overall report of symptoms at three to six months was about 37%, but there we began to see this dose-response curve, so that people with mild or asymptomatic cases had much lower report of symptoms, and it went up as we got to people who were hospitalized, people who were in ICU, certainly people who were ventilated. So we begin to see that. So it averages out to about 37%. That's fairly consistent across the literature, but for those who were hospitalized or in ICU, it's more in the range of 74% to 75%, and those are symptom reports, which we have to get to. Mental distress in all of this, as a psychologist, this is the literature that I pay a lot of attention to. Mental distress has certainly been very high, and risk factors for that were being female, age less than 40, presence of chronic physical or psychiatric diagnoses, being unemployed. None of that's particularly surprising. None of those risk factors are especially surprising for increased psychiatric symptom report. I'll say a little bit more about that in just a second. This is probably the most interesting set of studies. So LLE and ZEE did this study with VA records, and what's interesting about this, this was the first one that was published in 2021, and they looked at 73,000-plus post-COVID conditions that they defined in the VA system as having survived at least 30 days, and they compared that to almost 5 million people who did not have COVID. So it's really quite a robust sample, and they found significant hazard ratios for trauma and stressor-related disorders, anxiety-related neurocognitive disorders. Trauma attenuated when you adjusted for severity. So again, unsurprisingly, the more severe the case, if someone was in ICU, certainly if they were vented, they were going to be much more likely to have a trauma-related response, and that shouldn't surprise us particularly. And then neurocognitive disorders were equivalent for those hospitalized in their study. They were equivalent for those hospitalized for other conditions, which I thought was interesting. We definitely saw here this dose-response condition. Hard to see on the slide unless you're right in front of it looking at it, but what you can see is that for all of these conditions, they get worse as the condition gets more severe. So these are all confirmed COVID cases. These are not presumed cases. They're confirmed COVID cases, and even in mild cases, we saw increased reporting, but it definitely went up as people were hospitalized or as they were in ICU. Now this one is not yet... We'll be glad to send it to you, but this one's hot off the presses. By the way, if you're studying COVID at all, you will appreciate the fact that we were changing these slides until the day before yesterday, because it's just a deluge. So the reason that the slides are somewhat different is that we kept trying to keep up. So this is a follow-up of Z and L. Ali did a follow-up study also with VA records, but this time they did a really interesting thing was that they had two control groups. One was people concurrent with the folks who had COVID, and one was a separate sample of 8 million people seen before the pandemic. So a sample from back to 2017, which gets at one of the questions that we have, and we'll come back to this a couple of times throughout the presentation, is it COVID or is it the pandemic? Because I don't know about you, but whether you had COVID or not, the last couple of years have been pretty breathtaking for most of us. You see here the hazard ratios. They're generally in the 1.3 range, pretty significant for 1.8. For neurocognitive decline, they point out that it's a little complicated because of the age of the population, but nevertheless, this is comparing to other groups, so we're seeing that. I should... A couple of questions about this study that need to get raised and that apply to the literature in general. They used, in their study, they used the presence of a new diagnosis or the use of a medication in order to determine whether somebody had a new onset anxiety disorder, for example. Well, in most hospital systems, and certainly in the VA, the fact that somebody records anxiety in a chart doesn't really necessarily meet diagnostic criteria for an anxiety disorder. So what I want to say most about mental health and cognitive functions is that we clearly see an increase in reported symptoms. Whether or not those are actually diagnosable conditions requiring treatment is a different question, and there are various flaws. This is a really good study because of the controls, but then again, it's like, okay, so the records, we're relying totally on the records, and we all know how reliable records are. Doesn't entirely answer the question of how much of this is actually COVID and how much is a pandemic. A lot of diagnoses in this study and in others is based on screening measures or self-report, and I'll say a little bit more about that. The problems with these is that, first of all, we have a lack of information about pre-COVID information. If we know anything, we know that people forget. I always say this about concussions. I forget on a daily basis where I put my keys. If I fall down and whack my head this afternoon, tomorrow when I can't find my keys, I'm going to wonder if it's because I hit my head, and I'm going to forget the fact that I never remember where I put my keys. So we have to bear that in mind. There's that halo effect about the past, right? There are certainly lots of problems with bias, selection bias, non-response, reporting, a lack of standardized assessment of protocols and control groups in other studies than the ones done at the VA. When you base your assessment on self-report, you have to ask a lot of questions. Again, and we'll come back to this multiple times, when you have a patient in front of you, you have a person who's suffering that you want to address what's going on for them. But when we're standing back and taking a look at, well, epidemiologically, easy for me to say, then we have to ask a different set of questions. The pandemic itself impacted the statistics. This is a SAMHSA chart that just, it reflects two things that I think are kind of interesting. One is that if you'll look at this chart, you'll notice that the increase in mental health symptoms and conditions being reported was going up long before COVID. So this is not, this increase in mental health reporting is not brand new. This was going on before COVID. It's continued. But they actually, they declined to connect the dots between 2019 and 2020 because they had to change their methodology. Up until, through 2019, SAMHSA always did their studies in person, but they had to switch to a methodology that was telephonic for 2020. And they have a 61 or 62 page addendum to this report that explains what they found and why they declined to connect the dots between those two things. Ask me how I know that it's 62 pages, but, because I read it. Here's the problem. When we're using screening measures, I'm just going to take us back to, I'm going to take us back to basics. And I'm sorry, my alarm is going off for some reason. So I took, I got interested in this question, you know, is it that we're seeing more depressive disorders or is it that we're seeing more reports of depressive symptoms? And I started to wonder, and I noticed that in almost every study where, when I looked at this, we were diagnosing depression or depressive disorders based on a PHQ-2. You know, if it was a PHQ-9, it was a good day. Well, I couldn't really find good sensitivity and specificity statistics for the PHQ-2. I only found prediction for PHQ-9 scores. So I just went with PHQ-9, which has about a 0.88 specificity and sensitivity. And if you figure a point prevalence of approximately 8% for depressive disorders, if you do the math on this, roughly 61% of those who score positive on a PHQ-9 are false positives for a depressive disorder. That's on a good day. So we really need to bear in mind that so many of these studies are using screening measures for quite a number of these syndromes that we have a problem if we just make the assumption. When I read medical records I see in family practice all the time, you know, somebody scores 11 on a PHQ-9 and they have depression and they get an antidepressant. Well, maybe that's appropriate for that particular patient. Again, I don't want to say that we don't want to treat people who are having a problem, but that's not equivalent to a diagnosis. And I think that's important to bear in mind. And that kind of brings us to sort of, all right, so what's next? What are we going to be evaluating? What are the problems that are going to be coming in that evaluation? And Garson will take it from here. Okay. We are not real clear on what's going to happen next. And we are pretty confident that there are a number of variables moving forward. There's a lot of moving parts to this and it's going to be a moving target, both in terms of COVID and post-COVID conditions. The human population is going to range from people who are immunologically naive to those who are previously exposed and infected, whether or not they had symptoms, to those who are partially or fully vaccinated, to those who are vaccinated and boosted. So we're going to have a certain level of immunity. That immunity is going to wane with time. So that's not going to be a static situation. The incidence and prevalence is going to change with public health metrics, hygiene measures, and vaccination and boosted rates. The virus itself is going to change. It's going to mutate. It's going to change in terms of infectivity and virulence in regard to symptom production. We've already gone through the alpha, beta, delta, gamma, and Omicron variants, and we really don't know where that's going next. We may reach a level of endemicity with SARS-CoV-2. We don't think we're there yet, but we may get there with kind of a flu-like pattern with decreased virulence. But then again, we may see immunity-evading variant flares and outbreaks within countries or among countries. Okay, so we're going to look at, just briefly review potential pathologic mechanisms for SARS-CoV-2. There's been an explosion of literature and research on this over the past two years. Kind of the overarching concept is that SARS-CoV-2 has widespread effects due to its ability to infect a number of different cell types. So we see direct tissue injury, particularly to the heart, the kidney, and the lung. We see effects in neurologic tissue, neuroinflammation, and neurotoxicity, possibly with axonal transport from distal to proximal. We see vascular effects, both macro and micro clotting pathologies. Autonomic dysfunction or dysautonomia is a prominent feature with orthostatic problems like postural orthostatic tachycardic syndrome. Endocrine disruption, there's been evidence for that, particularly in tissues that have a large concentration of angiotensin-converting enzyme 2 receptors, hypothalamus, thyroid, pancreas, adrenal medulla, or cortex, and ovary and testes. There is evidence for immune dysregulation with hyperinflation and what has been called cytokine storm. There's some evidence for autoimmune activation, dysregulation of the host microbiome and virome balance or dysbiosis, and simple viral persistence, possibly through local or systemic immunosuppression or viral evolution. So there are many potential causes for persistent symptoms, and these may be differentially active in different people and even at different times. This is just a graphic summary of what we just talked about. You see on the left, long-term tissue damage in terms of the heart, the lung, and neural tissue with corresponding characteristic symptoms. On the right is the inflammatory process, viral persistence, lymphopenia, and gut dysbiosis and autoimmunity, again with characteristic symptoms. Post-intensive care syndrome is an interesting overlapping condition with post-COVID conditions. Post-intensive care syndrome refers to symmetrical muscle weakness both due to myopathy and neuropathy, lung gas diffusion problems, cognitive dysfunction, and behavioral health disorders, particularly anxiety and depressed mood. Now post-intensive care syndrome occurs in about 50% of patients who require mechanical ventilation across all ages. When you look at COVID-19 patients, about 20% of them require critical care, often with mechanical ventilation. So we may see an overlap of about 10% in patients who ostensibly have post-COVID conditions who may have post-intensive care syndrome. Maxwell in 2020 and his group suggested that post-COVID conditions may represent at least four distinct clinical syndromes, including continuing, ongoing, persistent COVID symptoms. Post-intensive care symptoms attributed to permanent heart and lung organ damage and postural fatigue syndrome. And again, Pearl and Van Elzaker reinforced this idea that different mechanisms may be active in different people or the same people at different times. We don't have a lot of information about risk factors for post-COVID conditions. Yong and his group did a study in 2021 that provided a good overview of risk factors, but the ones that they cited were pretty soft. Female gender, initial disease severity greater than five, characteristic symptoms of COVID-19, but again, there are about 85 that have been documented. They did find evidence for biomarkers, especially C-reactive protein, D-dimer, and again, lymphopenia. The Sue study in 2022 was an interesting piece of research. They found evidence for type 2 diabetes, Epstein-Barr viremia, SARS-CoV-2, RNAemia, where we can detect fragments of viral RNA in the circulation, and specific autoantibodies, which form to particularly GI and neurologic tissue. Some additional risk factors in populations, healthcare workers, as you would expect, are susceptible to post-COVID conditions. For some reason, younger workers are vulnerable to symptom report, and this has been documented in many studies. Individuals with obsessive-compulsive disorder are particularly vulnerable, whether or not they have been infected, and we're going to talk about that a little bit more coming up. Those with previous psychiatric diagnoses have exacerbations of symptoms beyond what would be expected, and substance abuse has been related in kind of a circular pattern where people who are substance abusers tend to get infected more than those who are infected, and again, even during the pandemic, tend to have increased substance use. We published a two-part paper in 2019 on delayed and failed recovery and unnecessary disability in work-related illness and injury. Some of the things we identified were adverse childhood experiences, pre-existing psychopathology, individual health cognitions, which include people's appraisals, their attitudes, their beliefs, and their expectations about their illness, and perceived injustice, and we found some of those factors operative in post-COVID as well. Beliefs may be the single most important influence. This paper by Mata in 2021 found that persistent physical symptoms were more strongly associated with a belief in having been infected than with laboratory-confirmed infection. In general, appraisals, attitudes, and outcome expectancies drive symptom tolerance. They drive recovery motivation, and they drive return-to-work outcomes. We did find some evidence for perceived injustice and embitterment, particularly in workers, in terms of contributing to post-COVID conditions. We looked for information on motivation and reward, primary, secondary, and tertiary gain, and learning and memory, but there is really nothing on post-COVID at this point. Let me just really quickly add that we've seen several papers now in which the belief that someone had COVID is, you know, there are a couple of others that have shown that people who believe they have post-COVID are more likely to have post-COVID symptoms, and even those without any evidence that they were actually ever infected. So, that's an important finding. Again, people are suffering. We need to pay attention to them, but that doesn't mean that it's directly related to a viral infection. Particularly when you're looking at causation, for example, in a workers' comp case or disability case, you have to be careful about that because you may get fooled. There may be a reciprocal or a circular relation between COVID-19 and behavioral health symptoms. So, for example, Bondini strongly suggested that COVID-19 caused anxiety and mood disturbance, probably by a neurotoxic or a neuroinflammatory mechanism, and Magnus Dauter felt that this effect was a function of the COVID illness severity and symptom severity. On the other hand, Bottomane felt that depressed mood exacerbated COVID-19 symptoms, particularly pain and dyspnea. They did not find this effect for anxiety. But in 2020, Nikcevic postulated a COVID-19 anxiety syndrome, which had a bidirectional effect between COVID-19 symptoms and behavioral health symptoms. In 2021, Hahn postulated that there were interactive effects among these different behavioral health conditions, anxiety, depressed mood, cyberchondria, which refers to escalation of health anxiety simply based on internet health-related searches, the experience of being locked down, again what Les was talking about, the experience of being in the pandemic itself, the perception of pandemic severity, and just generalized stress. Not to me. So this starts to get at the question of, you know, stress is high, right? We have huge reports of people being stressed. And you know, Cook did this study in 2020, and he talked about the pooled, they looked at his meta-analysis and systematic review. By the way, I've discovered reading many systematic reviews and meta-analyses is that they, like all other studies, are not created equal. Nevertheless, you know, about a quarter were pretty high for post-traumatic and psychological stress reports. Couple of interesting findings. They lay that out, and then they go on to point out that those studies that were published in the papers that they reviewed reported lower prevalence than those that were unpublished. It's kind of interesting. It suggests that perhaps peer review has some value. Heterogeneity was quite substantial, and methodology was mixed, and they talked quite a bit about how it makes it very difficult to draw conclusions. And you know, most of these studies that they found at that point, at least, that Cook found, lacked controls or clear evaluation of premorbid status. Nevertheless, their ultimate conclusion, did you ever read one of those reports where you're like rocking along, and it's like, oh, yep, they're making sense, they're making sense, they're making sense, and then you get to the conclusion statement and they took a left turn, right? This was my experience of reading this paper, because their final conclusion basically comes down to one in four adults require mental health services during the ongoing pandemic, which goes back to their original statement about the number of symptoms being reported. It's a pet peeve of mine as a psychologist that you have to pay attention to symptoms, but symptoms don't necessarily require psychiatric or psychological treatment, and they won't necessarily respond to it. Anyway, sorry, I'll stop ranting. I'm not stressed. You know, the pandemic itself has had an impact, and we've certainly seen that. I think we've all experienced it. I think we've seen it in our patients. We've seen it in family members. You know, this, I thought was, I'm going to, Gloatz kind of was one of the people that we cited before as noting that younger subjects tended to report higher stress. By the way, that was true before the pandemic as well. So we're seeing a kind of a younger cohort that's more likely to be reporting stress in the workplace in particular. We can make of that a number of things, but fact of the matter is that we know that it's true. This quote from Gloatz, I think is really, really interesting. He's basically saying that, you know, a sizable percentage of the population is suffering from anxious and depressive symptoms because of the uncertainty, right? Because it's just, there was so much uncertainty. Remember that? Remember when we just didn't know what was coming and what was happening? And I think that that's generally true of human beings. I'll say a little bit more about that in just a second. Taylor proposed COVID stress symptoms, or I'm sorry, COVID stress syndrome, and he developed a scale that he factor analyzed into these five components. Eventually, his most recent paper that I found referred to it as pandemic-related adjustment disorder, which I think probably is a better description, right, than a unique, to me, pandemic-related adjustment disorder with these five different avenues of getting there. You know, some of us worry about dangerousness. Some of us worry about, you know, being out of work. Some of us worry about, you know, we're convinced that it was brought to us by foreigners, right? So it's a xenophobic component. I suspect that the best description of this is it's really people kind of a mass adjustment disorder with several avenues to get there. That's my interpretation of that. And I won't read the whole quote. They should be available to you. This one's in there, I think. But the, you know, his basic point is that the post-COVID sequelae are going to be much more far-reaching and last much longer than the effects of the condition itself. And I think that's a fair assessment. This was one of the ones that was kind of interesting, you know. He noted that in one of his studies that the number of people emotionally affected by COVID-19 far exceeded the number of people who had been infected. So in his sample that showed high levels of post-COVID stress, only 2% reported that they'd been diagnosed, and only 6% were personally acquainted with someone who'd been diagnosed. That's enormous. I mean, that's an enormously important finding. And I think it's one of the things that we're only beginning to do is to tease out what's COVID and what's the pandemic and our response to it, which is a much larger question that I think needs to get addressed. To me, the most parsimonious answer to all this question is that especially in the beginning, infection with, you know, SARS COVID-2 was frightening. It was scary. The early impacts were really alarming. We saw people being carried out of hospitals in body bags and loaded in refrigerator trucks in New York, right? We didn't have much knowledge. Then the information got really politicized and between a short news politicizing the information, a short news cycle, and clickbait, you know, we were off to the races. And human beings hate ambiguity above all else. I am totally convinced of that as a psychologist, that we would much rather believe a good lie than accept the fact that we don't know. Right? It's just true. And it may turn out that that good lie that we believed is right. I mean, who knows? But the point is that we will do almost anything to avoid ambiguity. And I think that's what we're seeing here, is that we're seeing, A, a lot of patients who are latching on to something and becoming convinced that that's what's wrong with them. And as a profession and as a research cohort, I think we're doing some of the same. You know, we're latching on to solutions without really enough information. And that's one of the points that we want to try to caution you about this morning. Okay, so we talked a lot about the mechanics of COVID-19 causation and so forth. So what can you do about it? There are, we now have some pretty good guidelines in terms of evaluation. and management of post-COVID-19 patients. But a lot of this really comes down to good basic medicine. And we've got six different areas that I want to talk to you about. Again, we will say this over and over again, you need to establish the individual's pre-COVID-19 history. You need to find out what was going on before they putatively got their infection and developed these post-COVID symptoms. You can do that with medical records. But you need to establish their baseline health status and potential risk factors. You need to do a comprehensive medical, family, social, and occupational history. You need to look at the history of the present illness, the COVID-19 illness. Catalog any residual symptoms. And then you need to look at psychosocial considerations. Do they have job insecurity? Are they worried about returning to the workplace? Are they worried about going to the workplace and getting infected and coming home and infecting somebody else? And just general things like workplace stress and burnout. You want to document objective factors, which will be in general, the health of the patient. You want to document objective factors, which will be in general, much fewer than your subjective factors. You want to make sure you get at least one set of vital signs, preferably at every visit, including heart rate, respiratory rate, and pulse oximetry. We review many, many records that have a complaint of shortness of breath or dyspnea. There's no respiratory rate on the chart. There's no respiratory findings documented. Detailed physical examination that addresses all affected organ systems and prior and current testing abnormalities through lab imaging and more specialized testing. A number of clinical screens that you can use in the office. Cognitive screens include the Montreal Cognitive Assessment or the MOCA, the St. Louis University Mental Status Exam or the SLUMS, and the Mini Mental State Exam, the MMSE. I'm not sure there's a lot of difference among these, just whatever you're comfortable with and what you can administer rapidly. I started out with the Mini Mental Status Exam, but now I use the MOCA. Psychological symptom screens include the Generalized Anxiety Disorder Scale, which comes in a two-question and a seven-question version, the Kessler Scales for Assessing Psychological Distress, six-question and ten-question version, and the PHQ Patient Health Questionnaire that Les mentioned, which comes in three flavors, two, nine, and fifteen-question versions. The point that we would strongly emphasize about these screening tests is that they are not diagnostic. They're very useful to get an idea of where the patient is on a given date and particularly to follow them as you treat them, but you cannot use these to make a diagnosis. All you can do is use them to indicate that the person needs a more comprehensive evaluation. A couple of just really quick comments. I actually think that the Kessler Scales, which we don't use a ton of in the U.S., I think the Kessler Scales are probably in this situation most helpful because they measure general psychological distress, and they don't get this specific. There are components that address depressive symptoms and anxious symptoms. It's very quick, but in general, it's very highly correlated to psychological distress, and I think it's useful. It's a useful tool, and it gets us away from thinking that we're diagnosing with screening measures. I will say that of the cognitive screens, the SLUMS is somewhat more sensitive than the others. I think it has better psychometric properties, but anytime you get a positive cognitive screen is an indication for a more comprehensive assessment. It is not a diagnosis of cognitive decline. I can't tell you how many of those that I read, you know, where somebody has I've seen Alzheimer's diagnosed on the basis of a mini mental status exam. You can't diagnose dementia, can't diagnose anxiety or depression with any of these instruments. Office functional screening, you can do the board rating of perceived exertion scale for dyspnea. You can do the six-minute walk test, which is simply the number of meters that the individual can walk in six minutes. For deconditioning, and you can add pulse oximetry to that for exertional desaturation. There are several inventories that are available to assess basic and instrumental activities of daily living, what the person can do and cannot do in their day-to-day life. Activities of daily living involve simple activities like eating, toileting, self-care, hygiene, those types of things. Instrumental activities are more complex like shopping and cooking. And you can use the World Health Organization Disability Assessment Schedule, the WHO-DAS, now in the 2.0 version, which replaced the global, what was it, global assessment of functioning, the GAF, assessment of function in neuropsychological evaluation. If you're going to use the WHO-DAS, I beg you to use both a self-report and a collateral report, if possible, if at all possible. It's really important to find out what other people see. And in terms of testing, once you've done your history and physical, again, this goes back to the basic medicine paradigm, history, physical exam, testing. You should use testing judiciously, targeted on historical and clinical findings. This was one of the things that we were concerned about when we wrote our paper last year, was that we were seeing people go into post-COVID clinics and go to their primary docs and just getting a shotgun workup with echocardiograms and brain MRIs and everything else, even if it wasn't indicated. And this stuff is very often normal. You can do laboratory testing, you can do imaging studies, including chest x-ray, CT scan, or other testing results when clinically indicated, particularly pulmonary function testing, cardiac testing, either treadmill stress or cardiopulmonary physiology, and advanced imaging such as brain MRI. And finally, you need to look at the occupational and vocational factors. And again, all of the basic things apply. How many folks are familiar with the capacity limitation risk restriction tolerance paradigm? Whoa. Not a lot. Okay, this is a, this was published in the AMA guides to evaluation of workability and return to work. It's in chapter 2 of the second edition. It's a really, really useful paradigm to use when you're, when you're trying to figure out whether people can go to work and what their restrictions might be. It looks at their capacity and thus any limitations that they might have. It looks at any risk that they may pose to themselves or other people and thus the restrictions that are indicated. And then finally, it looks at tolerance or the person's tolerance for returning to work, which is a separate concept from the, from the first two. Okay, you want to look at job person fit in terms of job demands compared to the individual's current physical and mental capabilities, particularly with safety sensitivity in mind. And then you would need to look at causation, maximum medical improvement, and permanent impairment rating. And we listed some references that can help guide you in those. Can I say something just quick about the capacity and risk and tolerance? One of the things that I found most helpful about this paradigm is that it forces me to think about, you know, capacity is a, is a question of what can a person actually do or not do, not what do they think they can do. Risk is actually, actually, and that's usually, you can measure that pretty well. Limitations is pretty easy. Right. You know, risk is really more an actuarial question. It's, you have to go to the literature, you have to look at it. What's the risk? But the risk, you only prescribe a restriction if there is an expectation of harm to self or other, of actual harm, right? Everything else is tolerance. So as a psychologist, I don't restrict people who may, who feel more anxious by going back to work. Right. There's no evidence at all that someone will be harmed by becoming more anxious. I do want them to have additional skills. To, to tolerate it better, but it's a question of tolerance. It's not a question of harm. So. And typically, physicians can determine capacity limitation. They can determine risk and restriction, but you really can't determine, tolerance is a psychophysiological concept, and you really can't determine that. And one of the ways we get into trouble is to assign restrictions based on individual's tolerance, and there are two separate things. All right, this one's mine. So, the bottom line here, answer to, you know, for, I'm about to make everybody anxious because I'm going to talk about ambiguity. We don't know what's going to happen here, right? The long COVID has been accepted under the ADA as a disability that requires accommodation. Or that requires at least a good-faith discussion about whether, whether accommodations will allow that person to continue to work. This is a big problem that we have, is that we use disability in two completely different ways. Under the ADA, we use disability as being something that will allows us to get accommodated whenever possible so that we can stay at work. On the other side of the spectrum, we use the word disability to mean that a person can't work, and they're very different, but the same word. We have seen over time, you know, one of my comments to folks who would argue with me, I don't expect this here, but one of the comments I would, I would make when someone would argue with me about it, well, all those, all those excess deaths aren't really, you know, all those people dying aren't really COVID, and then you looked at the excess death numbers, and then people would tell me, well, that's not really real. Well, let me tell you, every single group life insurer reported an increase of deaths in 1920 and 21 of approximately 15 to 18 percent. They lost a lot of money. They pay actuaries a lot of money to make those predictions, and they were wrong because of excess death. So it doesn't really matter whether it was death from COVID or not. The fact of the matter is that we had 15 to 18 percent more deaths. And if you do the math, it comes out to be about the 900,000 people that we lost. So, so these numbers are real. What we haven't really seen, although we expected it, we haven't really seen, I didn't say this, but I've spent about, spent about 18 years of my career working in, with large disability group insurers, so I know the disability business, the private disability business pretty well. We, all of us expected a huge influx of people claiming disability on their policies, it's not really so far materialized. It's been about a one to two percent increase. It may increase more, and there's an artifact involved in that, which is that a lot of people lost their jobs, and therefore they lost their coverage. So we have seen an increase in claims for social security disability, and it's quite possible that as people got back to work and are again covered by group disability policies, that they'll then have post-COVID sequelae that they, on the basis of which they claim a disability, but we don't know. We don't know what's going to happen. The, the reason that I think it's worthwhile bringing up here is that if you're seeing people, you know, it's really important to evaluate all of these factors that we're talking about before writing people out of work. I don't think I'm, I'm probably preaching to the choir. My wife says the choir is the only people who listen, so. You know, we have seen some efficacy in terms of the vaccines appear to prevent post-COVID illness, right? They do, we know that they prevent SARS-CoV- infection. We know that they prevent COVID-19 reasonably well, less so with Omicron, but, but we, we know, you know, the best way to prevent post-COVID is don't get COVID. It's kind of a tautology, but it makes, but it makes a certain amount of sense. You know, but it, but it does reduce, you know, it does tend to reduce, even in those people who get infected, those who are vaccinated have, tend to have fewer post-COVID conditions. All right, and we may, we're, we're probably going to be learning more about that as there, there are a number of studies that are ongoing where we'll get more information over time, but in addition, you know, probably the, I said the thing that human beings hate above all else is ambiguity. The second, the second biggest thing they hate is waiting. There, I think that it's, you know, there, there's a huge amount of, because we didn't know a lot, besides the vaccine, we saw people doing self-management, you know, antiretroviral agents, chlorquinone, hydroxychlorquinone, ivermectin, you know, we see, we saw lots of trials, some of which looked pretty promising in the beginning, and then didn't pan out. Dietary therapies, you know, people will try anything, and I don't blame them, you know, I, I don't. If you don't have an answer, then you'll go anyplace to, to try to get an answer. We do have to raise a question about, you know, there's dedicated post-COVID centers, I think there are some centers that are doing very, very good work, and they're taking a very holistic approach to evaluating people and addressing their concerns and focusing on function. I suspect we're going to see centers that are, um, I'm going to get myself in trouble, but I'm going to say it anyway. You know, they're, they're going to be money-making opportunities. I mean, there's a huge market here, and it's, that's not lost on folks. So, I think we have to be careful about what we are doing and to whom we refer. Um, I, I think overall, you know, the academic and, um, the, you know, the academic institutions and the recognition of these, uh, of these conditions probably is going to have a net positive, uh, influence on people's lives. So, I think we're going to have a net positive, uh, influence. But so far, we really don't have much literature on whether they're helpful or not. We just don't know. There's a lot we don't know yet. And so, I think the jury needs to stay out, and we need to keep a skeptical eye. Um, and I don't mean skeptical in a cynical sense. I mean skeptical in the sense of, I, I should ask this question. I, I, I'm dying of curiosity. How many of you read the methods section when you read a research paper? Most of you. I'm impressed. The only reason that's true is because we're in an occupational medicine conference, right? I should have then asked how many of you understand it, but but I won't make us embarrass ourselves. I'm serious about what I just said. We're at an occupational medicine conference, so we all know that it's really important to get the detail. Right? A lot of our colleagues in other professions don't. And I'll certainly tell tales on my psychology brethren. There are, I think in general, management really needs to focus on kind of care that's customized to the individual. Again, I've said this before. We're going to keep saying it. You have a patient in front of you that needs some kind of care, and you've got to figure out what you're going to give them. And that doesn't mean just throwing the kitchen sink at them. That means paying attention to what they're describing and providing whatever is needed. And if what's needed is reassurance that you're okay, then provide that. You know titrating care needs to be titrated to symptoms and signs in response to therapy. I think we need to pay attention to that. I think supervised PT with home exercises is important so that you have somebody there who's monitoring. You know, those of us who have, I had a pretty severe, pretty serious bicycle accident last October, and I can tell you that one of the things that I did to myself when I was able to finally like move and start doing PT exercises, that I overdid it. Which then discouraged me, and then I didn't do enough. You know, that's a pretty common experience, I think. So I think that kind of level of supervision is important. We want to ameliorate symptoms, but ultimately we're all interested in improving function and getting people back to as much of their normal activities as possible. And that, I think, is possible with these folks. You know, so you have to be kind of balancing activation versus rest, so that people don't over exert or under exert. And become deconditioned. We, you know, we need to balance those things. This is also important in folks who complain of severe fatigue because they will go over into and just become completely debilitated if they try to do too much. Right, and then get discouraged and stop doing anything. Stop doing it. We've seen that. We see that time and time again. There are some guidelines out there, the ACOM guidelines. There's actually the, I think, the ninth edition of the ACOM guidelines related to COVID are out just recently in 2022. So those are, those are, I think, are good practice guidelines. There's available from the National NIH, WHO. There are individual guides. You see the references here. They're on our list. I think, and we just recently did, I was participated with several other people in a webinar for ACOM with MD guidelines. And one of the presenters there was Dr. Vinesh Kishore. I promised myself I would pronounce that correctly. Where he talked a lot about titrating return-to-work activity. And I think this is, we both think that this is really just a superb model, you know, to provide, you know, first of all, we need to provide frequent and regular work update, work status updates, every two to four weeks. We want to titrate return-to-work, you know, people can start out at home just catching up on what they've missed, getting reacclimated, increasing slowly, allowing self pacing when they're ready, and then, you know, really looking from there to just improve the quality of their experience. It's a really nice model. I do want to say that none of these titrated return-to-work models are meant to last a long time. You know, we're talking about fairly rapid progression here normally to get people back to function. That's a really important thing. It's important for the patient. It's important for the health care system. It's really important to employers because if you over-accommodate for too long, you've actually run afoul potentially of the ADA, and now it's no longer an accommodation, and the person's got to write a new job description because you accommodated it for a long time. So this is, it should be fairly rapid progression, but thinking of this in this logical way, I thought was a really good contribution from Dr. Ben-Ish-Kishon. And you can titrate it to the patient, so you can adjust these numbers four hours, six hours, eight hours, whatever, but titrate them to the specific patient in front of you. Pretty good shape. Okay, I mentioned that we had some specific concerns, and so we're going to talk about those now. There's a lot of concerns that we have about the state of the art of post-COVID management, evaluation and management at this point. These include adequacy of available information and the desirability of face-to-face evaluation, the role of myths and disinformation, and nocebo and placebo effects. Can you have post-COVID conditions without having had COVID-19? We're going to talk a little bit about medically unexplained symptoms and three particular aspects, deconditioning, brain fog, and association with syndromic illness, including myalgic encephalomyelitis and chronic fatigue syndrome. And finally, we're going to talk a little bit about administrative and medical iatrogenicity. Adequacy of, now we have encouraged you to to compile a complete picture of the individual, including past records. One of the problems with COVID-19, post-COVID-19 and similar syndromes, is that it's based on self-report, and this is often uncorroborated. Self-report is subject to many unconscious and conscious influences, including the personal health cognitions that we talked about before, beliefs in particular, misconceptions, popular conviction within the media milieu that the patient lives, and also low health literacy. Recall bias is a really important factor, as Les talked about forgetting where he put his keys. And this was shown by some really elegant work by Gene Karagy and Angus Dawn back in 2008 and 2009 on people that alleged spine injuries after motor vehicle accidents. Cognitive misattribution is a concept that Mittenberg initially advanced in the early 1990s with expectation as etiology. And what that refers to is that people recall events that never happened, and then they infer causation of their current situation on this event that never happened, but which they are utterly convinced that did, and they attribute causation to that. And in the basic, the classical mechanisms of fear avoidance and catastrophization. We have talked about symptom escalation and revision in the past, and this basically refers to the situation where symptoms get worse instead of better, even with the passage of time and with appropriate treatment. And this can take the form of amplification, which is an increase in intensity of existing complaints. Expansion, which is development of new complaints. So someone has pain in their arm, and then they develop paresthesia and numbness and tingling and weakness. Or extension of symptoms, which refers to spread to new body regions, either on the same side or the contralateral side. And again, this is seen in complex regional pain syndrome quite often. Revision of complaints refers to the attribution of new complaints to an original illness, even after a very long and physiologically improbable interval. So someone will have COVID symptoms in January, and they will have persistent complaints until September. Then they will start to develop new symptoms in September and attribute those back to the COVID illness when there's really no connection. We encourage you to get medical records when you can, but there are problems with this. You may not receive the records. They may be incomplete. We are still seeing handwritten records, especially from private practitioners, which may be poorly legible or completely unreadable. It's often difficult to extract relevant information from very pretty, nicely formatted, electronic medical records. You may get a six-page progress note that has two lines of new information that you have to figure out what's new and what's old. Records may focus on symptomatic complaints, so you may see diagnosis of shortness of breath or chest pain, which really isn't that helpful to you. Again, we've seen an explosion in the medical literature, and if you follow this, you've seen there are a lot of what are called preprint versions of studies. These are often not peer-reviewed, and it may turn out that really this is a practice to get information into the hands of clinicians as soon as possible, but these may turn out to be not replicable and not really reliable. There are many quality concerns with the literature, different forms of bias, lack of case definitions, lack of standardized assessment protocols, and many lack of control groups. One major problem that we found is insufficient subject numbers to ensure adequate power in a study, so you will see brain imaging studies that have 20 subjects where you really need 50, 60, 80, 100 to get a robust study that you can really trust. How many folks use telemedicine for initial evaluations? Okay, and how about for ongoing evaluations? Maybe just a little more. Okay. All right, our experience with telemedicine is really kind of limited, but based on what we've seen, we think it's a good method for screening and for straightforward informational encounters, and there are clinical studies that have shown that it's a good way to provide both urgent and primary care. In terms of post-COVID conditions, we would encourage you to think about whether you want to use these modalities or whether you want to bring the patient into the office so that you can have a face-to-face encounter with them, do all of your vital signs, and just get a better idea of what's going on with them, at least for the first visit. If you are interested in this, this Van Damme paper from 2020 talked about the importance of bedside skills in post-COVID conditions, and they looked at what to do before the patient encounter, during the patient encounter, and afterward. There's been a profound explosion of information in lay popular media about post-COVID conditions. A lot of it is accurate. A lot of it is constructive and useful, but both misinformation and disinformation are widespread. Misinformation refers to information that is not intended to mislead people. Disinformation refers to information which is specifically formulated to mislead or mischaracterize the illness. Two other terms you may see are infodemic, which is widespread acceptance of unreliable information, and cyberchondria, which I mentioned before, which is an escalation of health anxiety based on health-related internet searches. This is a very broad term. Unreliable health-related internet searches. This misrepresentation is really unfortunate because these conditions are really complex, and these patients are really complicated. And as we said, there's a lot going on with them, and so any degradation of the information that you have in evaluating and treating them really can cause negative consequences for people at all levels, at the individual level, the organizational level, even the societal level. There is some information about the role of stigma, where post-COVID conditions are considered to be an invisible illness because of their subjective nature, and double stigma, which is where post-COVID conditions occur in people of certain socioeconomic groups. I'm going to talk a little bit about nocebo effects. Language in popular media can have negative effects on both individual and public health. Our colleague Jennifer Christian has been writing and speaking about this for many years. Clinicians themselves can have iatrogenic effects, negative effects on the patient. It's been found that negative comments by clinicians tend to have a more stronger influence on the patient than positive effects do. Arthur Barsky talked about viscerosomatic amplification, which simply refers to symptom exacerbation based on medical information. The Haas study that we cited here from 2022 found that somewhere between a half and three quarters of the adverse effects that were reported by patients after their first and second vaccine doses were attributable to nocebo effects, either from clinicians or from media. So, can you have post-COVID conditions without COVID-19 illness? This is certainly possible if you had an exposure that resulted in an asymptomatic illness. By definition, it's not possible. If there's no documentation, exposure either by nucleic acid amplification testing or antibody testing. So, in these cases, if you don't have good documentation of a test, you really need to look for alternative explanations for symptoms. These two Denali studies that we cite, 2021 and 22, they found a circular relationship between health anxiety, the individual's conviction that they had been infected in the past, and symptoms. And this became a self-validating and a self-perpetuating cycle. You can also see nocebo effects from social media, which may result in stress and even possibly immune dysfunction. Medically unexplained physical symptoms. We're concerned that pre-existing or incident MUPS may confound the accurate and appropriate evaluation of post-COVID conditions. MUPS refer to physical symptoms that persist for more than several weeks, for which an adequate medical evaluation has not provided an explanation that adequately explains the symptoms. These run a continuum from very simple common adult health problems like headache and back pain, and go all the way through more serious illnesses to syndromes like fibromyalgia and idiopathic environmental intolerance that really have a major effect on people's lives. MUPS are common in both primary and specialty care and affect up to 50% of patients. Many of these symptoms are nonspecific. Most headache, atypical chest pain, shortness of breath, diffuse somatic pain, fatigue, sleep disturbance, and anxiety and depressed mood. So they overlap with both non-COVID disorders like common cold and influenza, and with COVID-19 illness. In COVID-19 patients, MUPS may be pre-existing and were never detected or recorded by anyone, particularly if you don't do a thorough systems review, or they may be of new onset concurrent with the illness. So these really have the potential to confound your evaluation and management of post-COVID-19 patients. We did not find a lot of literature on this. There are three papers, so this is just beginning to be explored, but we think this is something that you really need to keep in mind when you're taking care of your patients. In terms of deconditioning, people recovering from COVID-19 may be significantly deconditioned due to the severity of their illness or the length of their illness. They may undergo psychological deconditioning in terms of pandemic fatigue or compassion fatigue in the case of healthcare workers. So the bottom line with deconditioning is that even if you don't have good physiologic evidence of deconditioning, this condition can really be significantly debilitating people. And that's where your CLRRT paradigm comes in to help you with that activity paradigm that we showed you. Brain fog is a very commonly reported symptom. This refers to reduced cognition and concentration difficulty. Primarily affects attention, language, memory, and executive function. There are historical precedents with other viral illnesses. We still don't know what causes brain fog. There are some pre-existing risk factors that have been identified, including anxiety and depressed mood, learning disability, hypothyroidism. There is some evidence for inflammatory changes in the CSF that may provide a physiological explanation. This paper by Teodoro in 2018 was really interesting. They posited that brain fog may be a functional cognitive disorder, kind of along the lines of something like irritable bowel syndrome. They looked at 186 papers on chronic fatigue syndrome, fibromyalgia, and functional neurologic disorders, which are things like pseudoepilepsy, and they did not find any evidence for a separate cognitive disorder that they could label as brain fog. But they did find some evidence for attentional dysfunction. So this may be a functional neurologic disorder that we are just gonna have to deal with in that way. Do you have any comments? Quick comment, and we wanna leave a little bit of time for questions, so we probably have to move on, so I won't belabor this too much. But what we basically see in brain fog in general, we don't find significant deficits on neuropsychological testing. What we do see is people who have trouble with somewhat slowed cognitive processing speed and problems with divided attention. And what the Teodoro paper posits is that basically what happens in these conditions is that people's attention gets turned inward, and you get kind of self-absorbed in your symptoms. Same thing happens when we're anxious or depressed. We get internally absorbed. Well, guess what? If you're internally absorbed, you're gonna have trouble responding quickly to external stimuli, and you're going to have some trouble with multitasking, because you've already got a focus, right? Makes perfect sense. So it's not that brain fog isn't real, it's that it's not brain damage, right? I think that's the point. And I think that, I'll jump ahead to something I'll say in the conclusion, which is that people require reassurance, and they require plausible insurance, reassurance, right? You can't just say you're fine. So when I explain what I just did to people, they all do the same thing that many of you are doing, which is nodding your head, right? It's like, oh, oh, is that all? Like, yeah, that's it, your brain's fine. And it's helpful. So, sorry. And following up on that point, brain fog can really have profound effects in people, but you have to be very careful about over-evaluating and over-treating it, because then you're gonna get into trouble with iatrogenic effects, which we'll talk about in a second. There have been some assertions that post-COVID conditions represent a chronic disorder similar to myalgia, encephalomyopathy, or chronic fatigue syndrome, and maybe linked to fibromyalgia as well. Keep in mind that these are syndromic illnesses defined by symptoms, and they are very controversial within the scientific community, both within the context of post-COVID and without. There's no currently clear, unifying, or generally accepted physiologic or behavioral health basis for these conditions, and there's no consistently effective treatment approach except for symptom amelioration. Our comprehension of these illnesses is really in its infancy now, and we just encourage caution in attributing post-COVID conditions to these kinds of mechanisms. So finally, we're gonna talk about administrative and medical iatrogenicity. This refers to causation, facilitation, and exacerbation of a condition by a healthcare practitioner, or a process such as an insurance claim, particularly an adversarial process, rather than a pathological condition. May occur due to things that we do or that we don't do, and anyone can be a participant. There are five forms of this. Advocogenicity refers to inappropriate advocacy for an individual's sick role, work activity restriction, or disability. Medicalization is conversion of a non-medical issue, such as a common health problem, or a personnel issue to a medical condition requiring evaluation and treatment. Disproportionate fear of missing organic disease is something that we all suffer from because we're trained that way. But if you go too far in searching for organic disease, you may do an inappropriate workup and inappropriate treatment. The focus on symptom relief is a real danger in syndromic illnesses like this, again, getting into negative effects. And as Les pointed out before, disregard for the critical nature of time is a major problem. We know from many, many studies dating back to the early 1990s that disability is a function of time away from work and activity, so efficient and expeditious evaluation and treatment of these patients is really crucial. And I'm gonna make an executive decision and wrap this up more quickly than I might otherwise, so we have a few minutes for questions, at least. And we're standing between you and lunch, so we'll also hang out. Bottom line, there is something going on here that involves the pandemic that's about COVID, and the problem is that we don't know exactly what's happening yet, and we're not gonna know for a while. So for all of us, we need to get used to the fact that things are gonna be ambiguous. That doesn't mean that it isn't real. We really wanna stress that, that there's a two-part thing here. We're caretakers, we're physicians or psychologists, we're treating providers, or we're responsible for populations of people in taking care of their health. We have to take things seriously, but we also don't wanna get caught up in reifying something that isn't. We've all heard it. If you hear hoofbeats, don't think zebras. We have this tendency to think that things that are associated with the body, COVID-19, SARS-CoV-2 infection is real, and whatever happens in the mind is not real, and that's just patently not true. It's all real. The question is, what are we gonna do about it? So what we've basically said to you is enhance the accuracy of your evaluations and your understanding of the literature, and pay attention to the methodology when you're reading these papers, and basically, first do no harm, and treat the patient, not the disease. There are some additional slides here that I think probably we oughta just let go and take the last few minutes for questions. They're in your hands-outs. If you email me, I'll send you the whole collection, and you can take a look at them at your leisure. Trust me, we could've gone on and on forever. It's probably a good place to leave it. I know there are questions from online, and I apologize to the people who are online. I'm going to do my very best to read them. It's on a Chromebook, and the font is teeny tiny, but if you do have questions here from the room, if you'd come to the microphone, that'd be helpful, because it'll be recorded that way. Why don't I try and do this? The first question to go up. You're gonna have to listen, Ty, because I'm not gonna be able to hear you. Good afternoon. Great job. I'm Mark Leffer. I'm doing some contract work for the US Postal Service. The big point I get from this lecture that you guys made a great argument about is if someone asymptomatic comes in and says they might've been exposed, don't test them. I mean, that's what I come out of this lecture hearing. Don't test them because they think they might've been exposed? Right, I mean, if they're asymptomatic, and they're asymptomatic, think they might've been exposed, there's actually, testing can do more harm than good, as long as they stay asymptomatic. I'll leave it at that. I have actually heard that said by other people. That's probably a radical interpretation of our position, but it's, there is something to be said for it. You know, it's like, well, the question is going to be, is it gonna make any difference in your care? That's always my question. Is it gonna matter? Well, it matters because you keep them functional, keep them telling them that they're healthy, and give them less stress and a lot of other things. Right, yeah. Okay, thank you. Thank you for the excellent presentation. I have patients which I follow, whom I follow for more than two years, doing every workup, referring to. I'm sorry, can you speak a little closer to the mic? It's, I apologize. Yeah, I have patients with whom I follow for more than two years, doing pertinent lab workers imaging studies, referring to physical therapy, and referring to sub-specialists as well. Now the challenge I have is when to establish MMI, maximal medical improvement. And is there any guide or any idea from you or from the audience to help me with this problem? The only guidance that I could give on MMI without doing a whole other thing here is to say that I would apply the same rule to this that I would apply to anything else. We tend to forget, and bear with me because I teach a lot to psychologists and psychotherapists, which is a little bit different world, but they particularly, and I think a lot of us make the mistake of thinking that MMI means all better. And, but it means it's as good as it's gonna get for the foreseeable future, right? The foreseeable future varies in definition from jurisdiction to jurisdiction. Generally speaking, it's about 12 months. But the point of MMI is they're as good as they're gonna get. And, you know, there are people who are going to have lingering symptom reports, and, you know, it's probably not gonna go away at a certain point. That's the best answer I've got. I'm sorry, it's not very satisfying, but I think it's the only one that I can. Just make sure that it's not, you know, I'm gonna resolve every single symptom because I'm probably not. There's an article in J-O-E-M, I think by Jim Talmadge. It's 20 or 21 that specifically addresses MMI. So that might be helpful. What was that article? J-O-E-M. Journal of Occupational and Environmental Medicine. I think Jim Talmadge was the lead author. It'll be in the, it's in our bibliography for you. Anything else? Forgive me, I'm doing a quick eye test here. If we don't have any more questions in the room, I will try to make sure, okay. If an employer does not accept restrictions that titrate the number of hours per week, should the prescriber recommend physical therapy or group therapy as a replacement treatment until returned to full duty? Many employers will not necessarily accommodate. I know that's a problem, having worked in disability insurance for a long time and trying to get employers to accommodate. I know that's a problem. I would not, it's a big question that could take a long time, but I would not recommend additional treatment in place of employment. I would advocate for accommodations and take that position that, you know, employers often, they will pretend that they don't have to engage in a good faith negotiation around accommodations. And they're wrong. And they can lose their shirts in legal battles. Now, I'm not suggesting you advise your patient to like, go sue, but I think adding more treatment in place of returning to meaningful activity, I think is more likely to make things worse. That's my personal opinion. That's, in response to your question, that's Dr. Kertay's pot shot theory of the moment. It's not, you know, I can't say it's definitive. It's often very helpful to take a direct approach with the employer and just pick up the phone and call whoever your contact is and talk to them directly about accommodation. So, first of all, do not take the patient's word for the assertion that the employer won't accommodate. And secondly, if you call the safety manager or whoever and talk with them, a lot of times you can get an accommodation where they may not want to do it initially. You can bypass that whole problem. There's one more question from online and some comments, and I apologize to everyone if I missed anything. Was there a correlation between the incidence of post-COVID syndrome and vaccine administration? To my knowledge, there has not been any definitive study. There's a lot of anecdotal comments about that. You know, I think there's one unpublished study or published under, you know, kind of pre-print circumstances that suggest that, but I've not seen any evidence that's really solid that suggests that there's any relationship whatsoever. This is really a prototype, prototypical illness where you have to really balance science and humanistic concern. You, because of the symptomatic nature of it, these people are really going to be, they're going to be ill. And so you have to determine, try to determine why they're ill in terms of organ function or whatever. And you have to treat them, try to ameliorate your symptoms and get them back to function, but you have to do it with a very clear eye and not hurt them in the process. If I had one takeaway for folks, it would be that what I said about reassurance, that, you know, realistic reassurance is the thing that most people need and that we're not, we tend not to be all that good at giving, right? We tend to either say you're fine or we do more evaluation, but we tend to have a hard time just explaining things in common language that people will say, oh, okay, you paid attention, I'm okay. Another question. My question is regarding vaccination for people after post-COVID syndrome. I cannot cite the source, whether unfortunately, whether it was the general media or an article, but I have heard that some people's post-COVID symptoms improve following a vaccination. I've heard both. I've heard anecdotal evidence that people have gotten better and I've heard anecdotal evidence that people have gotten worse. I think that's an open question, frankly. I've not seen good, solid research on it. I've been told that the plural of anecdotal evidence is not data, so. And my response to that is anecdotal evidence is evidence. It's just not very high quality evidence. And, you know, again, symptoms are evidence. They're just not enough. Laters, for the speech later today. You need us to beat it. I'm sorry, what did you say? Just you talked about rapidly getting people back to work. Yeah. What's the definition of rapid in that context? Definition of rapid? Yeah, what are you talking? Three months, six months, two weeks? As short a period of time as the person will feel like you're paying attention to them and giving them room without going one minute longer. And that's gonna vary some, but in general, two to four weeks is max for me. Like I never recommend graduated return to work that lasts longer than a month for a couple of reasons. One is that it puts the employer in a bad position, but, and you don't want that person to lose their job because then they're disabled and don't have any place to work. But. Assuming that wasn't a factor. Yeah, assuming that wasn't a factor, I'd still recommend that. Knowing the mortality and morbidity associated with being out of work, it's a health emergency as far as I'm concerned. And so, I stand by my definition. If I had to go two months because that's what it took to get somebody back to work and I knew that I could get them back in two months, I'd certainly extend it. I don't have a hard and fast rule, but I'm talking two to four weeks typically. Thank you. We're getting the hook here, Professor. We're getting the hook. Okay. You can ask later. We'll hang out. Thank you very much.

occupational physician

clinical psychologist

post-COVID conditions

comprehensive evaluations

psychosocial factors

cognitive symptom screens

functional testing

occupational factors

vocational factors

workability evaluation

causation consideration

permanent impairment rating

occupational health