Okay, thank you everybody. Thank you so much for sticking around for this last session of AOHC 2022. My name's Dr. Cadet, and I'm an occupational medicine physician at Loma Linda University Health. And today I'm going to be talking about managing worker expectations of the return to work timeline. And I'd just like to give a disclaimer that all the opinions disclosed today are my own and not those of Loma Linda University. So, we're going to start with a clip. Everybody in the audience, now listen to me carefully, is being given a special package and I don't want you to open it. Do not open it. Cameras are on you, so do not open until I tell you. All right, open your boxes. Open your boxes, one, two, three. You get a cut, you get a cut, you get a cut, you get a cut, you get a cut, you get a cut, you get a cut, you get a cut, everybody gets a cut. So, if you have not seen this infamous clip from the Oprah Winfrey show, I am honored to be able to show it to you today. We're going to be talking about worker expectations. Everybody in the audience. So, I want everybody to imagine that that is what's going to happen at the end of my talk today, right? I finish my speech, you're walking out the door, and I say, I'm going to give you $500 at the end of my talk. And as you leave, I literally give you $500. What would you think if I did that, right? You'd probably not be too surprised. You'd be really happy. You'd say, wow, that was a great talk. I know exactly what I'm going to spend this $500 on, okay? Now, I want you to imagine that at the end of my talk, I'm going to give you some amount of money between $300 and $900. The talk ends, you're walking out, and I hand you $500. What do you think? Kind of disappointed, right? Like, 500 is better than 300, but you're really hoping to get the max amount of $900. One last scenario. What if I told you that at the end of my talk today, you're each going to get $10,000? And then as you walk out, I hand you $500. You're like, what? Burn the place down, this is outrageous, right? So nothing changed in any of those scenarios each time you got $500, but your expectations changed dramatically, and that affected how you felt. So if your boss says, you're going to get off of work at 12 o'clock today, and you were expecting to get off at six, you'd think, wow, this is pretty awesome. If you go to a fast food restaurant and you expect curly fries, but they give you straight fries instead, this is a tragedy. Or if your spouse is like, let's watch a movie, and you're like, it's going to be awful, and then the movie actually ends up being really good, you're like, give that movie an Oscar. The reason that I'm bringing this up is because in our field, occupational medicine, it's all about expectations. We succeed or fail based on what our patients expect. So the more we can control their expectations throughout the process, the better. So I have a few learning objectives today. We're going to identify the recognized time course for some of the common occupational medicine injuries. We're going to talk about barriers to recovery. And we're also going to go over some communication techniques for sharing the return to work timeline. Now, one of the biggest problems that we face on a day-to-day basis is that our patients' expectations are often wildly unrealistic, if not dead wrong. Workers' comp is confusing, especially if it's your first time in the system. And their coworkers tell them these glorious tales of indefinite paid leave off. So at the least, they think they're only going to go back to work when they feel 100% better, they have zero pain, and they're better than ever. And so I don't know where we got these ideas. I think a lot of us thought the same way before we entered occupational medicine. It may stem from childhood. You know, we're sick, your mom comes over, she puts her hand on your forehead, tells you you have a fever, she says you're not going to work to school today, and you just get to hang out. You play video games, you do whatever it is you want to do, she's bringing you to work, she's bringing you Gatorade every 30 minutes, she's rubbing you on your back as you're throwing up, and you don't have to do a lick of work. So we've kind of been conditioned to believe that when we hurt, or we don't feel good, life gets to stop. And there's a big difference between taking a day off from school as a child, and then being adult, and taking off eight months from work, because you don't feel good. The next biggest problem is that many doctors don't like to set expectations up front, because it can be a really hard conversation to have with patients, because we can feel like we're telling them, you don't get what you want. We're telling them that you don't get to be off of work for eight months. And in general, we want our patients to like us, and we want them to feel better. But sometimes, despite our best efforts, they don't feel 100% better, and to confess that may seem like a reflection on the type of doctor we are. Many of us don't like confrontation, and we don't want to deal with the patient's negative emotions when we have to tell them that they don't get whatever it is that they want. But here's the problem. If we don't tell our patients what to expect, they'll fill in those gaps for themselves, and we'll end up with things like prolonging the amount of time that it takes them to come back to work, absentee rates will increase, and absenteeism is the idea that you're missing large amounts of time from work for no reason. We'll worsen clinical outcomes because they're not being active, and we can actually cause iatrogenic disability, this idea that I, the doctor, caused you to be disabled because I pulled you out of work unnecessarily. Healthcare costs will increase, and perhaps the most impactful consequence to the worker is the loss of their social relationships. How many of us have just been overjoyed, cups filled at this conference because we finally had an opportunity to see people we hadn't seen in a while, and we connect with our coworkers? There's also the loss of the identity component. What is it that I do for a living? How do I contribute to the world? There's also a loss of the self-respect that comes from earning a living, so now you're relying on other people to take care of you, you're relying on government assistance, and none of that does anything to increase your self-worth or your sense of respect. So when we effectively manage a worker's expectations of the return to work timeline, we have the opportunity to do several things. The first is to improve their outcomes and their productivity, decrease healthcare costs, enhance client satisfaction, and we also have the opportunity to gain a reputation for being a value-based provider. So within our communities, we all know of OCMED facilities that run more like an assembly line style of medicine versus some of the more well-rounded experiences, but regardless of where you practice, you can develop a reputation for providing value. So employers want to send their workers somewhere where the care is compassionate, excellent, and the workers actually come back to work within a reasonable timeframe. So let me walk you through what it's like the very first time that I meet with a new patient. It's a process that I've learned and refined over several years, and I've made a lot of mistakes and some hard-won lessons. So I'm gonna tell you what I do step-by-step and exactly why I do it to make things easier between myself and the patient in any encounters going forward. So we have a 23-year-old female. She's a lab animal technician, and she comes to me with low back pain. Now before I even talk to her, the first thing I do is data mine her chart. It's unusual for such a young person to have low back pain, so I'm looking for things that might indicate did she have low back pain before I've ever seen her before I talk to her and hear her account of how she hurt her back. So I'm going through and I'm looking at what's her BMI, because we know obesity can cause low back pain. Is low back pain already on her problem list? Has she been seen in the ER for anything? Has she had any motor vehicle accidents? Do we have a history of dysmenorrhea or painful periods, which can also cause low back pain? Does she have any psych diagnoses that might be causing her condition or that might be flaring as a result of her condition? So things like anxiety, depression, adjustment disorder. What is on her current med list? Are there any narcotics? Is she taking any NSAIDs? Is there anything that may point to a prior diagnosis that generates pain? I also scan her prior imaging. Has she ever had imaging of her back before? And so why do I do all of this? It's to set me up for knowing what I'm about to walk into before I meet the patient. And if my data mind doesn't yield any jewels, then I'm walking into the room blind and sometimes that can't be avoided. So next I get ready to walk into the room. Is my attitude right? Am I rushing? Am I stressed out about something? I need to leave all of that outside the door because patients can sense when we're rushing, when we're distracted, when we don't care. And that sets the tone for how the encounter is going to go. So then I enter the room, I smile my million dollar smile underneath my mask. I make eye contact, I shake her hand and I sit down and I ask her, what's your name? My name is so-and-so. And so then I'm bringing this warm, caring and safe energy into the room. And again, most patients aren't trying to manipulate us. They're actually hurt and they need our help. And workers' compensation has a very bad reputation, just really horrible. And so if walking into the room, smiling, making eye contact, shaking their hand seems very basic to you, I'd like for you to think about that again because the physicians who do that actually gain a reputation for being the best. Right or wrong, they are perceived as the best. So best by the patients, best by the support staff and best by the adjusters. And so they're asking questions like, well, whose name have I heard being praised? That person is the best. Who can I go to to help me solve my problem? That person is the best. I have a difficult case, who can I take this patient to? And they will solve the problem with the lowest chance of litigation. That provider is the best. And so in the three seconds that it took me to greet the patient, I've already started to do my visual exam. How are they positioned? Are they already on the table? Are they sitting comfortably in the exam room chair? Are they standing up? Do they look uncomfortable? Is there an assistive device in the room? Did somebody come with them to the appointment? Why? Is it because the person couldn't drive themselves to the appointment? Is it because they wanted to be there for moral support? Or are they there to cause drama in the encounter? So I sit down, I notice that my patient looks very comfortable. She's in the exam chair. She's got good posture. And so maintaining eye contact, I ask her what happened? Why did you come to see me? And I let her talk and I don't interrupt. The average patient can get the entire story out in eight minutes or less. And so when you're an active listener, you're showing that you care. You show that you respect the patient and you're earning their trust. And for most of my patients, they can get the entire story out in three minutes or less. And I can listen intently for three minutes and so can you. So in this case, the worker says that her symptoms were caused by having to bend over in clean animal cages. She also has to lift them up and they weigh anywhere between 25 and 50 pounds, which is a pretty significant amount of weight. And her pain has gotten worse over the last week. So she says there were no other events that might've caused her pain. She doesn't work out at the gym. She doesn't fall. She does say that she thinks her workload has increased because one of her coworkers called out of work saying that he had a work injury as well. She says the pain is six to seven out of 10. And I want you all to remember that number with some occasional radiation down the right leg to the level of the knee. It's worse with sitting and standing. And she says she really doesn't know anything that makes it feel better. She takes about two extra strength Tylenol once per day, but doesn't think that's helping. And she is able to perform all of her ADLs or activities of daily living, but with pain. So once that's finished, I come in with my million questions. And that's okay because at that point, I've already earned the trust of the patient, right? So I've been very kind. I've listened attentively. And so now they're ready to answer my questions. All right, so back to medical school. We wash our hands before we touch the patient, don't we? Not all of us are washing our hands and the patients are looking at us like you're gross. You didn't even clean your hands before you touched me. So I wash my hands. I do her physical exam, which is normal, right? So as I'm pushing on her back, she's got some subjective complaints of pain. When I ask her to bend forward, she says that it hurts. But for me, the exam is objectively normal, okay? We know that pain is subjective. We also know that the majority of the time, range of motion is under the influence of the individual and can also be considered subjective. Now the patient doesn't think their exam is normal because she's in pain and it hurts when I press on her. So based on our mechanism, the history, our physical exam, we say she has low back strain. Now, while we know what that means because we diagnose that 15 times a day, she does not know what that means. So we must explain to her what that means and how it was caused. And we must emphasize that there's nothing dangerous going on with her back. She's not broken any bones. The likelihood that she tore any ligaments or had any herniated disc is extremely low. And the reason that it's important to explain this to patients is because when they're in a lot of pain, they create a horror story in their mind about what's wrong with their back. I've had patients tell me, I think I have cancer in my leg because it hurts so bad. So we must take the time to explain. So then we're gonna tell her, your injury's very mild. This is how you treat it. And says, he's stretching. And then we must, must, must set up our expectations for the return to work timeline. So we tell her six to eight weeks and I'll get into that number in a little bit. But we also wanna talk to her about on-the-job recovery, and how we achieve that through work restrictions. So we give her a restriction that says, don't lift more than 10 pounds. Don't bend or stoop repetitively. And we tell her that we don't remove workers from work for simple muscle strain and that she'll actually get better faster if she's active and doing some type of light duty. So she follows up with you in a week. She says nothing has changed. Her back is still hurting at a six out of 10. So we give her a PT. Now a yellow flag should go up at this point because she's 23 years old. She doesn't have any comorbidities. She's got work restrictions. There should be no reason why the pain score hasn't come down over the last week. So we use the follow-up visit as another opportunity to reiterate the timeline. So you tell her, you know what? It's okay, your back should be feeling better, max six to eight weeks. And you investigate her job satisfaction, right? So does she like the job? Is she getting along with her supervisor? Is she getting along with her coworkers? Is her employer even following the work restrictions? Is she following the treatment plan, right? So she tells you that she's actually not getting along with the coworker that she mentioned earlier because she feels he's faking his injury. And as a result, she has to do a lot more work. She says she does like her supervisor and she's only taking the ibuprofen once a day. So we remind her that the prescription was actually for three times a day. So why doesn't she increase the frequency of the medication and see if she feels any better? We also send her to physical therapy. So over the next four weeks, we see her several more times. She ends up doing 12 sessions of PT. So when she comes to see you on week seven, she says the pain is five out of 10. So again, the timeline that we set was six to eight weeks. We reemphasize that to her and we order an X-ray of the lumbar spine because now we're beyond six weeks. X-ray doesn't show any acute findings. It doesn't show any degenerative findings. So we tell her that pain is not a reason to keep indefinite work restrictions in place, especially when there is no objective evidence of an injury. And this is where we introduce the concept of tolerance. So at her eight-week follow-up, she says her symptoms are improving, but she still has pain. And this is a great time to empathize with the patients. We're not cold-hearted machines. We don't like for them to hurt, so we wanna empathize. But again, we emphasize that because of the lack of objective findings, we're not able to continue her work restrictions. So we do offer her a third round of PT, almost as like a little bargaining chip to soften the blow of being told no. And we explained to her that utilization review may deny that request for another round of PT. And utilization review is where insurance companies go through, they look for the medical necessity of treatment, and if they find none, they can deny payment. So she ends up being amiable to that plan to do a trial of full duty because this isn't her first time hearing the information. It's been something that we've talked about many times over her follow-ups. So at her final follow-up appointment, she actually has done 18 sessions of PT. She's tolerating full duty, and she tells you she actually applied to change her job. So that's not something that happens a lot, but sometimes when patients recognize that they actually can't tolerate the job, they don't wanna stay in this position for a long period of time, they'll change job positions. So I've been doing this for a while, and there are some absolute patterns to it. You know, every patient is different, but the first of the patterns is that bedside manner is everything, right? So our bedside manner communicates care and respect for the patient. They're more likely to hear what we have to say because they feel heard and respected. They're more likely to trust our advice. They know that we care about them, and so it makes it easier for them to tolerate our no when we say, you know, it's time to go back to work. So we have a 54-year-old female, she's a diet aid, and she comes in with foot pain of sudden onset that started in November and then in December got worse and became constant. She cannot tell you a specific incident that started the foot pain off, but that she has been working in her current job since June, which is about five months before she presents to you. She tells you there's a sharp pain on the sole of her foot, and it's worse with walking. She initially thought it was a cramp, and it's improved with rest. So the initial provider who saw her did an X-ray, which showed no acute findings. They started NSEDS PT, and they gave her work restrictions that said for every hour of work, I want you to take a five-minute seated break. So when the worker expressed concern that she was being sent back to work and said, I'd rather have one to two weeks off to rest my foot, the provider said, no, that's not appropriate. We're not gonna do that. And so his delivery was described as being very forceful, and the worker's behavior was described as being very argumentative. So the patient was transferred to my care, and she said, I did the PT. I've seen some improvement in my foot. I'm pretty busy at work, so I wasn't always able to take the five-minute seated break, but I tried to do it when I could. So I probed a little bit further to investigate her job satisfaction, and found that while she enjoyed her work, she was planning to cut down her hours to 20 per week so she could start working in real estate. So when I reviewed her imaging again, I found that she actually had flattening of the second metatarsal head. And when you compare to the other metatarsal heads, which are nice and curved, okay? So this could indicate Freyberg's disease, which is known to be caused by things such as progressive traumatic injury, and the worker did say that when she was younger, she was a long-distance runner. So after explaining that this type of injury is most likely not due to her work, but more likely her age and progressive trauma, she was amiable to discharge with a non-industrial disposition. She understood after we spoke to her that she could work safely through her discomfort, and that orthotics would be helpful, and because she was cutting her work hours, more than likely her pain would also decrease because she wasn't standing up for eight hours a day. So when we talk about how can I improve my bedside manner, we've already talked about the importance of listening, but touching the patient is extremely important as well. You can also ask for feedback, feedback from your co-providers, the medical assistants, the nurses. You know, the patients will give you feedback. They'll say, you know, you're amazing. You're the best doctor I've ever had. And so has any of your patients told you that over the last 10 years? If nobody has said anything to you, you might need to work on your bedside manner. If you're not taking care of yourself or you're suffering from the effects of burnout, you need to address those issues, right? So do you need to take time off from work? Do you need to cut back on your work hours? Do you need to adjust your practice environment? Do you need to establish new health habits? When you take care of yourself, it's easier to take care of other people. Okay, so the second thing that increases our ability to have a successful interaction with our patients is to set expectations early and often. So remember, patients are coming to us with their own preconceived notions of what's going to happen to them as a result of their injury. They have their own ideas, their own goals. I've had patients say to me, I just want to be able to wear cute shoes. So I'm like, all right, bet. And so the encounter is to align their expectations with mine so we can arrive at the same destination. So we have a 43-year-old nurse who's got low back pain. We see back pain all the time, so forgive me for the duplicate, but she was helping a patient put on undergarments. And she says when she was stooping over to do that, she tweaked her back. This happened in September, 2019. So she goes to her friendly neighborhood ER and they ordered a CT scan because that's the best imaging study to order in this situation. So it shows some degenerative changes at L4, L5. They gave her muscle relaxants. They gave her NSAIDs and sent her on her way. And so this is a photograph of the CT scan. It's kind of hard to see, and I don't know if my, but there's some narrowing between the vertebrae and I've circled the herniated disc, which might be kind of tough to see. So two days later, she comes to OCMED and she's like, I need a wheelchair. I can't walk. And we're like, okay, we'll get you a wheelchair. She says sitting makes her pain much worse and that she does not feel safe driving her car. So we do her exam. Again, it's objectively normal. I've got a little bit of pain when I'm pressing on her back. So we continue the conservative measures that were prescribed in the ER and we give her work restrictions that say we don't want you to lift more than 10 pounds. And since sitting makes your pain so much worse, we want you to stay on the majority of your shift. So a week later, she comes back and she's like, the pain is seven out of 10. Pain was out of proportion to exam. Her physical exam was still completely normal. So we said, okay, well, we're gonna start you on some physical therapy. She said, no, no, no. It has to be aqua therapy. Okay, we'll give you some aqua therapy. Okay. So over the course of her care, it became obvious or it became known to us that she had had a previous workers' comp case five years earlier in 2014. And she basically said because she had to twist and reach and bend while caring for a patient, she hurt her back. So there was an MRI done in 2014 that showed some disc protrusions at the same level. So this is her MRI from 2014. And I've circled her disc protrusion. So if you start at the top and kind of work your way down, you can see how all the other discs are kind of sitting in position and there's a slight bulge at L4, L5. If we look at the axial view, if you start at seven o'clock, and I'm so upset this isn't working, but if you start at seven o'clock at that black circle in the middle, that's her disc, and you just work your way around, everything's nice and smooth, nice and smooth. As you get to about six, 6.30, there's a protrusion down to the left kind of going into the spinal canal area. And that's the disc protrusion and it's on the right side of her body. And then just to compare that to normal, on the left you see the disc nice and smooth. There is no protrusion into the central canal there. And so the reading radiologist also said that there's no nerve impingement at that point. She did go to neurosurgery at that point and they said do conservative care. She went to pain management. They said we could do a steroid injection and she said no thanks. So over the next several months as I'm treating her, she keeps telling me how bad her back is hurting. There was no improvement despite the NSAIDs, despite the aqua therapy. She starts to tell me that her entire right leg is numb in all dermatomes, both upper and lower leg. And she says she's just really having a hard time bearing weight. So I order an EMG and there's no radiculopathy, there's no plexopathy, there's no entrapment neuropathy. And so given her complaints, the lack of objective findings on exam, EMG, MRI, I send her to neurosurgery. They order an MRI of the spine. And this is happening now, we're back in the present 2019. So on the left is her 2014 imaging that shows the protrusion. 2019 there's the protrusion and there's practically no change Now the reading radiologist said he would even argue that maybe there was some improvement to the 2019 imaging. So that I thought was very significant. And so if we look at an axial view, again on the left we see the 2014 imaging and how that protrusion is coming into the central canal. The 2019 imaging you can also see the protrusion and there's practically no change there. So neurosurgery sends the patient to their physical therapy spine team. They also help us out and send her to pain management and I'm being facetious. And pain management says, well, we can give you steroid injections and she says, no, thank you. So over the next several months, she continues to complain of pain, inability to bear weight. She did report some compliance with the home walking program that we put her on. So that was a positive. So we relaxed her work restrictions. So instead of don't lift more than 10 pounds, we said don't lift more than 25 pounds, but she resisted the full removal of the restrictions and her return to full duty. So at five months, we're now in February of 2020. She tells me that she recently came back to the United States after traveling abroad with her family for one month. She tells me that she also found another job as a diabetes educator and would no longer be required to lift and transfer patients. So we were able to completely remove her restrictions and discharge her. So what went wrong in this case? There were a number of things. Number one, I did not set expectations with the worker on the return to work timeline. Now she said she injured her back by bending over to help a patient put on their undergarments and that mechanism of action makes strain most likely and you would have expected that to get better within one to two weeks. We could push it to six to eight. You also would have expected it to get better with conservative therapy, which she says that it didn't. So in this case, I left the timeline very much open-ended. So it's like come in and see me for as long as you want. Number two, I let the worker drive care. So at first it was like, I don't wanna do traditional physical therapy, I want aqua therapy. And then once we do that, it's like, well, I want 34 sessions of PT. And then after that, it's I want neurosurgery and then I'm doing pain management. She also requested to go to the Neuropathic Pain Center, which is a specialty clinic that's unique to Loma Linda. And so without any objective evidence on any of these studies, these specialty referrals really aren't indicated, right? There was no nerve impingement. Her EMG was normal. And so her whole description of this right leg numbness that did not follow a strict dermatomal distribution is actually invalid according to the AMA guides. And so the part that I love the most about this case was her ability to travel abroad for a month. So she can't do her job, but she can carry her heavy luggage, the airport, she can stand in long lines, she can sit on the airplane for multiple hours at a time, but she's not able to do her primary job. And then number three, I was not situationally aware of her prior worker's comp case because I did not adequately data mine the chart before I went into the room. And so that left me open to being more easily carried away with all of her complaints and requests. Now, what could have been done differently? I could have set expectations that, hey, this is simple strain, max it should be better in six to eight weeks. I could have better explained causation to the worker and explained to her that this protrusion that we initially found in 2014 is radiographically the same, if not improved to her newest imaging in 2019. I could have better explained that we don't think this protrusion is due to your episode of helping a patient put on undergarments. And I could have also said degenerative findings are not indicative of pain sources, right? And so I also should not have supported her being referred to multiple specialists. So those are some of the things that I could have done differently. So how do we establish the return to work timeline? So for those of us who have done OCMED residency, we learned the timeline in residency. But if you've not done residency, you can look at the ACOM guidelines, MD guidelines is another really good source, and you can also do literature searches. So in this longitudinal study by Zeydal, they looked at almost 791,000 short-term disability cases, and they found that the median length of disability for back pain claims was 51 days. When they looked at sprains and strains, it was 41 days. When they looked at lower limb fractures, it was 62 days. So when the patient first comes in to see me, I only reveal the first phase of the treatment plan. At the first follow-up, if there's still pain, then I'll give PT. But I don't go into, oh, we're gonna do MRIs, we're gonna do imaging, we're gonna send you to neurosurgery. I don't reveal all of that initially, right? I base what I'm telling the patient on their presentation at the time. The reason I do that is because, number one, if I go down the rabbit hole of all the possible treatment options that's overwhelming for the patient, and then it causes the patient's mindset to change. So it's like, oh, well, I must have a really serious issue, and this is gonna take forever, as opposed to focusing on, no, this is actually a really simple strain, you're gonna get better very quickly just doing conservative measures. Okay. Now, after six weeks, if a patient is still complaining of pain, I will do X-rays while continuing physical therapy. But per the ACOM guidelines, X-rays of the lumbar spine are not recommended in the absence of red flag symptoms within the first four to six weeks. Now, sometimes, if the patient is super anxious, I will order what I call a therapeutic X-ray just to get them to calm down and cooperate with the treatment plan. But in general, no imaging before week six. The same is true of MRIs. The ACOM guidelines say there's a poor correlation between low back pain and degenerative findings on imaging studies, and you should only be doing an MRI if you're going to be going after a disorder that's surgically correctable. So I will use this to my advantage when they come in and they're pressing for this MRI, and I'll say something like, you know what, yes, we usually do an MRI when we're planning for surgery. And then they'll back off because they're like, well, no, I don't really want surgery. So that's something that I use. Okay, here's another good story. So I have a 39 year old female, she's an RN in the ER and she catches COVID. Symptoms are things like headaches, sore throat. So we need to come up with our initial timeline. So going back to Zadell's paper, as I'm trying to figure out, how long should it take her to recover? COVID was one of those diseases where we didn't know anything about it when it first came out and there's still a lot that we don't know. So I start with, well, how long does it take us to get over a cold? It's like seven days. If you're talking about pneumonia or the flu, maybe two weeks. So in Zadell's paper, they found that upper respiratory infections took a median of 16 days. But we also need to consider the patient's other comorbidities in light of COVID. So if the patient has asthma, diabetes, is immunocompromised, it's likely going to take them a lot longer to recover. And in the first wave of the pandemic, I noticed that a lot of my patients who were in their 30s were taking a lot longer to recover, like three to six weeks. So this patient that I'm discussing today, she's 39 years old, she's got these comorbidities. So I'm gonna set the initial timeline at two to four weeks. So at her week one follow-up, she tells me the headache is still the same. At her week two follow-up, the headache is still the same. So I use this follow-up appointment as an opportunity to reiterate the timeline, that it's okay, it's gonna take some time, we think it should take anywhere between two to four weeks. Week three, the headaches are still unchanged, and she starts to say things, you know, I'm really stressed out, I'm the person in my house that does everything, and now that I have a headache, I can't do everything, and everybody in my house is doing nothing, and it's causing a lot of stress. So I said, well, you know, here's the phone number for employee assistance, why don't you call and maybe get some counseling to help deal with some of the issues that are going on in your house? Week four, headaches are still unchanged. Now, the initial timeline was two to four weeks. So she's telling me she still has this headache, I'm like, okay, she says I'm not ready to return to work, she didn't call EAP. So I have, we all have the liberty to adjust the timeline. So I do a one-time extension, and we say, okay, well, now we're gonna move our timeline to four to eight weeks. By four to eight weeks, you should be feeling better. Now, you wanna keep in mind that by week 12, the odds that she will ever return to work dropped to 50%. So we really wanna try to get people back to work before week 12. So at our week five follow-up, headaches have not changed. So we refer her to neurology, and we're suspecting that they're just going to say, you know, we're gonna do watchful waiting, the headache will eventually go away. We also send her to physical therapy for deconditioning, because she's been sitting around her house for five weeks. During that week five follow-up, we also, again, reemphasize the timeline, that we're hoping you're gonna feel better within four to eight weeks. So at the week six follow-up, she'd done three sessions of physical therapy, and she's like, hey, my headaches are starting to feel better. And I'm like, great. And she's like, well, I don't think I need to see neurology anymore. And I'm like, even better. We were still waiting for the authorization anyway. So why don't we go ahead and cancel that? All right, so when we get to week seven, she's willing to do the trial of full duty at this point. So she's open to it, because we've been reinforcing it the whole time. She still doesn't feel her 100% best, but we've kind of primed her, and she's at least willing to try. We do warn her that because she has COVID, she's probably gonna feel really, really tired. So week 10, she comes in, she says she was able to tolerate her work trial, and she's ready for discharge. And we remind her that she probably will still have some fatigue. She probably will still have some intermittent headaches, but that eventually we expect those things to resolve. So she asks you again about EAP. She wants to deal with some of the issues going on at home. So I give her the phone number again for EAP. So this case went well, because we had been reinforcing the timeline all along, so nothing was a surprise. We gave her flexibility by giving her that one time extension. And we also attempted to address other variables, like the psychosocial issues that were going on at home. We gave additional support for her deconditioning. And we also use positive reinforcement, telling her that she was gonna get better, telling her that she was gonna go back to work soon. And we were also realistic about the possibility that she would have some mild ongoing symptoms, and we didn't make promises like, you're gonna get 100% better like tomorrow, right? We normalized that it's okay to go to work, even if you're tired, and even if you have some mild headaches. And so the third lesson that allows us to have a good patient-provider interaction is to look for red flags and troubleshoot. So you're going through the chart, and you see that the person is a frequent flyer. Like I've had patients where they've had two encounters with the health system for over a year every week, and so it's like a yellow flag. And it kind of primes me that I need to look more closely at their presenting complaint. Is there some type of ulterior motive for them coming in to see me? Now, I don't call the patient out about this. I just use it in the back of my mind as something that's gonna inform me on how the encounter could possibly go. I'm also looking for a discrepancy between the reported mechanism and their symptoms. So I had a secretary once who came in, she said she hurt her wrist after closing the drawer on the printer, and her wrist pain was so bad that she could not go to work. And so I'm looking at her, and I see that her hair is perfectly curled, because she had curled it that morning with a curling iron. And if anybody has never curled their hair with a curling iron before, you have to be pretty agile. There's a lot of twisting motion with the wrist, and so I've already done my exam, and I didn't even touch her, right? I'm also looking for discordance between the physical exam. I've come up with this thing that I like to call the T-shirt sign. So the patient comes in, and they're like, oh, doc, my shoulder, it hurts so bad, I can't do anything, I can't go to work. I'm like, no problem, why don't you take your shirt off so I can examine your shoulder? And they whip it off, and I'm like, you're fine, you're good to go. And I once had a patient, this was like a few days before Christmas, she came in, she said her back hurts so badly that she could not go to work. I said, okay, no problem, why don't you hop up here on the exam table so I can check you out. So I grab her bag to move it from the exam table to the exam chair, and it weighs like 30 pounds. And she walked into the office with no problems. So I said, I already know what your disposition is going to be. Now, sometimes the red flags are apparent on intake, right? So I had another patient, he's a patient transporter, and he was complaining of cough after exposure to propane fumes. So as I dig into the history, I'm trying to figure out what happened. He tells me that a homeless woman was dropped off in front of the ER with burns to her face and her hands. So apparently the propane tank that she was using to warm her encampment exploded. So I was like, oh my goodness, were her clothes burned? No. I said, did she smell like smoke? Did she smell like propane? No. I said, so why do you think you had an exposure to propane fumes? He's like, I don't know, I was standing next to her in the ER and I started coughing and my supervisor sent me here. And so he, I've actually treated this patient before for something similar, where there was a mismatch between the mechanism and the symptoms. He was no longer coughing, his cardiopulmonary exam was normal. So I said, I think you're good to go back to work. You have not had a propane exposure. Okay. Sometimes the red flags only become apparent over the process of care. So I had a 70 year old neonatologist who came to me after tripping and falling in the hospital and hit a metal bar that was on the ground. So he comes to see me and I'm really concerned, hypervigilant for any type of pathology. And he's like, no, I'm fine. I said, are you sure you fell and you hit your head? He's like, I'm good. I'm like, you don't want any work restrictions? No. Do you wanna come back and see me in a week just to make sure everything is okay? No, I'm fine. Three weeks go by, he shows up in the lobby without an appointment saying he wants to be seen, that he's got these new onset headaches, he's got some gait instability. And I'm like, that just does not line up with what we would expect from a head injury. We'd expect for you to start to demonstrate some symptoms soon thereafter, not three weeks later. So against my better judgment, I brought him back in. We did a CT. It was normal for his age. We also sent him for vestibular therapy. We're like, I don't know, maybe some otoliths got dislodged. No improvement with vestibular therapy. So a week later he comes in and he's saying, I'm falling more at work. And I'm like, what are you talking about? You never said you've been falling. That's new. So I give him restrictions that say seated work only. He doesn't follow the restrictions. A week later, he says, Doc, I need a disability license plate. And I'm like, but you're not disabled. He's like, no, no, I'm totally disabled. Vestibular therapy told me I'm disabled and that I will never go back to work again. A week later, he sends an email to myself and his entire leadership chain talking about blurry vision and how he'd seen his ophthalmologist. He had vitreous detachment and swelling. And I said, this is not work related. This is not all coming from the fall, not three weeks later. So ultimately he decided to transfer care and he was taken out of work. And so it kind of bothered me that he's been iatrogenically disabled, but sometimes that's just how it goes. And so all you can do is document your care and your findings. Now, sometimes the red flags are worsened by other providers inadvertently. I had a 34 year old female. She was a police officer who came in with left-sided headaches, left-sided neck pain. And she said the entire right side of her body from her scalp all the way down to her toes was completely numb. That she had been doing some tactical defense training at work and got hit in the head twice. Now she had on the full garb, nice head gear, foam padding, metal wiring across the front. And she said at first she didn't think that her symptoms were even due to work, but she went to go see her primary care doctor who diagnosed her with a post-concussive syndrome. And that's why she came to OCMED. So she tells me that she went to like four different ERs at different medical centers. She got a CT of the brain that was normal, an MRI of the brain that was normal. She got a CT angiogram that was normal. She got a CT venogram that was normal. She saw the neurologist who said he couldn't find anything wrong. And she was really concerned about her symptoms. So her physical exam was completely normal, right? And so her headaches could represent post-concussive syndrome, but it's anatomically impossible for the entire right side of your body to go numb in the manner in which she was describing. So I sent her to neurology and they agreed that that, well, maybe this is a migraine. They wanted her to take medication for that, follow up with her PCP, do some stress management. And they also recommended that she follow up with psych. So with the lack of objective findings, I told her I did not think her current symptoms were due to her work incident. So I discharged her back to her PCP. She did not like that she was discharged back to her PCP. So she filed a complaint against me with the California Board of Medicine. Now, in talking with the legal team at my hospital, they determined that she had recently transferred police departments from Texas to California. And they surmised that she was going about her case in the way that she was, perhaps to gain a medical retirement in California. Three months go by and all of a sudden she appears on my schedule to be seen for follow up. So I call the adjuster and I'm like, what's going on? Why is she on my schedule? And they're like, well, her job is saying they don't know what to do with her because she's saying that she can't work. I said, well, I released her with no restrictions so they can just follow that and have her go to work. So I also advised him that my legal team, who I called at this moment, said I have the right to refuse care. And I think that's really important for us because so often we've been taught that we have to bend over backwards for our patients, that they can talk to us any type of way, that they can treat us any type of way, and you actually can refuse care, especially if you feel like your license is being threatened by an individual. So she ended up seeing us, this would be the third neurologist at this point since the last time I had seen her, who also said they couldn't find anything wrong. Her care was transferred elsewhere. The provider did give restrictions, which is unfortunate because you've had so many doctors say that nothing was wrong, and it kind of has the inadvertent consequence of tethering her to the workers' comp system for no reason. Now, sometimes the timeline needs to be extended for valid reasons, and we kind of talked about that with our earlier COVID case. And then there's other times when the worker wants to extend the timeline for invalid reasons. And so we've got this 54-year-old ICU RN who comes in with trapped strain. Now, this was during the Omicron surge, and the nurse-to-patient ratios were completely skewed. So instead of taking care of one to two patients, they were being asked to take care of two to four patients, sometimes five, and she did not want to go back into that environment. So we were constantly talking about what the expected timeline of recovery was for a strain. She refused to try to go back to work, but she was able to help her college-age son move across the country into his new dorm. So in conclusion, managing musculoskeletal injuries, most of these do have a defined time course. It's not written in stone, but we do have some general guidelines for how long it should take for these things to recover. And this is very important for preventing system-induced disability, iatrogenic disability, and it's a skill that has to be mastered with good bedside manner, repeating our expectations early and often, and then looking through the red flags and troubleshooting those. So I'll take any questions, if there are any. Thank you. And I'm just kind of scrolling through the chat. Okay, here we go. When exploring a patient's chart for past medical history, do you obtain consent to get prior medical records from the patient prior to seeing them? Our EHR is completely independent from our local hospital system EHR. It is my understanding that legally, the personal medical record and work comp medical records are to be kept completely separate. So how do you obtain the history other than asking the patient for their history? And if they consent to obtaining records, how much do you enter into the chart? So that's a really good question. Usually, I don't request records from their personal file. Sometimes if it's a transfer of care, the adjusters will be able to get records that are specific for the case, but I usually am not trying to go into their personal record. The EPIC actually sometimes bleeds over with Kaiser. So sometimes I am able to see their information because it's already in the chart, and I will use that. The only time, so for instance, I'll have a patient come in, I've done the whole thing, and I'm like, I actually do need to see some other things. I will ask them for their consent and ask them to sign a release form. So our clinic does do that. Any thoughts regarding the use of ODG guidelines? Yeah, I love ODG guidelines. I didn't mention them on the slide, but they're also another really good resource. Awesome. Okay. Well, thank you so much, everybody, for coming. Enjoy the rest of your week.

Dr. Cadet

occupational medicine physician

worker expectations

return to work timeline

setting expectations

patient experience

patient outcome

bedside manner

building trust