Let me see, why are they transferring this patient to me? Let's see, either the patient's attitude was a piece of work or the doctor wasn't that great and they fired him, but still, it's front desk, I've asked them a million times. Instead of blocking off an hour, they put new patients in 20 minute slots. How do you expect me to address all these issues in 20 minutes? And then I get into the room and every body part hurts. It's like head, shoulders, knees and toes, knees and toes, knees and toes. Hi, I'm Dr. Leslie Cadet, I'm an occupational medicine physician, and I'm going to guess that at least at one point, someone in this room has felt how I felt. Negative emotions, negative justifiable emotions, we all have them. So how do we remain grounded and empathetic when we are communicating with patients? Now, how many of you felt how I felt 30 seconds ago? Thank you, yeah. A lot of us feel this way, and sometimes we can feel so overwhelmed by it all, we felt like, man, it's over. I'm quitting my job in healthcare, I'm going to the Caribbean, or I'm going to lay on my couch with my feet up, whole month, staycation. Before you quit and move to an exotic island, hear me out. I think I can help support you to move through those negative emotions, so give me just a moment before you decide to quit and trade in your stock options full time. Mr. Miller, 54 years old, an aquatics facilitator and operator, the pool boy. He worked at one of the local schools and was driving down the I-10 when his work truck was hit head on in a motor vehicle collision. Mr. Miller was traveling at speeds of 40 to 50 miles per hour, and on impact, his airbags deployed, and his truck flipped over the railing and down the side of the interstate. He lost consciousness. CT scan of his abdomen and pelvis showed intestinal hemorrhage. X-rays of his right leg showed a fractured femur. He was rushed for emergency surgery where parts of his large and small bowel were resected. Internal fixation of his femur was performed. He was in the hospital for 11 days. Mr. Miller began physical therapy, and his orthopedist gave him work restrictions to include no lifting more than 10 pounds. His pulmonary embolism was treated with Eliquis. That was in March. Now it's May, and Mr. Miller and I are meeting for the very first time. On the day I meet Mr. Miller, he complained of left hand pain, which worsened when picking up objects, right hip and thigh pain, right ankle pain, soreness in his neck, numbness over his chin, diarrhea, difficulty sleeping, and stress and anxiety from the incident. I thoroughly addressed each of his concerns. Mr. Miller and his wife seemed happy with the care they received. All their questions were answered, and they were clear on the instructions going forward. I ended the visit by explaining to Mr. Miller that injuries of this nature may take four to six months to recover from, and that at some point in our journey, we will begin the process of returning him to work with restrictions with an eventual return to full duty. I explained that sometimes patients get upset when I tell them it's time to go back to work. As I make a joke about orthopedics sometimes keeping people off of work for a hangnail, he and his wife laughed gurnaturedly, understanding that that's ridiculous, and it's reasonable to expect people to go back to work as their bodies heal. So what did I do during this encounter? I walked into the room and showed the patient that I am ready to listen. I look at him as he's speaking to me. I'm not buried in my electronic medical record. When it's time to examine him, I clean my hands. I ask him to get onto the table, and I literally examine him. I touch him. I go over the diagnosis and treatment plan slowly. We learn medicine in Latin, literally. Commun frigus, fractura, dolor, tumor, rubor. You all know what I'm talking about. Our patients don't learn Latin. They don't know what we're talking about. And if the patient doesn't know what we're saying, they can never get on board with the treatment plan, and we could experience unnecessary delays in the patient reaching their treatment goals. I set expectations for how the treatment course is going to go. I ask him if he has any questions. I pause to give him ample time to think, feel. I want him to feel safe to ask or share. I ask him if there's anything else he thinks I should know. I even look at his spouse and invite her to share her insights and her questions. As I get up to leave, I let them know that I'm glad to meet them and that we're going to schedule Mr. Miller's follow-up appointment for four weeks from now. The encounter is all about warm energy. I'm attentive. I make myself available. If you need me, call me. Email me. Message me on the patient portal. If you haven't heard from your adjuster, let me know. Our office will help you chase down whatever it is we need to get chased down. I create this atmosphere of teamwork, this idea that we're in this together. One of the first things we ask our patients is, what brings you in today? Providers interrupt patients after a median of only six seconds. Some studies show that patients who are not interrupted are able to fully express what is wrong with them in 11 seconds. But we're in a rush. We're always in a rush. How many of you see upwards of 20 patients per day? Yeah. We do. This is a reality. But we can't interrupt patients. They will provide information more quickly if we let them speak. And besides, it builds a lot of trust. We all learned in medical school that the exam is important. 80% of the time, we should know what's wrong with the patient without even touching them. We know what's wrong with them. They don't know or understand that we know. So we need to physically touch them, and they expect us to in order for them to understand that we are learning about what's wrong with them. And even though we know what's most likely wrong with them, because it's our own little secret, the exam is a part of our nonverbal communication. Some of us, for the most part, have abandoned procedural touch in the form of a physical exam. We've heard your story. We know what's wrong with you, and the case is closed. But when you touch a patient expressively, you show them that you understand. When they begin crying and you hold their hand, you are connecting to them on a human level. The warm energy relaxes the patients, and when we're treating a patient, we're not just dealing with the physical. We're also dealing with the emotional and spiritual aspects, and touch can help us access those deeper levels of connection. So why is it that we don't touch them? Why is it that so many patients, or excuse me, doctors, diagnose patients without really ever examining them, even though we know that touch builds trust? We're too busy. The reality is, in order for you to give your best service, you have to operate through these basics in the very first meeting. You have to touch them. And because we're always rushed for time, we don't always build rapport. If the patient trusts us, the entire experience will be so much better. How do you build rapport? Well, check your appearance. Is it clean, ironed, professional? No dirty, wrinkled, white coats or clothing? Smile and make eye contact. Give the patient a solid handshake. Find common ground. Discover shared experiences. Be empathic. Radiate compassion and care. Actively listen by paraphrasing back to the patient to show them you are listening. Ask thoughtful questions. Be interested in what the patient has to say. Well, that's the first meeting. But what about the second meeting, that first follow-up appointment? My communication approach with patients begins before I even walk into the room. I check myself. Is my attitude right? Am I rushing? Am I stressed out about something? I need to leave all of that outside of the door because that sets the tone for how the encounter is going to go. I can't pretend to care. I have to care. Why is it that we think patients can't sense that we don't care or that we're stressed out or in a rush? They don't know what we're in a rush for, but they can feel that we're in a rush. What do you think that translates to them? That I don't care about you. You're invisible to me. But it's our responsibility to show up for our patients. So I enter the room. I smile. I make eye contact. I shake the patient's hand, and I bring this warm, caring energy into the room, a very safe energy. And, again, most patients are not trying to manipulate us. They're not trying to manipulate workers' comp. They're hurt, and they need our help. They're vulnerable. Workers' comp has a horrible reputation, horrible. So if you think that walking into the room, smiling, making eye contact, shaking their hand is so basic, I'd encourage you to think about that again. Because basic is probably the most important thing you can do to help this patient transition back to work. The doctors who do this are perceived as the best doctors, best by the patients, best by the support staff, best by the adjusters. Whose name have I heard being praised? I'm going to that doctor. They're the best. Who can I go to to help me solve my problem with this worker? I'm going to that doctor. They're the best. I have a difficult case. Who can I send them to for the case to be resolved with the lowest likelihood of litigation? I'm definitely going to that doctor. They are the best. And so in the three seconds that it took me to greet the patient, I've already started my visual exam. How are they positioned? Are they already on the exam table? Are they seated in a chair? Are they standing up? Do they look uncomfortable? Is there an assistive device in the room? Did someone come with them to the appointment? If so, why? Is it for moral support? Is it because the worker can't drive themselves to the appointment? Or is the person there just to add drama to the encounter? So I sit down, and with eye contact maintained, I say, how are you doing since the last visit? What's working? What's not working? And when you're an active listener, you show that you care. You show that you respect the patient and you earn their trust. And so when I communicate with patients, my language is such that I always speak from a position of getting better and returning to normal life. It's almost like mental programming. Now, I don't always promise a 100% healing, but I always encourage them to envision a place of improvement and recovery. The worst thing you can do in these situations, especially if you have a patient with significant injuries, is to be so buried in your EMR, so buried in your laptop, that you're not making any eye contact or spending any time truly engaging with the patient. And that's through your body language and your energy. Even worse is rushing them through the encounter. So I can already hear in your mind, Leslie, this takes time. I know it takes time. I know you don't have that much time. But making the time now will save us a lot of time later when the patient is resisting going back to work. So in addition to practicing good medicine, one of the most efficient things you can do to help heal a patient is through active listening, active caring, and verbally projecting future improvement. Now, disclaimer, my next question is rhetorical. Which one of these are you skipping? Don't. It's more time-consuming to skip it, even though I know it doesn't feel that way. So I invite the patient to envision returning to their normal life in the initial appointments. This programming in the office is critical because the next time I see my patient, several weeks have passed, and during those weeks, my patient was exposed to real life, and their negative self-talk counteracts the positive visualization of returning back to work and normal life that we discussed in the office. Some time passes, and Mr. Miller, his wife, and his nurse case manager return to see me. He tells me that he's still experiencing stress and anxiety related to the accident, and although his psychology referral is authorized, he's still trying to find a provider. His facial expressions are normal. He doesn't appear stressed or anxious, which is a good thing. His right leg pain is mild. He's completed all of his home physical therapy. He's begun his first 12 outpatient physical therapy sessions. He's using a cane when walking outside his home. He tells me that his orthopedist recommends he remain off work, although I haven't received any orthopedic notes. Regarding his loose stools, they're still watery, and he hasn't noticed any benefit when increasing his fiber intake with Metamucil. The loose stools happen mostly in the afternoon and are associated with cramping. He notes he's been losing weight and requests to see a nutritionist. I explain to him that as we are now 4 months out from the date of this accident, femur fractures typically heal within 3 months, and that we would be advancing his restrictions to seated work only and allowing him to use his cane at work while he continues physical therapy. He appears to agree with the plan. Regarding his loose stools, he was advised that it could take some time for the loose stools to resolve after surgery and that this could very well be his new baseline. I refer him to GI for post-op diarrhea. Consistently reviewing the timeline of recovery with the patient is crucial, as it is a constant reminder that this experience will evolve. Mr. Miller, we know that it takes bones approximately 6 to 8 weeks to heal. It has been 4 months since you broke your femur. You're healed. I know that it's uncomfortable for you, but your discomfort does not indicate that you're hurting yourself by using your leg. I get that you're in pain, but it's time to start our transition. I'm not asking you to run an 8K. I'm asking you, telling you, that it is time to start seated work. That means I don't want you to go and clean the pool right now. I want you to go to work, sit in the office, help with paperwork, answer telephone calls, do any desk work that needs to be done. Remember when I told you when we first met that eventually we would come to a place of transition? Well, today we have arrived at the beginning of that transition. Cementing the timeline of recovery is vital for helping the patient transition back to work mentally, which is just as important as the physical transition back to work. Now, many practitioners don't know how long it should take for a patient to heal, so they're unable or unwilling to offer an estimate that the patient can have to help them prepare psychologically and face the reality that they will be returning to work. If you can give this estimate, you have made your job so much easier. How many of you take the time to do research in order to give a justifiable number that the patient can take to expect to be in treatment? Now, I hear what you're saying. Leslie, this is ridiculous. I have 50 patients in a day. I don't even have time to figure out what patient I'm seeing next, let alone sit there and do research for femur fracture healing times. I hear you. I hear you. For the five minutes it would take for you to do some research on MD guidelines to figure out the prognosis and the recovery timeline for femur fractures is going to be well worth the two extra hours the patient is going to stay in your office arguing with you because they're furious that you've suddenly dropped it on them that you're sending them back to work. If we don't set expectations of the return to work timeline, patient expectations will suffer and then we will suffer as we attempt to bring the case to a healthy conclusion. Mr. Miller's on my schedule today, two weeks earlier than his scheduled appointment. That's interesting. Mr. Miller said he made an earlier appointment because of his stress level and anxiety. He says that when his supervisor called to facilitate his return to work schedule, he began to have panic attacks. As he said this, he began to cry. He was not ready to return to work and during our last visit, he felt like he was being pushed back to work. He said he could not bear the thought of seeing his co-workers and have them ask him how he was doing. He was also concerned, namely because he has to use the restroom multiple times per day because of his loose stools and he fears being questioned about it by his co-workers. He says that he's having flashbacks of the incident and when he looks at his surgical scar or experiences diarrhea, the flashbacks are activated. He also feels like the accident and its consequences are negatively affecting his family. His wife, Mrs. Miller, begins to speak and says that he's having stress, anxiety, and panic attacks at home. I placed the psychology referral four weeks ago and his first appointment with them is in two days. I must say I'm a bit confused. Stress and anxiety were noted at the initial appointment, although not reported as severely as what is being described today. The concerns he expresses today are in the setting of my previous return to work recommendation for seated work. His femur fracture has healed, his pulmonary embolism has resolved, there's no signs of PE recurrence. Today, the worker describes multiple complaints related to going back to work. Does this happen to you? Where you begin to get this sense that the patient is not willing to go back to work. Anticipating that the patient is going to resist being asked to go back to work is almost normal. Dare I say expected. So I role play in my mind. I get ready for when they resist and preempt reasons they could offer as to why they are refusing to go back to work. I prepare my answers, my potential possible responses so that I can counter quickly. How you counter matters. I remind the worker of all the treatments we've done and all the restrictions we've put in place during our journey together. I remind them of the time course of recovery we initially shared at the onset of care. I do my best to offer a solution that's a win-win for both of us. I phrase the return to full duty as a trial or a tryout to try to make it more palatable for the patient. Think about how you prepare as a doctor for the curveball that is coming. Do you prepare? Language matters. The phrasing that you use when dealing with this curveball is critical. It is a communication art that must be mastered and we need to keep that in mind. How do you communicate difficult news to a patient? Most think it begins when you walk into the examination room to give the patient the difficult news. For me, it begins the day I meet them. I set expectations in the first appointment. You must tell your patients that there is a goalpost here. Mr. Miller, it can take up to three months for your femur fracture to heal. Mr. Miller, it can take about the same amount of time for your intestines to heal. Mr. Miller, you will eventually go back to full duty. The good news is we don't throw you immediately back into full duty. We will slowly ease you into it. We can start with four-hour shifts where you sit most of the time and we can slowly increase it to a full work day, maybe with a few seated rest breaks sprinkled throughout and then shortly thereafter we will take off all of your restrictions and let you go back to full duty. We're going to be working very hard to guide you through this expeditiously because the longer you remain out of work, the lower your chances are of ever going back. Now those are the words you can use and your non-verbal communication needs to support those words, not tell a different story. So sit down, don't stand over the patient, posture matters, take a deep breath, relax. Don't be so stilted when you're delivering this news to the patient because that's the energy that you're transmitting to them. Your tone matters. Do you sound aggressive, rushed, annoyed, bored, like you've said this a thousand times? The patient will hear your tone before they hear your words. And speaking of words, words like never, failed, those are negative words and they don't support our constructive message. Phrases like doing your best, change in direction, new opportunity, acquire more skills, this is a gift, help you build a bridge for the patient. So think about the language you use with your patients. What word or phrase are you going to stop using? It's seven months later, Mr. Miller's femur fracture is resolved. Orthopedics has discharged him with no restriction, his pulmonary embolism has resolved. He still has some diarrhea, although GI ruled out short bowel syndrome as the cause for his loose stools because not enough intestine was resected. He hasn't had any bowel accidents and GI would like to investigate non-industrial causes of his diarrhea. We've come to the end of the case from an occupational medicine standpoint. He has no functional limitations. He's at maximum medical improvement. Work restrictions are no longer indicated. I discuss the concept of tolerance with Mr. Miller while showing empathy for the fact that he still has pain and diarrhea. I tell him that although I am returning him to work with no restrictions, if he feels he cannot tolerate his essential job functions, he can search for alternative employment as it's no longer necessary medically for him to be out of work or on restrictions. What do you think Mr. Miller feels? He's livid. He's absolutely livid. He turns bright red and I can hear the anger quivering in his voice. He seems surprised like he can't believe the day has finally come and in no few words he tells me that he's not ready to go back to work but fine, he says to me, fine. I'll go back to work and shit all over myself. I offer Mr. Miller a follow-up appointment to further discuss his first few weeks back to work and he declines stating that he will follow up with his attorney. He wishes to be discharged. What do you do? What do you do when the patient starts to use profanity? When they start telling you what a lousy and pathetic doctor you are? Don't match their energy. Radiate love and compassion. Do not allow the patient to abuse you as a doctor. Leave the room. Give the patient some time to calm down. Return to the room and offer to continue the conversation or to reschedule for another day. But what if he's not abusive? What if he's just furious? Don't match his energy. Radiate love and compassion. Empathize. I get it. You're scared. I understand. Remind him of your purpose and empower him. Mr. Miller, I understand. I am getting paid to help you go back to work so that you can resume your rightful place as a productive member of this society. Going back to work and earning your full paycheck without government support is good for you. Socializing with your co-workers and participating in a daily routine that involves work is good for you. Tell them who you are and that you're okay with being fired. Mr. Miller, it's okay for you to be upset. And I understand if you would like to see another doctor. Patients who stick with me, in time, go back to work. It will be hard. But you will be so glad that you went back because now you're not relying on the government to take care of you. You'll get a self-esteem boost from being able to take care of your family members the way that you were before your accident. Your mental health will improve because now you're socializing and interacting with your co-workers and your peers. There's all sorts of health benefits to going back to work. So my job is to help you regain those aspects of your life and health even though you don't see it right now because you don't feel ready and you're anxious about going back to work. I understand that. But believe me, I know you are ready. So I say it in a loving way and even when they get angry with me, I maintain calm and peace. I'm very confident in what I'm doing because I know I am helping them. Just like you're helping your patients. You want to restate your commitment to the patient. Mr. Miller, if you want to leave my care, I'll be sorry to hear that but I will let you go. If you stick with me though, I will get you to the end. And I would love for you to stay because I like taking care of you and I never take it personally when patients want to leave my care. I'm a tool in the system. I want you to get better. I totally understand that you're upset but it is your best interest to stay right here with me and finish what we've started. But if you do choose to go, I send peace and blessings to you. I do not take offense. So I give them the option. Do you let patients abuse your time, abuse you verbally, or psychologically via manipulation techniques, tears, cursings, or fabrications? How do you respond to the abuse? Well, we're not heartless robots. Even though we think certain things, we don't say them. We never say them, even when the patients are verbally abusing us. And this is why we shouldn't accept verbal abuse from them because we never say, oh you have no functional limitations. Your work restrictions aren't indicated. If you can't tolerate your job, get another one. But Dr. Cadet, I'm scared I'm going to have an accident at work. Have you had any accidents? Your intestines are healed. Go to the bathroom whenever you want. Nobody's stopping you. If that's a problem, wear a pamper. Like we don't say these things and I know you all think them because I think them too. Now the opposite of abuse is holding space and love, care, compassion, and calmness, especially when you're being disrespected. Now in theory, all of this sounds wonderful but it's not easy and I know that. Now this is how I have managed to find a way. It's pretty hard to do if you're rushing. So for patients that you know you have to deliver a difficult message to, book the patient in the last slot of the day so you have ample time to speak to them. Set an intention that the communication with the patient will be successful as this all starts in your mind. Plan out what you're going to say. You can create a rough sketch on a sticky note. Restate the history of the patient care experience thus far to the patient. Mr. Miller, we've successfully treated your injuries. Do you remember when I explained to you that workers comp cases do not go on forever? That there are recognized timelines of recovery for different illnesses and injuries? And I told you that a broken femur can take up to three months to heal in our first appointment? And do you remember when I told you that eventually we would come to the point where everything is healed and we could send you back to work even though you might not feel ready? I gave you my joke about orthopedics and hangnails. Do you remember that? I know you don't want to go back to work but research shows that the longer you stay out of work, the chances that you will ever go back continue to diminish. We're going to start you off at four hours a day for about a week and then we're going to bump you up to six hours a day and then by the time I see you again, you will do a trial of full duty eight hours a day. So focus on the psychological experience of the patient as you're sharing difficult information. There's an emotional self and an objective logical self and so when we're given information that we don't like, our emotional self can respond in anger and if we allow it, it will take us down an unproductive path behaviorally. So this often happens to patients when they are hearing information that they don't like. So give them a moment to be reflective so that the objective or rational part of the brain can be given an opportunity to respond, to input its guidance, hopefully overriding the initial emotional response that may lead them to participate in poor behavior. There's power in our words. The language that we use should bridge them to a new life. So phrases that empower patients are things like why don't we look at some other job opportunities? I'm walking through this portion of the journey with you. I know it's scary. Phrases that defeat patients, you'll never go back to work. The treatment failed. The surgery failed. As we create space for compassion by using empowering words, it's important to realize that one of the reasons we have to create the space is that we are practicing in a system that was not set up to give us the space or the support in delivering difficult messages. But knowing this, we choose to remain in practice within the system anyway so then by default it becomes our responsibility to serve our patients with the oath we took instead of subscribing to the system's broken approach to care, which is to cram in as many patients as possible and rush through everything. And I know what you're thinking. Leslie, I didn't spend 12 years of my life going through this, spending half a million dollars to go to medical school to practice in and deal with such a broken system. You're right. You didn't. I didn't. But here we are. And so there's many of us who have decided that we're going to transcend the limitations of the system through the power of who we are and how we care for our patients. We are going to serve and care for our patients in spite of the system. We've not acquiesced and we found ways to get involved, promote change, and to support those who have decided to wear the administrative mantle. A disclaimer. You may not like the next thing that I say. Even if you follow my advice and do everything I say, you're still going to miscommunicate difficult news because there's one element that I can't teach you how to do and that element is the part of you that wanted to become a doctor, your humanity. I cannot teach you how to access your humanity. I can only show you how important it is in caring for patients and delivering difficult news to them. And at the end of the day, they're human, we're human, and if you don't come back to your humanity, there will be an essence of inauthenticity when communicating difficult news to your patients and they can feel that. And this will ultimately eliminate care from the conversation, which is exactly what you need. Your humanity and vulnerability will translate into authenticity and allow you to care. Your patients need you to care and they deserve it. And so everything I shared with you this morning you already know. I simply reminded you of it. Now you have to deliver some difficult news to yourself. What type of doctor do you want to be? So thank you, I love to teach and train, so if anybody has any questions, that's my contact information. There is a microphone in the middle of the room if anybody has any questions. Okay. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. I'm a practicing occupational medicine physician there, and thank you for your talk. This is amazing. Thank you. This is fantastic. The only thing I wanted to add and ask you about is sometimes, some of us are our parents, and we see some of this in our personal lives as well. And one of my colleagues told me that, you know, his son often yells at him, but not his mom, not his wife, and it's because he is his son's safe person. And he feels safe just kind of expressing his anger. And I'm wondering if maybe, as we create these safe spaces, we do need to expect to receive some anger from our patients because we are their safe person in all of this. Would you agree? That is a very good point. And I will say that I've had a number of patients who, when they are expressing anger, I can very much tell that it's not directed towards me. It's directed to frustration about their injury, frustration with all of the hoops they had to jump through as they were going through workers' comp. And so I think making a safe space does include the ability to let them express that. But when they cross the line and it comes to, you know, personal attacks, then I think we do need to protect ourselves. You know, we've been trained to just let patients talk to us however they want. And I don't think that that's healthy for us as providers. But I do agree. I think we should create a safe space for people to be able to express anger and frustration. Yeah. Thank you. Thank you. Hi, Leslie. Hi. Great job. Thank you. Such a positive messaging. And, you know, I saw you as a resident. Yes, you did. And you've really evolved. I love the messaging. The communication with the orthopedist, sometimes they see the people every six weeks, as you know, and then you try to jump in front of them and turn people to work. I'd like you to comment on that, how you went past that. And then what tripped us off the rail? We have these 5% of our people we follow, and 5% just trip off the rail. I'm still at a mystery to this for a long time. I can't figure out what happened. Yeah. Why would they go get a plaintiff lawyer who tells you not to go back to work, get more diagnostics, stay out of work, get more surgery? Yeah, it just drags the entire thing on. It's a mystery to me too, Dr. Winters. Thank you for your comments. Hi, first of all, thank you. Thank you. Two questions. First question is, how do you tell an employer or a comp adjuster that you're taking someone off work? And then my second question is, how do you tell a DOT driver that you're disqualifying them? So for your first question, I typically will tell the worker first that I'm taking you off of work, and then give them their work note. The way our clinic is set up, the adjusters automatically get our notes and see our work notes, so I don't have to say anything to the adjuster. We tell our patients to hand a copy of that work note to the employer, and that is our way of communicating with the employer. But there have been times where the patient doesn't give the note to the employer, so they're in the gray. And usually these patients, there's something else going on in the midst, and you already know it's gonna be a tough case. So I will pick up the phone, and I will call the employer. And I'm not revealing HIPAA, but I'm just saying, hey, I saw Mr. Bob today, he has the following work restrictions. And sometimes I'll get their email address and send it to the employer that way. You know, for a DOT driver, right, this is their livelihood, like all of our patients, so I follow the same steps. I make sure I'm not rushing, and I make sure to really explain why they're being disqualified. Half of these people don't even know what vital signs are. So when I come, and I'm talking about diabetes and sugar levels, it's totally over their head. So I try to use practical examples of, hey, you know, diabetes is dangerous because it can affect the nerves in your feet. And you may not have a problem with feeling in your feet right now, but this could develop to where you're not even able to tell where you are in space to push down on that gas pedal. So for that reason, I'm not able to recertify you today, but I do want you to go see your PCP so you can get this addressed as soon as possible, because I want you to be able to go back and drive your truck. And then I'm the type of person where I'll even give them information on healthy eating, plant-based diet, because we can reverse all of those things. Thank you for the lecture. And you may not necessarily have an answer to this, but one of the difficulties that I face, you mentioned in your case how you would remind the gentleman that part of going back to work is regaining the dignity in life that he may have had before, which I agree with, unfortunately. However, a lot of what it feels like I'm seeing now in the world of occupational health is their work may not be treating them with dignity, rather they are manipulating and infusing and simply squeezing out the last drop in a corporate profiteering system that doesn't care for their well-being. And I welcome your comments. Yeah, that's a real problem as well. And so sitting down with the patient, so just like we have boundaries, I talk to my patients about having boundaries for themselves. And when they feel like they're working in an environment where the businesses not care about them, where they are not being valued, that they're just another cog in the wheel and we're gonna run you into the ground, I have a very real conversation about, you don't have to tolerate this. You are not a victim. I know you think the only skill you have is X, Y, Z and you are stuck here. However, there are all of these ways that you can gain additional skills and find an employer that values you as a person. So sometimes the answer is for them to take their agency, stand up for themselves and find a different employer. I found it can be very hard to talk to big businesses to change the culture. It's gonna be tough. So I try to empower the patient. You're welcome. Yes, sir. Hi, my name is Dr. Jonah Sullivan. I'm a consultant in occupational medicine in the UK. Nice to meet you. And basically we have slightly different systems over there. I was interested when you say you give a piece of paper to the patient, which you give to the employer and sometimes they don't give it. The way I do things is I specialize in sickness, absence and the vast majority of it is on Zoom these days because of COVID. I write the report on Zoom with the patient watching. Therefore they are totally signed up to it. When they agree to it, I'll change the wording as long as I don't have to change the meaning. And then I email the report to them and to HR simultaneously before the end of the consultation. So everybody knows what's going on and there is no doubt over communication. I love that. And it sounds like you all are in the 21st century. Well, we only do occupational medicine. We don't do any treatment. We don't do any GP type work. Yeah, I agree. I think removing the patient's need to go hand something to the supervisor, I think is superb because there's so much that can happen in between them leaving the office and getting to the supervisor. So I like. But the big thing is the patient sees what's going to go before it goes. Yeah. And they have informed consent of what the outcome is. I love that. You know, perfect. Yeah, thank you so much. That was an excellent talk. Thank you so much. I come from a unique perspective where some of my occupational health flow is organizational as well as with individual patients per se but it's in a virtual platform. With the workflow process that you recommended, scheduling the patient in the past, informing them, providing an action plan. I can see that but are there any changes you would make in your workflow if the whole process is virtual? Specifically if it's telephonic in nature versus video telephonic. Some of these cases can be telephonic or not. The COVID pandemic or post pandemic has really transformed in some settings how we're communicating to our patients as well as our populations and organizations. That's an excellent question. I think off the top of my head, the only change I would make is similar to what the other gentleman mentioned is I would utilize assistants or scribes to help with the documentation and then after I've done my portion, transitioning the patient to almost like a occupational medicine concierge that will then make sure, hey, these are the things we talked about today. I'm sending these notes to the various parties and then making sure the patient doesn't have any questions about follow-up appointments or anything like that. I think putting patients that you feel may take longer towards the end of the day is still something that could be done in the virtual space. Thank you so much. You're welcome, thank you. Yes. Thank you so much for such a wonderful discussion. Thank you. Recently, I'm seeing some patients that are actually challenging. Challenging in the sense that I perceive they don't want to go to work. But the reason they are giving me is that the distance they have to drive is too far for them. And one of them also says that from the place they park their car to their workstation, they have to walk about a mile. And for that reason, they can't go to work. So I'm trying to see how to navigate getting them. It's not the job itself, but how do they get to the station. Yeah, so that's beautiful. So you all know that workers' comp, again, this is a part of the system, they don't care about how you get to work. They don't care that the commute is a super long thing. So I typically, it would have to be an extenuating circumstance, but typically I don't take the long commute time as a reason why you can't go back to work. My job is can you do the essential job functions? Now, once you arrive on site, if it takes you a mile, then I put on my advocacy hat and I say, hey, well, could you talk to your supervisor or the parking folks to allow you to park closer? In an Olive Branch moment, Olive Branch is my way of saying, I'm trying to make peace because I just told you I'm not gonna help you with your commute, but I will help you with maybe a disabled placard temporary so that you can park closer to the building and we can do that while you're healing. That's kind of the trade-off that I would offer those patients. Thank you. You're welcome. Hi. I'm Ashley Nadeau, I came from Minnesota. Nice to meet you. I'm a resident. So now we have patients, great speech, by the way. Thank you. We have patients who will leave kind of feedback on the social media platforms and they can say some very somewhat abusive types of things. How would you respond to someone saying certain, calling names or saying certain things that aren't necessarily something you would want other people to read or aren't respectful to you? My first question is, do you have the power to delete said comments from the platform? Is it like an institutional platform or is it kind of like Twitter or Instagram or? It's like just out somewhere else, not something you have the power to. Do you have the power to respond? Potentially, yeah. Okay, so then it depends on how much energy you have. Yeah. I don't know. I don't know. I don't know. Because if it's me, I'm very, very busy and I don't have time for a bunch of nonsense. However, you're now messing with my brand and you're messing with my reputation and I'm all about boundaries. So I more than likely might solicit some help to go on and address each of those comments. In my personal opinion, when I found that people are responding to the person's argument, you now have both sides and the person who's reading it can make a more informed decision as to whether or not they wanna come see you. But if we just let people go up there and say whatever they want, that could potentially impact how many new patients you're getting. So if it was me, I probably would very lovingly, very respectfully comment because you're not gonna lie on me. We're gonna present both sides of what happened here. But again, if you're in the middle of COVID and you've got 10,000 patients to see in a day, then I just don't have time. Yeah, hope that helps. Hi, Dr. Cadet. Hi, thank you. I just was gonna comment to her question, which is most of us are in health systems. I'm sorry for my voice. If you're in health system, there's service recovery processes and there's also leadership. So I think try to remain as objective as possible and use those chains of command to help scrub and identify what the initial issue was. Agreed. If you're in private practice or solo practice, it's a different game. And maybe to reaching out to others, there's reputation, software online, et cetera. Right, because at our institution, the, not in occupational medicine, but in other clinics, the patients are allowed to go up and rate you and give comments. And all of that impacts how you're perceived on the site. So great questions. Yeah. Leslie, in the middle of this, you said that he was having panic attack, anxiety, depression. It seems like psych's broken there in California, like it's broken in Massachusetts. If you could have gotten into a cognitive behavioral, a few cognitive behavioral therapy sessions, do you think that would have short-circuited this? Great question. He actually was able after, okay, so you order the referral. You all know how this goes. You order the referral. Three months later, they finally get their first visit. And they did start doing some CBT with him, which I was super happy about. But the patient did not complete the therapy. He short-changed it. He stopped going after maybe five sessions and said he didn't think it was helping, which all points back to my original argument, which is he just doesn't want to go back to work. And so now that I'm telling you it's time to go, you want to create a story about how anxious and panic attacks and all of this stuff. And then when I offer you treatment, you don't even complete the treatment. That would indicate that this really isn't an issue. All right, well, I appreciate you all's time and attention so much. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

occupational medicine physician

grounded communication

empathetic communication

safe space for patients

compassionate communication

communicating difficult news

active listening

building trust with patients

humanity in healthcare