Hi, I'm Jennifer Christian, and thank you for coming to this session. Are you hearing me okay? Okay, great. So we're here to talk about how OCDocs can help unlucky workers have a happier ending, and they have uploaded for you two handouts as well as the presentation, and one of the handouts actually is a document that kind of describes who unlucky workers are, but basically they're people that are at risk of a very poor outcome, and the question is can we actually help workers at risk of a poor outcome from having a better one? So the learning objectives are listed here, and they are listed in the program, but there is a mismatch between the steps in a worker's combined biological, psychological, vocational recovery and the legalistic, particularly workers' compensation claim closure process, and when I have a small clinical practice, and I started really looking at what does this worker need in order to land on their feet as best as possible versus what is the worker's comp system, what's the worker's comp system's process, and I started really seeing a mismatch, and so I want to describe a bit of the uncertainties and the challenges that I have noticed that some of my patients have had and just use them as illustrative examples of where there's kind of a shortfall in service where the OCDoc might actually be able to step in and help get things on a better track, and the particular moment when this occurs is when the worker realizes they have to really find a new job or find a new career, and there's nobody around to help them start thinking that through. And then I am going to list some examples, or not exactly list, but we'll discuss in the cases some examples of the specific guidance that I have discovered that in order to try and help unlucky people who are really at risk of losing their livelihood entirely, it is to how to help people move towards vocational recovery during the biological recovery period and the delays that are caused by the legalistic work comp process. So how I'm going to set it up is I'm going to introduce the four cases and talk a little bit about my background, about how come I have been thinking about this, and then try and create a big picture of the status quo in which these four cases are occurring and many other workers are the kinds of how they are responding and what's happening to them in the system as it's organized today, lay out some premises for what might be better, and then I'm sharing the cases because they're some of my first attempts to step outside what we have thought of as kind of our role and supplement with what the primary treating physician may be doing, or if you're the PTP to do it, I am not the primary treating physician in my role, but provide, supplement what the traditional doctor is doing with providing some big picture guidance and counseling that patients may need in order to manage the whole predicament their injury or illness has caused. And I welcome your feedback and suggestions. This is kind of raw material. I actually haven't looked at the four cases myself, and I don't think I've seen what's there. I'm just here to kind of tell you the story of how I've approached them. I've discovered in the past, I've been in this business now for a while, that if what I really listen for is what's needed and try and do that, what does the situation call for in order to get us to the best outcome? I end up discovering new ground for us sometimes. So, as I said, I'm going to be sharing what I've learned on the job. I have a very small virtual clinical practice in California. I provide biopsychosocial care for workers with work-related chronic pain or other persistent disabling symptoms and prolonged recoveries. It's odd because the program's called a chronic pain program, but it's turning out to be the chronic distress program. And in my setting, the primary treating physician prescribes and is responsible for the return to work decision making, and I'm basically consulting on the issue of the biopsychosocial elements that are present in this case and trying to advance them towards a good recovery. So, most often, my repertoire of interventions consists of me, me as a coach, a guide, an expert, an advisor, a CBT therapist partner with whom I work closely. We have interdisciplinary conferences at intervals. I can refer for PT, and I also find that I'm using educational materials or websites because often what I'm discovering is that patients are not prepared with the information they need and the skills they need in order to be able to navigate this difficult period. So, I'd say that my realization is that some patients deserve, and I, in my mind, or need and deserve some anticipatory guidance to start thinking early about plan B so that they have a soft landing. In other words, there's going to be an ending to the claim, and if there hasn't been some anticipatory guidance and they haven't thought ahead, they may end up, at the end of their claim, just dropped without any support whatsoever. So, how I've been, where I've been noticing this is that when I recognize that full recovery looks like it's impossible, doubtful, or uncertain, and then also when it's unclear or doubtful that they're going to return to their usual job or employer for any reason, and then to help them plan for their future employment and livelihood, because I'm really interested in reducing job loss and loss of livelihood as the result of work-related injuries. So, the four cases were all referred to me, and under California law, I'm what's called a secondary treater, and the 4R, Matt, who's a 39-year-old machinist with a traumatic amputation of his right hand, he was referred four months after he actually had the surgical amputation that followed the traumatic one. Rudy, a 59-year-old concrete worker with a left shoulder replacement, he was referred 60 days after his total joint replacement. Rachel, a 59-year-old cashier with right hand pain and bilateral carpal tunnel syndrome, she was referred six months after her initial onset of her problem. And Tony, a 46-year-old prepared food, sort of wholesale food manufacturing worker who'd been hospitalized with life-threatening COVID, and had spent two months in the ICU, one of it on a ventilator, and then later in a rehab hospital with sequelae, and he wasn't referred until 16 months after his episode. I didn't think of any of these as classic chronic pain patients, but so I said, this is sort of what's turned into the chronic distress group. Now, this is a teeny-weeny slide, and this is, I have to confess, there are a lot of slides with a lot of teeny words. Please forgive me. These are more to cue me. You are not expecting you to read 12-point type. But I wanted to make sure that you understood what a weird career I've had, and why I'm interested in this. My career may not match yours at all, but maybe as a result, I've learned or thought about stuff in a deeper way than you had a chance to in the way that your career has gone. So yeah, I'm a board-certified OCMED doc, but I'm also by temperament a systems thinker and a change maker. I left clinical practice in 1994, and have spent most of the time since then working at the program and system level as a chief medical officer, and then as a consultant. And my focus has been pretty steadily improving life outcomes for injured workers. I actually was interested originally in PM&R, because to me, I've never been particularly fascinated with diagnosis. What I'm fascinated with is the impact of a health condition on somebody's life. Very pragmatic. And so as a consultant, I've done a lot of new programs and pilot projects, things like that. I founded the 60 Summits Project in 2006 to promote ACOM's work disability prevention model across North America, and I had led the group that developed the paper called Preventing Needless Work Disability by Helping People Stay Employed. That non-profit multi-stakeholder event has really convinced me more powerfully than ever that the solution to the problem of poor outcomes in workers' compensation is a multi-stakeholder solution, and it requires us to work across stakeholder boundaries, social silos. And increasingly over time, I'm realizing that part of the reason, and please listen to this very hard, part of the reason why medicine has been screwed the way it has is we mostly talk to ourselves. We are one of the most insular sectors of society in healthcare. We really don't interact as colleagues with people in the other professions and stakeholder groups who we have to know and have to have working relationships with in order to deliver the best results for patients. Another really big learning experience was I designed and delivered a May's Master's program that was aimed at very high-cost workers. I had gotten kind of mad at employers and insurers for ignoring all my primary, secondary prevention messages. You know, it's so important to do the right thing the first week, get the thing off on the right ground. And so I got mad one day and decided to earn a lot of money by working at the back end where claims are screwed up like so many other people do. But because of my excessively Girl Scout-y temperament, I decided I was going to try and improve those people's lives. I wasn't going to try and improve their medical care. I wasn't going to try and get them back to work because I knew they had very hardened feelings about both those things. So what we offered in our program was to have a life that's fulfilling and satisfying again. And with really no exceptions, the people who accepted the program ended up deciding on their own that what they wanted was to work, but they were refusing and insisting that they couldn't work when we started the program. In 2014, I began behind-the-scenes care management in individual cases, and I resumed this tiny specialty clinical practice in the current program in 2019. Now, in addition to working kind of one-on-one with people, in 2015, I got involved in federal disability policy and wrote a paper proposing a community-focused health and work program, a multi-stakeholder coordination intersector collaborative structure to provide more workers with access to stay at work and return-to-work services. And that paper, I was amazed, delighted, and cried when I heard, inspired and provided a vision for RETAIN, which is a now $180 million demonstration project that the feds are conducting in five states. After that program launched, I worked there at the U.S. Department of Labor watching the groups in the five states. It was eight states to start and winnowed down to five, trying to build a multi-stakeholder program that would stand independently, stand independently of insurers, stand independently of employers, and provide services to workers who were at risk for having a poor outcome and leaving the workforce. I then founded, and this is where I am today, the Alliance for Bridging Health and Work. The 60 Summits project was really a thought-shifting project, and with the Alliance for Bridging Health and Work, we're calling ourselves a change-making organization, wanting to support people in jurisdictions who actually want to do a smaller, cheaper version of RETAIN. This RETAIN state's got $20 million. They're running it as a very fancy, administratively heavy, randomized control trial. And right now, we're actually working on a little project in Rhode Island to do the building of one of these independent stay-at-work and return-to-work community-focused services using more of a community development model. So, a lot of stuff, but that's kind of like why I'm where I am and why I think of it. But let's start here. We need to say this sentence to more people that we work with. We need to say it to ourselves, that loss of livelihood is actually a devastating health outcome in a working person. We haven't really seen and had that as our flag, and it is a powerful sentence because it means that if the healthcare system has been involved with this worker and they've lost their livelihood, it is a very bad outcome. It's actually not as bad as dying. It's the loss of livelihood actually is the next worst possible outcome of a working person's health problem. And yet, it's not recognized as number two, especially it's not recognized as number two by workers' comp systems. And we ourselves haven't really had that as our flag. And yet, loss of livelihood often can be prevented, could be prevented. So yeah, the worst outcome is death. And the second one, let's talk about why job loss, loss of livelihood, and lifelong worklessness is so terrible. Well, long-term worklessness causes declines in physical and mental health. If you have stopped working, your health will continue to go down. You will have additional things go wrong with you, as well as personal, family, social, and economic well-being. And entry on to long-term disability roles, especially social security disability here in the U.S., is usually a one-way street. So there is no coming back off. Once you have become a person who has withdrawn from the mainstream of society and is now on disability, you are unlikely to come back off. A small number do. Loss of livelihood can be caused by over-impairment and needless work disability, both of which are actually iatrogenic, although I define the term slightly different than what most people do, and potentially preventable. I use the word iatrogenic when I speak with multi-stakeholder audiences because the most narrow definition is, you know, it's caused by the doctor. And the broader definition, which is more common, is it's caused by the patient's interaction with the healthcare system. But really, in the case of an injured or ill worker, they are interacting with a series of professionals and actually other laypeople, and it is the response of the people to whom they turn for help that can actually be supportive of a good outcome or supportive of a poor outcome. And that's why I'm talking about it being iatrogenic. And then, of course, the workers' comp system has always acted as though the second worst outcome is residual impairment. And there we're talking about, you know, obviously loss of an anatomical body part or loss of a physiological capability, such as amputation and stuff like that. And over the years, when I have gotten involved with disability rights advocates, they want you to know that they can have a good life with a disability as long as they have a job and are not sidelined, and that life on disability benefits is a life of poverty. This is a quote. I was working with disability advocates in Phoenix, Arizona when this happened. And one guy said, being on disability is having nothing to do and no money to do it with. You know, if you think about the public policy that underlines the Americans with Disabilities Act, is that is the idea. It's just don't sideline us. You know, let us participate. And also, residual and permanent impairment, although people tend to think of it as concrete, in fact, in the group of people who end up with PPD awards and being considered to have permanent impairment, there's actually a lot of preventable impairment in there. Part of it is tangible iatrogenic harm that's as a result of medical treatment, over-aggressive treatment, poor surgical results, you know, just plain old harm, careless care. There's also system-induced or fear-based self-limitation. I would call that over-disability, where somebody believes they can't do something that they actually could. Medically unexplained physical symptoms, which are benign but distressing psychogenic sensations that are experienced as disabling or experienced as dangerous. The mind, the person's mind is categorizing them as dangerous. So all this thinking has got me sort of thinking of things from a slightly new angle. When I was working for the Office of Disability, or no, when I was a part of what's called a Stay at Work and Return to Work Policy Collaborative, they asked me to write a paper on health as a, no, excuse me, on work as a good outcome. And I said, I don't want to write a paper on a platitude. I want to write a paper on how to establish accountability for delivering work as a good. Oh, I ran away from it. Thank you. I want to write a paper on delivering, on accountability for delivering that outcome. And so a couple of days later, when I was kind of walking around in my mind thinking about it, I realized that loss of livelihood is not currently noticed, treated, counted, or reported as a poor outcome by the healthcare sector. This fosters a lack of accountability. And that loss of livelihood and withdrawal from the workforce is a very poor outcome of a worker's injury or illness, but it's not usually treated, counted, or reported as one by either employers or benefits administrators or governments. And this too fosters a lack of accountability. If you think about it, here in the U.S., an employer has to report if somebody misses a shift, if they go to the hospital, if they die. But we don't need to report that people have lost their jobs. And yet, we've passed the Americans with Disabilities Act that says, you know, you ought to be, as an employer, making a reasonable effort at accommodation. So I wonder if we started asking people, please report how many people have lost their jobs and what kind of an effort you made to help them stay at work, what kinds of result we would find. And few employers, including actually me, I'm not an employer, but few people seem to realize that a worker with a newly acquired minor disability, whether temporary or long-term, like a bad shoulder or knee or chronic illness, actually qualify under the ADA for the duty to accommodate. Several years ago, a guy from the EEOC and I had a conversation and I said, oh, you know, workers comp, that doesn't count because what we do is we do reasonable accommodation after the person's at MMI. And he said, you do realize that that employer is violating the law by not having an interactive process for reasonable accommodation by about a month off work. So are you, has the situation changed? Are your employers having discussions with reasonable accommodations as soon as one month after injury when people are off work? And by the way, it would be more fun for me if you respond when I, yeah. I like talking to you, particularly when you're, you know, like looking at me and responding. So what do you say? Has anybody got an employer who pretty regularly is having interactive discussions about reasonable accommodations by about a month after? Okay. So we're a little behind the times. Okay. And so the other thing is I've kind of noticed that no one is actually guiding, supporting and standing for workers most of the time throughout the whole journey to get their life back on track, especially the ones whose employers don't want them back. And especially those who are most expendable or vulnerable, disadvantaged or at risk for poor life outcomes for a variety of reasons. So this this is kind of fun you know that we tend to work in our silo and we tend to accept the ground rules of the systems in which we operate and every once in a while it's kind of fun to stick your head up and look a little bit to the left and notice where you have been being obedient to a system that may not actually be smart or doing the right thing. So governments spend four dollar signs worth of millions billions to create jobs and reduce unemployment because we actually all know that worklessness is bad for people and for the country's economy. So why isn't preserving or restoring working people's ability to function and participate fully in life and work set as a fundamental purpose of medical treatment and health care services and of workers compensation programs? And why isn't preserving and restoring each workers participation in the workforce the economic engine of the country an explicit policy goal? We do it when it's convenient right? We do it when it's easy but if it's hard there's nobody usually saying what are we going to do? Who's who America it was very important. Okay I did turn the sound off that's a strange part. I apologize. And then the third question and this was that most exciting when I just thought of this recently Medicare and Medicaid have what they call special populations. They've declared that for these populations different things are expected as the standard of care or the right thing or even what they'll pay for because the government has a commitment to that special population. And one is you know pregnant women and babies another one is the HIV population another one is immigrant workers another one is the elderly other one is I guess the Medicaid population the very poor population. Why isn't the workforce considered a special population for payment purposes? Because the workforce is the economic engine of the country. It is in the country's strategic interest to have as many people staying in and being part of the productive workforce as possible. So and if that if the workers were considered a special population then efforts made by health care organizations employers and payers to keep every working person in the workforce would be seen as valuable to the country and worth incentivizing and rewarding. I hope our new lobbyist likes that idea and I hope that ACOM leadership likes that idea. So now let's just start talking about really what injured and ill workers and particularly the unlucky ones and how it is that some of these ideas might apply. Now when you look at a thousand or ten thousand workers comp injuries you see a lot of variability and I'm going to declare that the unlucky workers look almost identical to the lucky workers at the outset. They may have seemingly identical biology but they're going to have very different outcomes. And so the unluckiness is occurring sometimes it's in the condition itself the nature of the health care problem but it's also because sometimes the workers themselves vary in their educational level, their personality, their past history, their overall health status, their worldview, their intentions and stuff. But also they the people that are taking care of them vary. Physicians and health care professionals vary in their competence, their philosophy, their attitude, their interpersonal skills and outcomes. What if that patient has got a dud for a doctor? Employers vary. There is in their way that they respond to injury, their tangible and intangible workplace environments, their willingness to support the worker in recovery. What if that worker has an employer who will not engage, is not interested or might even be downright hostile? And then the worker is also engaging with a benefit manager or a legal system and those people also vary when their skill, availability, philosophy, the alignment or malalignment of the incentives in the programs in which they operate. And I often say how unfortunate it is if who your claims adjuster is is the person who is going to get fired next month. So in addition to all these personalities and the chances that the worker is taking by just the luck of the draw with who they work for, who they seek care from, who manages their claim, there are also things that happen during the unfolding of an injury and illness that drive it towards a better or worse outcome. So one of the handouts you have is this document. It's actually a long document. It's just one page and this was developed in part with the assistance of the AECOM work fitness and disability section and it was essentially thinking through as an episode unfolds there are risks present at the onset and most of them or a lot of them are in the worker but there are also risks that occur or that manifest themselves as the episode unfolds over time. So the way this document is designed is the events are occurring down the middle and if the right thing happens you are more likely to have a good outcome and if the wrong thing happens you're more likely to have a poor outcome. And so in this first thing at the moment of injury like what are some of the known obstacles to recovery? So you see here a list of known obstacles to recovery and could you just tell me where they're located? Where are these risks physically located? Whose brain? Okay and so if we want to influence these risk factors where do we have to work? In what domain? Okay and how do you affect someone's brain? Yeah baby, words, conversations, interactions. Yeah because it's actually we also have nonverbal words right so we can influence how somebody is thinking and feeling by how we behave in an interpersonal interaction and also how we speak and I am not clear at all that in medicine what I call as body doctors I in my medical school we were not taught the power of words as a therapeutic intervention but if what we want to do is influence risk factors we got to get good with words. Now there is a whole gang, a whole part of the healthcare professions that only has words as their interventions right? The psychological and mental health professionals so they have the science is very good that some of their therapies are very effective so we do know that words work. Words, I am I'm your therapist I'm gonna speak words through the air to you and I will be changing your brain with the words I use but only if I'm good at it right? Speaking at you in a relationship where you don't trust me it doesn't matter if I use the best words in the entire world if you don't trust a damn thing I say my words are going to be ineffective. So I think we have an opportunity in occupational medicine to really say okay I want to learn how to use words and relationship in a healing manner. So you can see the rest of this chart here and in the four cases we're going to be talking about oh I was calling him Rodrigo for a while but now I'm calling him Rudy so if the four cases are all where I was interacting with the people was in the part that's in the red bracket and I'll read you the teeny-weeny words is number four is is the worker already back at work because the employer has temporarily adjusted job demands improved safety ergonomics or made reasonable accommodations per the ADA these people were in trouble with this part the other thing was does the worker accurately appraise the situation and cope successfully with the challenges deal with the normal human reactions to life disruption learn how to manage self their own how to self manage their symptoms navigate the health and benefit system discuss their situation with their employer with or without professional support so one of the cases that we're talking about is talking about that here and does the worker enjoy rapid and full recovery by 12 weeks none of the all these people have gotten well beyond 12 weeks and then number seven does the worker overcome their pain related distress discouragement accept the chronicity of their condition and loss adapt to their situation often with a new view of themselves in the future with or without professional support professional support is code word for you or for the or the therapist you have as your partner and then number eight is the worker safely and stably back at work because the employer has improved safety or ergonomics or made reasonable accommodation so these cases that I'm sharing with you are all people who were in these problematic things and I'm assuming you've had plenty experience with people who are headed in the wrong direction because the employer won't accommodate right so unlucky workers get stuck in the maze and the clock is ticking we know already that elapsed time out of work is the enemy the longer that somebody's off work the less likely they are to ever go back to work there are a lot of different graphs with this this data on it this is a particularly aggressive graph which shows that by 50 by 12 weeks 50% of the people in this population's was GE workers comp workers some years ago in an unpublished study but there are other studies from the graphs from Washington State and other places that show that you're down to 50% by six months so sometime between three and six months post injury the odds of the person ever going back to work have dropped dramatically and they are going to continue to drop every single day and by the way it's not the interval since you saw them one of the cases we're talking about this has showed up it is not the interval since you first met them it's the interval since their life was disrupted that is the duration of interest so poor outcomes are rare very costly and often preventable and if you want to be known as a helpful person you will help with the cases reduce the number of cases that have very poor outcomes because 90% in Washington State and we don't have any particular reason to think it's not true elsewhere 90% of total workers comp benefit costs arise out of just 10% of all claims and in the when I've worked with physician I built a network in one of my jobs and what was interesting to me was how much pride the Octocs got out of the fact that 90% of their patients went right back to work are you noticing what's missing the 10% that count the 10% where all the dollars are so if you really want to make a difference where the place is to be different is the cases where it's hard so many of these most expensive claims are due to potentially preventable what are called adverse secondary consequences that is a phrase that was used in a letter from the medical directors of the Washington and Colorado State work comp systems and Catherine Miller was one of the two and they they had this sentence that many or most of those expensive claims are due to potentially preventable adverse secondary consequences of routine musculoskeletal injuries and I have played in both the workers comp and disability benefits space and when you talk to disability medical insurers they sell you the same thing it's basically the 80-20 rule and so in that list of the catastrophic claims that they they have what they call lost runs for if you're an insurance company my husband as my business partner he and I once got hold of a reinsurance company's lost runs for workers compensation and what we discovered to our amazement was how few of the cases that cost more than $500,000 were actually for biological catastrophes almost all of them a stunning number started with a relatively common sounding thing just like the medical directors of Washington and Colorado said so many workers with unnecessarily poor outcomes end up on federal disability programs and as I said that's almost always a one-way street so I think we have a population with unmet needs and a gap in our social fabric I've been using this slide for probably 20 years now but it has more meaning to me now because I realize nobody feels accountable for those little guys in the middle that nobody feels accountable for making sure they actually get there to the other side we I think we are unique in our specialty one of our claims to fame is that we try and reduce needless work disability but we kind of do it as long as somebody's paying us for it or we haven't really thought about what do we do if the employer says no I can't accommodate and we're basically I believe unfortunately abandoning those workers so I think we need to draw other people's attention to the fact that loss of livelihood is the second worst possible outcome of a health problem in a working person so let's just check whether any of this is actually accurate in your world we got four items here if that if it is true would you please be willing to raise your hand just so we can see I'd like to speak something that's true in your world then if it's not I'd like to kind of hear what's going on in your world so is job loss and with and withdrawal from the workforce not tracked and reported of as outcomes of health care workers comp or disability insurance programs in your world is that true okay that's not thank you very much I love the fact that you look at me and you nod your head I love the fact that you do it I'd love the fact that you do it and the rest of you are you asleep please interact with me we're peers we're colleagues I think that's a great question do you know if there's reports any reports going to anyone okay yeah oh I don't know it's different than no no okay so I'm how about this did it make you curious right isn't it weird OSHA requires all that stuff but we don't report job loss okay how about professional time and effort spent by health professionals to facilitate stay at work and return to work is not generally included in medical fee schedules or paid by another mechanism are you getting paid special stuff for the for the specific time you spend on facilitating stay at work and return to work anybody getting paid allow you to do it okay yeah that's it I wonder how many people know that so cool all right all right great great to hear that sometimes these breakthroughs you know four people know about the breakthrough and nobody else does so maybe whatever we can do to help other people know that they are getting reimbursed because when they say we just didn't have the time to fool with it right you say well actually you can get paid for it also vocational counseling and services delivered that for the purpose of enabling return to usual or another job aren't considered medical treatment or a medical rehabilitation this is what I realized the voc rehab people are not considered health care professionals so their services are always built on a different line and they are really excluded so do you are you in a system where vocational counseling and services are considered part of health care services or that's it that's it and then it's not even built if you in workers compensation they call they call it medical loss if it's health care and it's called claim adjustment expense if it's not I don't even know does anybody know enough about claims to know is VR is voc rehab in medical loss or in claims adjustment do you know we don't want you the VR influencing the doctors thinking or the other way around we don't want the doctor influencing the VR is thinking okay all right and oh how bizarre so anyway to hear that that's screwed up because if what we want to do is avoid that second worst outcome of an injury and illness in a working person we want to have somebody that actually knows how to help them get back to work so in the little project that I'm doing in Rhode Island is turning out that I've partnered up with a wonderful vocational rehabilitation she's she calls herself a rehabilitation counselor she runs a rehabilitation counseling program and she says it's like we're we could finish each other's sentences we both know how terrible it is for people to end up not working but the voc rehab world has been kind of corrupted by the plaintiffs and defense bar and oftentimes it's turned into a claim settlement tool and we it just would be really nice if we could somehow persuade others that having professionals who know how the the stay at work and return to work process works and the rehabilitation process works because the voc rehab people understand the emotional consequences of injuries and that by the way I meant to mention that that is a another discovery I've made by working now with what I think people need as opposed to what you know doctors usually do in a workers comp claim is you know what when you lose a body part you grieve when you lose the use of part of your body when you've had a traumatic incident it is a very big emotional deal and I think when we've been talking about preventing needless work disability I don't think we've thought and by the way we means me because I've led a couple of these papers right I I don't think we've really acknowledged we've called it normal human reactions and you could say we were talking about it but really being able to help people through and acknowledging the normalness of their grief is important so if you have any thoughts or questions you want to ask at the end why don't you write them down now we're going to try and do them at the end so in the next segment I'm going to run fast here and share four sets of four four premises to start from a foundation for potential clinical practice policy and program changes describe four individuals who have the most influence over the outcome of individual situations summarize the status quo very succinctly and how the injury management process typically or too often proceeds and some specific things that create good versus bad outcomes make four recommendations for change and then discuss my four patients so one of the premises is that our country's definition of healthy needs in addition there is a woman named mocktail tuber who led a group from the Netherlands who published in the BMJ and said that really the WHO's definition of health is the absence of anything bad is patently absurd because we do all have illnesses over the course of our life and bad stuff happens in life and so what they said is they proposed modifying the definition to include the concept that healthy adults cope with and adapt successfully to whatever life has dealt them and if we did that when we talked with patients and we talked about how part of your job now is to figure out a way to have a good life, even though this has happened, and I'm here partly to help you walk through that process, right? So a healthy adult, a working person who's had a health misfortune, is going to do their best to find a way to keep participating in life and remaining an active contributor, engaging in productive activity, paid and unpaid, as long as possible. Because we know that makes a happy life. People like to have a sense of purpose, they like to be engaged, and they don't like to be sidelined. And interestingly, this, part of this line of thinking that I went into, happened because I came up, have you ever heard of these Zen, are they pronounced Koans, K-O-A-N? They're kind of like enigmatic statements. And so I made up one called, what does healthy look like in a person with a chronic condition? What does healthy look like in a person who was either born with or acquired a structural disability of some sort? We need to make it available to people, a vision of what healthy is going to look like. And also, as a big concept, I already said this, that maximizing the number of adults who are self-sustaining taxpayers and contributors to the country, to the economy, is vital to our country's future. But today, workers who suddenly find themselves work-disabled are left to fend for themselves, to cope with the life predicament that their medical problem has caused, especially the impact on their livelihood, because, and this was that weird day when I was looking at who is accountable, that none of the three front line and professionals who usually get involved in an individual worker's health-related employment disruption, that's the long term I came up with, feel responsible for actually delivering a good employment outcome. And they are not called to account if they don't. Nor do the organizations in which these professionals work, and nor do they, these stakeholders, coordinate their efforts to work as a team. So this situation reflects the fragmented, complex, and dysfunctional nature of our society's healthcare delivery and social welfare models and systems, in both the private and public sectors. And one way to deal with all this is to say, oh, okay, we're just screwed because the system's so terrible, or the other one is to try and figure out what you can do about it. Okay, so the four front line participants, or players, in every health-related work disruption are number one, the affected worker, who actually is the most powerful person and feels the least powerful. Because the worker is the one who decides how much effort to make to get better, and they are going to come up with a strategy for the best way to handle the situation. And one way for that worker to feel more powerful is to be told how powerful they are, and to be told the role they play. And if they, and this is what's important, if they don't feel prepared, is to strengthen and develop that person's ability to handle what life has dealt them. And that is a very good role for us, is to be thinking of ourselves as strengthening and developing the ability of workers to handle what life has dealt them. And then there are the professionals in the three separate sectors of society you know about us. The workplace supervisor acts on behalf of the employer, and they have the discretionary authority to decide whether and how hard to look for a solution. So remember that stuff about where risk factors lie? One of the risk factors is an employer who isn't interested, right? And this is another group that if we get really good at words, and we get really good at conversations, we might be able to influence and reduce that risk factor of the way the supervisor is looking at it. And same with the benefit claims representative. They act on behalf of the benefit program, the health plan, the worker's comp insurer, whether public or private. And they also have the discretionary authority to decide what to pay for given the rules. And likewise, the way they see it and the way they're feeling about it and the way they're responding to the worker has an influence on the worker and the outcome. And if we get great with words and great with relationships, maybe we can get them to really support the worker. Now each of the frontline professionals operates in a separate world. And the typical doctor, I got to go fast here, works in a health care delivery organization and often it feels like an assembly line. This is not you, I hope, views their main responsibility as making decisions about treatment, thinks stay at work and return to work, paperwork is administrivia, that would include me for years by the way. The longer the form, the lower it goes in the pile, I hate it. Typically not aware of the worker's job and unfamiliar with workplaces. Many doctors went to college, went to medical school, and the only workplace they know is a hospital. They're not curious whether the worker's going back to work, getting a paycheck, or understressed. Now what might be more useful to you is to think about workplace supervisors and HR professionals. They view their main job as forwarding the mission or business of the employer. They look at managing injuries and illnesses as a bother too. And they represent the employer and they, as I say, view these benefits as a bother and a distraction from their real job. They decide, they have the discretionary authority to decide how hard to look for a solution. And their interest ends when the worker is terminated. They have no interest once the worker is terminated. And they actually have no interest once they've decided that the worker will be terminated. In worker's comp, they often can't officially discharge anybody that's against the law, but they can break with them emotionally and have written them off. Now the benefits payer, the worker's comp case manager, acts on behalf of the health plan, the worker's comp, or disability benefits program. They decide who to pay for what given the rules. And their interest also wanes if the worker's not going back to the original employer. This is really more abandonment. So how to avoid over-impairment and loss of livelihood is to make sure that somebody is guiding and supporting the worker, orchestrating, I advise us not to use the word coordinating because anybody can coordinate, an administrative person, a nurse can coordinate, but only a doctor can orchestrate a treatment plan and orchestrate the way a situation is evolving. And also somebody needs to be driving the episode towards resolution, keeping an eye on the clock, making sure it's moving forward and coordinating with other parties as needed. And that means keeping an eye on the clock because elapsed time is the enemy and ensuring that the medical treatment focuses on maximizing functional recovery. But here's this new one, restoring, strengthening, and developing the worker's motivation, intention, and capability to cope with their predicament and anticipating, looking for, and addressing obstacles to recovery and return to work, including is there an obstacle to returning to the old job, is there an obstacle to arranging accommodations, is there an obstacle to finding a new job, and how can we get around those obstacles? So we need to expand our repertoire of intervention options. So as I said, I'm going to skip this on evidence-based way to look at words, but if we start thinking of words as a powerful therapeutic tool and technique that changes brains and affects outcomes, it gives us a real area for professional development and effectiveness. And you can see the slide. This is the power of words is they can do harm as well as help. And if we haven't been using words thoughtfully, we may have been harming rather than helping. So you can jot down any other question if you want before you get it. But now let me discuss the four cases briefly. By the way, are we doing okay? Yes. Okay. You have 10 minutes. Since I have to wear my C-short glasses, I can't really see your eyes. I usually tell... Gosh, I went all the way back to the beginning. I hate being human. Okay. All right. So let's talk about Rudy. Rudy is a very likable guy, 56, had a left shoulder replacement. Whoops. Oh, I was just going to remind us these are the four, Matt, Rachel, and Tony. We'll do them one at a time. So Matt had a degloving accident and amputation from a machine. He worked as a fabricator, machinist, and he had the surgical amputation just three days later. And he was referred to our program four months later. At that point, his diagnosis was PTSD, phantom pain, depression, and he still had pain from his injury. So I realized in working with him that he very clearly had grief. He'd lost a body part. And I had personally never actually dealt with a person who'd had a significant amputation. And so this was... My temperament is I'll sort of try and hit any baseball that comes my way. So I was trying to do the best that I could with him. But what I didn't really know is how long his grief needed to, for his well-being, how long his grief needed to slow down his recovery process. Was I going to harm him if I pushed him too hard to start thinking about return to work? And I was reminded that I have become kind of friends with the Deputy Assistant Secretary of Labor who's quadriplegic. And one time when I was talking about the kinds of questions that people have after their injury, like who's going to help me? How long am I going to have to lay low? What is this going to mean about me? What's it going to mean about my future? I said that people like with back injuries and shoulder injuries, that's all their questions and that we're not really answering those questions. She came to me afterwards and said, when I broke my neck, those were the questions I woke up with. So I think Matt did resist thinking about his new job and his new future. This was the challenge in working with him. But I think that I got the conversation for what are you going to do now started almost early because when was it obvious he would need vocational rehabilitation? The day he lost his hand, the day, right? And the work comp system wasn't going to make a VR available to him until he was at MMI. And I will say that it's now April 2023 and he is still not at MMI because he has still not mastered the use of his prosthesis. And this was one of the big issues for this claim. And I think I've learned something and I think I'll be a stronger advocate next time. I think his hand surgeon was beguiled by a, oh, I've just forgotten the word, myoelectric hand. Absolutely state of the art model thing. What do you call that thing where it's still in development? And so they went down this deep hole of giving him the world's fanciest hand that he'll be able to operate just by twitching little arms. And as a result, he still doesn't really have a fully workable prosthesis. And I had heard early on that they thought they were going to give him a cosmetic one. And I thought that was a great idea because he had a lot of shame about the disfigurement and he wouldn't go out in public. And it seemed like I could help him with the shame if he had a cosmetic prosthesis, you know, a hand that doesn't move, but it looks like a hand. And I knew that he could have actually done a lot of work with his arm if he'd had a traditional whatever you call this kind of prosthesis. But they were beguiled by the fancy one. And I won't let that happen next time. I'm going to be an advocate that he needs to be able to restore as many functions as possible. And I'm totally happy to support him for the myoelectric hand, but we need to get people functional rather than have him sit around and feel so low and so disfigured. And it was really hard. He was a very, very nice guy and it was very hard to watch what he was going through. And he did successfully deal with his PTSD. He had originally been referred on opioids, but by the time he actually came to the first appointment he was already off them. He didn't want to be on drugs. He also worked successfully, you know, I paired him up with our CBT therapist, worked very successfully with his phantom pain and depression. And it did cheer him up amazingly to get the hand. It did cheer him up. And at the very end, I think I have this here, here's a lot more words, not for you to read, but just for me to remember, I referred him to CBT to address his PTSD, teach him his pain coping and management skills, assist with grief and acceptance. And it was completely normal that he have that, right? Completely normal. We weren't going to try and take it away. It's part of the adjustment. But he also needed to be encouraged to start creating a comprehensive vision of a desirable revised future that includes the self-respect and financial benefit of returning to productive work. He wanted to support his wife and children. And he continued the hand therapy with a hand surgeon. And I instructed him in the opportunity he had to reassure his brain, which was because he was afraid of going back into the place where he was injured. His employer actually wanted him back, but he was so traumatized by the accident he refused to ever go back. And so I coached him on reassuring his brain because his primitive brain is still frightened and remembering the moment of that injury, that there's nothing wrong now. There's no danger now. It doesn't need to keep creating the phantom pain to protect him. And I also got him asking the hand surgeon about the time fine for recovery. I asked him to ask about what other patients have been able to do and inquire about career counseling and voc rehab options right from the start. But as I say, I couldn't really engage him too much in it, although he was willing to do some work-like activity. As I said, he's still TTD, temporary total, per the PCP. He has successfully resolved his PTSD, his depression, his anxiety, no medication. Now interestingly, as a development, he calls himself an amputee. I think that is part of the healing, is you are able to say that you're an amputee. That was a surprise to me. I didn't know that was part of it. And he says his prosthesis is used like a real hand. Uh-oh. Two minutes. What case do you want to do? Rudy, the concrete worker with the left shoulder replacement. Rachel, the hand pain in the carpal tunnel. I vote not on this one. You want Rachel? And how about Tony, the guy who nearly died from COVID? Rachel, she's kind of most representative of cases that I deal with. You deal with. Okay. Let me see if I can make it go backwards. Uh-oh. All right. This is the most frustrating one. It had a recent twist in the road. Okay. She... I have seen this before. Something weird happens at work, and it's going to get chalked up as one of those weird things that's not really in the medical books that happens. And then it turns into a diagnosis. So she's 59 and was working one day in her cashier job, and suddenly she got a very, very sharp pain in the back of her hand, right about here, and she actually had temporary vascular compromise. It was blue and white and hurting terribly. So she went to the ER, and she stayed out of work for a while. Then she came back to work, and they said, don't use that hand, because it was still bothering her some, really, remember, sharp, severe pain. And then she started developing symptoms of carpal tunnel in the other arm. And so she ended up going out of work and had been out of work, I can't remember how many months I said it was by the time I saw her, six months maybe. And so now she has not been working for several months because of her carpal tunnel in both hands, but that wasn't actually the original reason why she left work, which is confusing to me, right? Because carpal tunnel doesn't usually develop, in fact, overnight, if you're doing your regular job, which she had been doing for years. So that triggered something in me, like, what is the actual issue here? Is the carpal tunnel actually symptomatic, or is something else going on? So yeah, she was referred to me six months later. And then she announced at the first visit, very proudly, that she was 80 days sober, and that made me think, so I inquired a little bit about what her childhood had been like, and she admitted it had been very difficult. She had been to see two orthopedists who had found no problem, basically they had said in orthopedic language, you're nuts, go home, which she found very insulting. And so the PTP is the one who had ordered the EMG, which confirmed the mild and moderate carpal tunnel. So my plan was hand therapy, refer to a third ortho, and get some CBT. And I worked very closely, there's a CBT person that I knew well, and I introduced to her the idea of the connection between the mind and the body in pain, and that emotions can sometimes, the brain can sometimes use the body as a channel for expressing emotion. She was very open to the ideas, because she now had pain, widespread pain, and she was very disabled, and very freaked out by what was going on, you know, if I moved my hands at all, that kind of thing. So I instructed the CBT to have her calculate her ACE score, and educate her on the connection, and to help her disconnect the two. She really liked the CBT person, and she went to work doing that, she loved being able to say out loud some of the stuff that had happened to her in her childhood. And they worked together, and her pain got down, the one I saw in February of this year, she said her pain level was down to one out of ten, and that she was able to use her hands freely, and she was pleased to report she's been sober eight months, and was so grateful for the program, I can see this connection with stress and my pain, not just past stress, but present stress, and she didn't want to have surgery, and she was wearing her braces. And there, you can see her pain catastrophizing score has gone down from 46 to 24, which is now lower than an average pain catastrophizing score for somebody in that situation. And so, the two little weird things that happened were, at that visit, when she was so happy, I said, you know, I think it's really time for you to talk to your employer and say, I think I'm getting ready to come back to work, and I'd really rather not go back to cashiering, she was a long-term employee, she liked them, they liked her, the other co-workers liked her, and I said, I think it's time for you to call them and just see, can we talk about that, what could possibly work out, and I'd like to come back slowly so that I don't put a lot of load on my hands right at the start. And she said, oh, I thought I wasn't supposed to call them. And so, this is the workers' comp system, she's gotten the message somehow that she shouldn't be calling them, and I don't know if you remember, but we have, in this work fitness and disability section, we have a brochure for workers on how to cope with a health-related work disruption, and one of the things we say is stay in touch with your employer, keep your relationship, act interested, because if you're not in touch with your employer, they're going to start to wonder. But this woman, Rachel, just was really genuine. She had the impression she was not supposed to do it. So she then did contact the employer, and they had a nice conversation, and she talked to another co-worker, and they were talking about opportunities, but then she went to see her new PCP, her new PTP, and the new PTP said, gee, you really have carpal tunnel syndrome, gee, you should really start PT, gee, you should really think about surgery, and the whole thing has started over again. So I don't know where we are. This is part of the problem of being the secondary treater, but without a close relationship with the primary treater. Thank you very much for attending. I was trying this out on you, next time I'll do it 90 minutes, because I would have loved to hear your questions and comments.

Jennifer Christian

workers at risk

poor outcome

mismatch

recovery process

vocational rehabilitation

early intervention

loss of livelihood

carpal tunnel syndrome

COVID-19