All right, I'm Garson Caruso, I'm an occupational physician in Pennsylvania. My colleague is Les Curte, who's a clinical psychologist in Chattanooga, Tennessee. And we're going to explore this topic of abandoning the mind-body duality with you this morning. These are the usual disclosures and disclaimers. We are both more or less independent consultants. We have no financial arrangements or conflicts of interest to reveal, although we do have a bunch of axes to grind on this topic. We will ask, we're going to ask for your comments throughout the presentation, and Les will have a microphone and he'll come down. We're going to ask you to keep your comments very, very brief so we can hear from as much people, from as many people as possible. The slides have changed a little bit from what you have in your, on the website, so if you want a copy of the updated slides and references, give me your business card, send me an email, and I'll send you updated copies after the presentation. This is a very fraught area in philosophy. It's very complex and it's very controversial, but we're going to try to stay out of the philosophical weeds here as much as we can and just give you what you need to know to understand what we're saying. So this morning we're going to talk about the history of mind-body dualism just a little bit in medicine. We're going to look at the overarching difficulty that we see. We're going to review the problems with dualism in both in Western medicine and in occupational and environmental medicine. We're going to look a little bit at why we aren't addressing this, and then we're going to give you some potential approaches and ways to think about this. There are going to be two overarching themes to our presentation. The first is that mental and physical processes are inextricably linked. There's little or no role for Cartesian mind-body dualism in our current practice of medicine. Secondly, we're going to advocate a combination of compassion and scientific rigor in patient care, trying to make a blend of regard for the individual's experience with the logical application of valid scientific knowledge about how best to manage it. So why are we here? My interest in this topic came about really from three things. I worked as an occupational clinician for several years, and then I've been, for the last 12 years or so, I've been medical director and disability advisor. First of all, I got very frustrated when I was taking care of patients at delayed and failed recovery and unnecessary disability that I encountered, even though I seemed to be doing everything right for them. At the same time, I developed an evolving appreciation of the role of behavioral health factors in delayed and failed recovery. As a medical director, I just had continual encounters with scientific ignorance, denialism in workers' comp and disability insurance, and a really extreme resistance to change on the part of all stakeholders, insurers, employers, and attorneys, everybody. So that's why I started working in this area. Russ, what's your story? So here it is. I am an incorrigible nerd. I have been really, really frustrated lately at the change in language. All of a sudden, we are talking about what we've always referred to as mental health conditions, but we're using neurological language. So we're no longer talking about behavioral or cognitive distortions. We're talking about speaking to our amygdala. This is just nonsense to me, right? And I understand the point, and I'm happy for it that we're finally having a conversation where we recognize that these things are inextricably intertwined. We can't separate them, right? Just when did we think that mental health activity took place without activity in the brain? That never made any sense to me. It's always been the brain, and it's always been mental health. We are people. And so that's sort of my scienciness is my pet peeve these days. And finally, just that we've finally gotten to be talking about the fact that we have to consider both mental health and physical health when we're dealing with patients, but I don't think we've gone far enough. It's not just that they're associated. They're the same thing. Mental health is health and vice versa. It's one thing. So that's what got me here. And I dragged him along for this talk. Willingly. Willingly. Okay. So next question is, why are you here? Does anybody have any thoughts, any reasons why you came here, questions you potentially want to have answered? So I am originally from India. I was born in a culture where we usually treat mind and body a little bit closer to each other. So we do meditation, yoga. They all teach mind-body connection. So I wonder what you have to say from your... Les, that's right up your alley. I'm here because I've started getting interested in lifestyle medicine, and I barely have read one book on it, but they're interested in stress and how that helps with general healthiness. And I'm interested in learning how to apply those concepts in occupational medicine with our population where... So oftentimes we just are there on a surface level, I think, to recover their injury in a certain way, but we're not even dealing with their whole mental health aspect. So I want to see how that comes together. Make sure you get the reference list, because there are a lot of references in there that might help you. The reference list has the references that are in the presentation, but there's also an additional reading list as well. Thanks. Steve and Ali from Jaguar Land Rover. I look after employees all over the world, and I'm continually struck, surprised, and often taken aback by the differences. How we approach medicine in some countries is very, very different to other countries, and I've been caught up multiple times, particularly around this, particularly around the difference between physical and mental, and in some countries, how that, to the point that the lady said from India, how that comes across and how you can then approach it from an occupational health point of view. You can't impose a certain style of medicine that we may see in the West and other countries because the views are so different. I think we should be having you do this. One more? I work at the World Research Center Health Program, and we do following on the cohort of World Research Center responders, and very often I see that how patients perceive their health and what physical objective findings are completely different, and we all very often see some patients with significant finding on the testing, on imaging, and they perceive themselves as absolutely healthy, and others have so many problems and all objective data does not support. Okay. Great. Thank you very much. All right. We're going to have a little history lesson in dualism today. Mind-body dualism is a metaphysical stance that the mind or mental processes and the body or physical processes are two distinct and unlike entities that have different properties, although each has its own essential nature, and this is a branch of dualism called substance dualism. The mind or res cogitans was an unextended immaterial thinking substance that was not subject to physical laws, and in this context, unextended means not occupying physical space. In contrast, the body or res extensa was an extended or occupying physical space, material, unthinking subject that was subject to mechanical laws. Back in the 17th century, this doctrine challenged the church ethical teachings that mind and body were one and the body had to be intact for the soul to ascend to heaven. It demythologized the body and permitted the study of anatomy and physiology, particularly by dissection. If you dissected the body, it was no longer whole, could not go to heaven, not good. In this situation, physicians and other scientists like anatomists were sort of seeded the technical body, while philosophers and theologians were assigned to the mind, which was considered to be more of a moral ground. This doctrine was really embraced by the medical field to provide a scientific basis for the practice of medicine, which was growing at the time, and it laid the groundwork for positivism or logical thought and empirical science based on objective observation, measurement, and verification of natural phenomena. Kind of what we would call evidence basis nowadays. So the overarching problems that we see with dualism now are twofold. The first part of this is that all mental phenomena are physical. All neurological phenomena are ultimately dependent on physiological processes, and this is another sort of branch of dualism called physicalism. So if you think of energy producing cellular metabolism, that's a biochemical physical process. The biochemistry of neurology, for example, the basic membrane potentials, sodium, chloride, potassium flux across membranes, the anatomic configuration and interneuronal synapses and synaptic activity, and on a larger scale, complex systems like neuroendocrine, neuroimmunologic, and even neuronal networks. These are all based on physical properties. On the other hand, all physical phenomena are dependent on mental processes. So our perception and response to neurologic phenomena is ultimately dependent on very complex CNS processing. Pain perception, proprioception, other musculoskeletal senses are modulated from the peripheral nerve to the dorsal root ganglia of the spine all the way up the spine and into the cerebral cortex. And motor and sensory function are controlled by the CNS. We also have higher levels of processing, for example, at the hypothalamus, the thalamus, and the limbic system that affects our responses to sensory motor inputs. It determines our affective responses or emotional responses, our behavior, and our cognition or thinking responses. In 1995, Chalmers pointed out these easy and hard problems of consciousness. The easy problem was this mechanistic analysis of neural processes having a biochemical basis and producing all these effects, affect, behavior, and cognition. The hard challenge of consciousness was why and how these processes result in awareness, experience, and consciousness, or what Nagel termed the feeling of what it is like to be The feeling of what it's like to be at this conference, the experience that we're having being in this room right now. You can't really reduce that to biochemical processes. In 2016, Gendel pointed out that supervenient medical states like consciousness emerge in a bottom-up way in the brain from these underlying physical systems, but the higher systems also exert top-down causality on the subvenient physical substrates. The bottom line here is that we cannot reduce conscious experience to brain activity, biochemistry or physiology. We can only find correlations with those experiences. For example, some of the work that's being done now in functional MRI and PET scans. That's kind of an overview of the philosophical basis of what we're talking about. At this point, we want to switch gears a little bit and explore the practical side of it. What, if any, major real-world problems do you perceive with mind-body dualism right now in your practices? I work at the Veterans Administration, and I see many, many veterans with back pain and musculoskeletal pain. One of the first things they'll say to me is, well, you know, I've had this for years, but everybody just tells me it's all in my head. I usually tell them, well, if it wasn't in your head, you wouldn't know you had it. You've got to have a head to know you have pain, but we don't really work that way. You know, if you're in orthopedic surgery and you don't find something on the imaging, it's not there. So I think it's important to know it's got to be in the head. Yeah. Yeah, it's interesting. I did a lot of work with people who were ill, and they would get sent, or felt ill, they would get sent to me by primary care and, you know, go see the shrink, right? And they would say that exact thing. They just think it's all in my head. And my comment typically was, I don't, you know, it's not a question of whether it's all in your head or not. Instead, your head's the only thing that it doesn't work with, so I want to see what we can do about it. And that was, surprisingly, people wouldn't tend to engage with me about that. Like, I just didn't start learning. Anybody else? No? All right. Okay. Well, we won't solve any of your problems now. All right, we feel that there are really four major problems with dualism in Western medicine now. First of all, it facilitates the biological reductionism of disease. It focuses medical science on resolving the body into its component parts, and it has encouraged neuromedical specialization and what we refer to as silo medicine. Secondly, it promotes a dispassionate and mechanistic approach to patient care. It kind of encourages this role of diagnosing and treating the patient's illness by limiting our attention to the body rather than the person who is experiencing the illness. And it disregards the subjective lived experience of patients, kind of going back to the consciousness idea. Thirdly, it supports medical practices that don't really encourage wellness or healing. There is often a presumption that diagnosis indicates a specific treatment regardless of the individual factors in the situation. We see this very commonly in patients that have chronic pain who just kind of get plugged into an interventional pain paradigm, and they stay there. They never get out. And certainly this is true of treatments for nonspecific low back pain where we see a lot of unnecessary surgery. This discounts the significance of the mental states in the experience of disease and maintenance of health, and it may negatively affect patient health behavior in terms of caring for themselves, self-care. And lastly, it disempowers patients. It encourages the perception of the clinician as the ultimate source of knowledge and wisdom about the condition and about the patient. And we may like that, but that is not necessarily the best thing for either the patient or the clinician. It fails to recognize and understand the dynamic nature of human beings and their relationship with their environment, and we'll see how that works in a minute. And probably most importantly for behavioral health, it implies that there should be separate services for people that have nonphysical problems, either in origin or nature, and it generates this kind of current separate but unequal division of medicine between physical problems and mental problems. And this creates a lot of problems, for example, stigma about mental health conditions, and it may disenfranchise entire groups of patients. This is the classic biomedical paradigm. This was advanced by Gordon Waddell in 2008, and we've used this as kind of a jumping-off point for our work since then. This assumes that we evaluate the patient and we recognize the pattern of symptoms and signs. We make a diagnosis by deducing causal pathology, usually organic. We then treat the patient by applying known therapy to that pathology, and we expect the individual to recover. We expect them to be cured. And... Garson, just, I want to add something to that, because I think there's a misunderstanding about how psychologists are trained, because in point of fact, we are also primarily trained in a biomedical model. Diagnose, understand the symptoms, make a diagnosis, provide treatment, and expect a cure. Right? We also, I think, in our training, and I have a colleague here who may or may not agree with me, but I think that we are heavily trained in this biomedical sort of way of thinking about people, and we've lost sight of the fact that we are dealing with someone who, a person who is sitting in front of us. All right. In occupational medicine, this sort of translates into this very simple paradigm, where we have a disease or an injury, which creates symptoms and signs, which then results in impairment, disability, or incapacity. And we define these, we define impairment as a demonstrable loss of structure or function, disability as a limitation of activity and or participation in activity, and incapacity as an inability to work. In the early 2000s, Patrick Loisel and his group expanded this greatly in their ecological model, which has kind of evolved into the Sherbrooke model. So they included personal considerations, which is the behavioral health and the mental health considerations we're talking about. They included healthcare system factors, they included legislative and insurance system factors, they included elements that are found in the workplace, and the whole thing was encased in an overarching environment of culture and politics. Now we adopted this model when we revised the ACOM Practice Guideline for Disability Prevention and Management in 2011, and we carried it through in the most recent revision. So this makes this model much more complicated. So we've got multiple behavioral health factors, and in our 2019 paper, we elucidated a number of these. We looked at psychophysiology, we looked at adverse childhood experiences, learning, motivation, perceived injustice. The one that we found was the most important in this context was health cognitions, which include appraisals, attitudes, beliefs, and expectations. Both of the patient and of the other stakeholders involved. Then there are the contextual factors, there's personal behaviors like substance abuse, the environmental factors, the legislative, economic climate, insurance climate, and workplace factors. Now these can produce symptoms, they can produce illness, which is a subjective feeling of being unwell. They can produce medically unexplained physical symptoms, which we're gonna talk about in a moment. And they can produce sickness, which is a social status according to the ill person. And then the final element that is involved here that we feel is very important is iatrogenicity, which is causation of deleterious effects by medical activity, whether it's the clinician, the insurer, the employer, an attorney who's involved in a case, allied health personnel, whomever. So this raises two questions. So if our outcomes are often the same, impairment, disability, and capacity, first, the clinical presentation and the needs of the individual are gonna be similar regardless of the underlying cause. So is it really sensible for us to have two sets of services physical and mental for the same presenting problem? And secondly, when a certain part of a person's presenting problem can't be attributed to a discrete or identifiable underlying pathology, going back to the basic biomedical model, is it morally just to decide that they are either denied help or they're provided help in a suboptimal or secondary fashion? So I'd like you to think about those questions a little bit as we go. So we identified four major problems with dualism in occupational medicine. First of all, it promotes an overemphasis on this diagnosis-treat-cure sequence in the biomedical model to satisfy multiple stakeholders. For the patient, it may provide an understandable explanation for their condition, whether or not it's reasonable. For the insurer, it may provide diagnosis and treatment, whether it's right or wrong, for remuneration. And for the employer, it hopefully will provide a cure to minimize their expense and facilitate stay at work and return to work. Second problem with dualism is that it leads to overdiagnosis of what we call non-diseases. Almeidor wrote a paper titled Non-Diseases in 1965. So this concept has been around for at least 50 years. And we include things like medicalization of normal human characteristics, which Conrad published an entire book about this in 2007. It also leads to the invention of spurious illnesses and disease categories, some of the syndromic and functional disorders that we have, and frankly, fabricated conditions like chronic sprain and strain. Thirdly, it does not account for medically unexplained physical symptoms. Now, medically unexplained physical symptoms can account for original complaints that are misattributed to work activity. And the example of low back pain is probably the most common there. It can account for symptom escalation after an individual has a workers' comp claim or injury. It can account for evolution into chronic pain syndromes, primarily by the mechanism of somatization and central sensitization. And again, it can account for delayed and failed recovery. We feel that this is really a large, under-appreciated problem in occupational medicine, and others agree with us. And it's certainly under-recognized by occupational clinicians. Now, the fourth aspect of dualism in occupational medicine is that it provides a strong potential for iatrogenesis. We identified five different ways that iatrogenesis works. Advocogenicity refers to inappropriate advocacy for the patient. For example, putting them on work restrictions when they don't really need them. Accounts for medicalization, over-evaluation in terms of fear of missing some occult disease and working up the patient within an inch of their life. A focus on symptom relief as opposed to functional restoration. And a disregard for the critical nature of time in recovery. Ivan Illich published a book, Medical Nemesis, in 1976, and he added a sixth idea, which was clinical iatrogenesis in the form of misdiagnosis and medical error. So at this point, I want to say a word about evidence-based medicine and dualistic reductionism. We are both very firm believers in evidence-based medicine. We incorporate evidence in everything we do. But evidence-based medicine may tend to concentrate on single ideological and management factors and fail to give suitable way to clinical variations in patients and all potential therapeutic modalities. Both modern medical education and the demands of our current busy medical practices direct our attention toward mastering scientific knowledge and away from treating the whole patient. As Goldenberg put this, the seeming common sense of evidence-based medicine only occurs because of its removal from the social context of medical practice. So in summary so far, we've tried to make a case against continuation of the classical separation of mind and body, both in general and occupational medicine. It really is not working. It's not serving us well in taking care of patients. So going forward, we have two suggestions. We need to consider non-physical influences in evaluation and management and much more integration of mental and physical issues. And kind of as an end to that, we need to focus on desired outcome, which is functional restoration, really with less concern for the underlying disorders. So why aren't we addressing dualism? So if you'll take just half a second, I'm not gonna ask you to comment on this, but take a second and ask yourself, what's your experience of yourself? When you just sort of think, who am I, where am I, where do you go, right? We naturally experience ourselves as having a mind separate from our body. We think of ourselves mostly, when I ask people, if I really ask people to pay attention to this, if you close your eyes, where are you? You're sitting inside your brain somewhere looking at a screen that is your experience. That's the way that we experience ourselves. Part of the problem with this is that intuitively, we think of these things as separate, right? And if we don't challenge that, then we don't get past it. So that's sort of my answer to this question. It just seems like body and mind are separate. And we think that we're doing two different things when we're addressing them, but ultimately we're not, right? So some of the other reasons that we don't address dualism are this rigid belief that I was talking about before and adherence to the biomedical model, the persistent stigma for behavioral health influences, really ignorance of alternative approaches. And I mean ignorance in the sense of not knowing. There is also a very strong inertia and comfort with business as usual, particularly in our administrative and insurance factions. There's a fear of change and uncertainty. There are practical concerns when we refer folks for cognitive behavioral therapy, for example. It's difficult to find practitioners in some areas. It's very difficult to find practitioners that take an occupational functional focus. And it's difficult to find really high quality practitioners. There have been historically concerns about the cost of mental health services in say a worker's comp claim. We are not, the jury's still out on that. We don't have a lot of good evidence for meaningful impact on outcomes or return on investment, but I think that's growing as well. I think a comment that I would make here is that I've been watching the history of this. I started talking about behavioral health and disability for like 22 years ago and nobody wanted to hear it. Nobody wanted to hear about it in disability. Certainly nobody wanted to hear about it in workers' compensation because we don't want to, quote, buy a mental claim, right? Seems to me about seven or eight years ago, we started to have that conversation. There started to be at workers' compensation conferences, there were presentations about behavioral health. And everybody got excited. And immediately what happened was that there was a large number of cottage industries that grew up about providing mental health services to workers' compensation clients. And it took about two years before workers' compensation in general totally lost interest because we didn't produce the outcomes, right? We've started again to have this conversation. I think we owe a debt to, as weird as this sounds, especially after our talk yesterday, as weird as it sounds, I think we owe a debt to COVID-19 pandemic. Not because I really think that it caused a huge wave of mental health problems, but I think what it did was it shone a light on a huge problem that we've had all along. And so we're starting to talk about it again. And partly, what's behind my motivation for wanting to put this talk together was that I think we have to take a different sort of approach. And we have to understand that if we're going to help people get better, we can't just throw an app at it. We can't just throw CBT at it. We can't just throw a solution at it. We have to start paying attention to how we approach patients and treat them. All right, this brings up a dilemma that we talked about in our 2019 papers. These were published in the AMA Guides newsletter, by the way. Causation and apportionment are major issues in occupational medicine, particularly workers' comp and short and long-term disability. So we recognize that conditions like some of the behavioral health conditions, some ancillary conditions that a patient may have may be non-work related, but they may be totally work relevant in terms of the individual's recovery and stay at work and return to work. And again, contributing elements can be behavioral health influences, medically unexplained symptoms, iatrogenicity. The bottom line here is that workers may not recover from a work related illness or injury unless these work relevant factors are addressed. And so the question that we posed at that time was, how are we to decide which of these factors are compensable? One factor that would come up would be an individual that needed orthopedic surgery under a workers' comp claim who had severe coronary artery disease and they couldn't survive the anesthesia. We have many, many behavioral health overlays in workers' comp cases, anxiety, depression, PTSD, and so forth. So should the clinician be responsible for addressing every potential influence on the patient's illness or injury and or recovery? What are your thoughts? Okay, one at a time. Is this your chance? So this is the audience participation question. If I were to... When I'm teaching, I walk to the back of the class to make sure everybody's awake. I think the short answer is yes. Well, you don't have to be the expert at addressing all of them, but recognizing them and identifying that there are indeed problems and there may be, and thinking about them. And even though, so you're responsible for owning the case? And assisting? Okay. Yeah. I think we'd have to define what address means, right? Like how far do we go? What's the scope of address? Yeah, so what do we mean by address, right? You're talking about ownership, but not necessarily having the expertise to handle it or to treat it as addressing, but you're asking the question, well, what do we mean by address? And I would say it's interesting, as an osteopathic physician, it's really cool to hear osteopathy is, that's my philosophy, is being conveyed to the rest of the world. Thank you for catching up. My question is, what's the outcome? And that's, as a physician, my outcome is trying to get him back to functional life, right? If that's your outcome you're shooting for, then the answer is yes. If the outcome you're shooting for is, I've checked the box that they don't have some abnormality of the spine that needs a surgeon, then you don't need to worry about this. But my outcome, my focus is on getting that person back to functionality as a physician. And I think you do own, you have to at least address all of it. My biggest frustration is that I can identify that there's some mental health stuff I can kind of take a little bit of a swipe at, but trying to get, if there's a significant overlay, trying to get the support in a worker's compensation setting is nigh onto impossible. Yeah, that's a really helpful observation. I feel like I identify with my mind. I'm very fond of my limbs and internal organs, some more than others, but I really identify with my mind. And I think a lot of people feel that that's where their self resides. And I think it's not just getting providers to focus a little bit on the mental health aspects of cases, but getting patients to be willing to accept the idea that there is a connection. And as our colleague said at the beginning of this conversation, well, they're telling me it's all in my head. And people are terribly fearful of that because the head is so related to the sense of self. And so I think that's the real challenge for me when I think about these cases. It's like, all right, well, how do I try to make that work? So that's why I'm here today anyway. Yeah, that's a really, I think, a wonderful observation. And you're anticipating what we're going to say, what our answer is to this, because it's really also about the patient, right? And helping them to pay attention. So yeah, that's exactly where I was going with this as well. So I am, background about me, I am a family medicine as well as lifestyle medicine trained. I heard you mention that earlier. And I have a very unique kind of training background. So at the same time that I was learning family medicine during my residency training, I was also going through integrative medicine as well as behavioral medicine. So I actually take a BPSS model to taking care of patients. And I'm also gotten some training in trauma-informed care. And so, and I'm doing Jedi work and stuff. So I'm really starting to retool and reappraise how I take care of people. So to your question, it's partnership, right? There's a yes and no to this answer. I think that we're floating around terms like integrated, whole person care, and it sounds really nice. But at the same time, in terms of influences and factors, what I've learned, and I work in a community health center space, there's also to some trauma or even mistrust or how much can I really share with a doctor, right? So that also influences what type of information we may receive so that we can't take care of some of the underlying things. So long story short, I think the fact that we're having a conversation is gonna push us in the right direction, but also to the major drivers in America is gonna help us get there with value-based care because we're really gonna have to start figuring out this fee-for-service thing is not working anymore, and we're going to have to really address the really well-being piece of this. Yeah. Yeah. But y'all are really putting an underline about what I love talking about these things about biopsychosocial work and thinking to occupational medicine audiences, because of anybody, y'all get the fact that we have people in front of us, and the point, if we're going to get them to function better, is to address the person, right? Not every audience is as friendly as you are to this idea. Okay. At this point, our opinion, the answer to this question is probably no. We feel the clinician should strive to understand all the relevant influences in a case and with a patient, but really has no duty to address or resolve all those factors. We need to identify reasonably related and treatable elements, but not manage untreatable conditions for those that may need to be referred elsewhere. Now, we want to emphasize this is a high, as some of you folks said, this is a highly individual and situational question, and it really is going to depend on the relationship of the clinician and the patient, the partnership, the employer situation, the insurer situation, whether there's legal involvement, and the specifics of the case. This is something that we're going to have to kind of feel our way with going forward on a very individual basis. The only other thing we would point out here is the patient also has to be expected to exercise personal responsibility for their condition and their recovery to the extent that they are able. They have free will and choice. They can take medication that's prescribed for them or not. They can show up for physical therapy or occupational therapy or not. They can honor work restrictions or not. And they also have to avoid the moral hazard of insurance and compensation systems. So finally, we're going to propose some potential approaches for you to think about, consider for your own practices. We would ask you to keep the following in mind. As Gawande pointed out in 2002, medicine's ground state is uncertainty. We are often working with incomplete information, and we have to make assumptions about patients based on our best information that we have at the time. This paper by Loeser and Sullivan was written 25 years ago, and they pointed out that looking at environmental factors that influence the patient's thoughts and behaviors can often be more productive than searching for some occult pathology that is probably not there. And finally, a quote from Osler, the good physician treats the disease, the great physician treats the patient who has the disease. How many of you are familiar with the capacity limitation risk tolerance paradigm? Wow. Okay. All right, this was advanced by Jim Talmadge, Mark Millhorn, and Mark Hyman in the second edition of the AMA Guides to Evaluation of Workability and Return to Work, which was published in 2011. And under this paradigm, capacity is what the individual can do. Limitation is what they cannot do. That's pretty simple. Risk is what they should not do because it poses some risk to them or others. Restriction is what they must not do. So these four elements are more or less objective, and they can be determined by the clinician. The fifth element is the individual's tolerance or what they are willing to do. And conversely, this is more or less subjective and cannot be determined by the clinician. So in the original formulation, these were separate. So capacity limitation, risk restriction were kind of on one side, and tolerance was considered to be something else. We would propose that these are not necessarily mutually exclusive. They're not binary. It's not just tolerance that you're dealing with. So we may need to consider the individual's tolerance a little more along while we are considering their limitations and generating their restrictions. So some of the thoughts on dealing with dualism. Swietenkowski proposed an interactive dualistic approach. This was based on a dual aspect theory that was in turn proposed by Nagel, in which the mind and the body are irreducible, but they are interactive properties of the individual. And this involves taking the patient's clinical narrative seriously, including both their subjective and their objective criteria of illness, treating the lived experience of illness, and again, treating the whole patient. When I was at Temple Medical School in the early 80s, right up the road here at Broad Street, they told us time and time again, listen, and the patient will tell you what's wrong. Rocha advanced this idea of genuine complexity. This is an ecological perspective that's based on understanding complex interactions, which is directly opposed to the silo specialist approach that we have now. This recognizes that the whole person is composed of parts, but the overarching identity and function of the parts is defined by their interactions within the body as well as with the environment, the history, the context, and the lived experience. It acknowledges that the lived experience, meaning and interpretation, are not side information to be tucked away in a social history or wherever, but really significantly influence the individual's illness. They felt that the clinician has to consider the genuine complexity of the person and the emergence of this whole out of these various parts. The whole was obviously greater than the sum of the parts. Hendrade and Stegenga advanced this idea of general medicine. They made the point that the benefits of medical interventions are systematically overestimated and harms are systematically underappreciated. They advocated less medical interventionism and more conservative management approach, both in evaluation and therapeutic. This kind of goes along with the idea of avoiding iatrogenicity. This was active, realistic management of patient's expectations and hopes, their health cognitions that they bring into the situation, and more emphasis on lifestyle changes and overall more attentive care of the patient. We would like to propose an emphasis on functional optimization. This focus on maximal functional restoration serves as kind of an integrated outcome of all of these evaluative and management processes, getting at those three conditions that we encounter in workers' comp, impairment, disability, and incapacity. It bypasses mind-body dualism, concentrates management on this goal alone. It involves a change from overarching disability focus to a capability focus. It recalls the Spice-Biceps models of recovery and rehabilitation, which involve brevity, immediacy, centrality, expectancy, proximity, and simplicity. How many of you are familiar with the Spice models? We gave you the reference. This College 2000 is the original paper on that with a modification by Mancey. The Biceps model was a little bit of an extension, came from the US Army Field Manual from 2006, if you want to take a look at those. This approach involves using all the resources available, usually in a stepped fashion, including mainstream treatment, both medication and surgery, allied health interventions, therapy, behavioral health interventions, and adjunctive measures like acupuncture and hypnosis, whatever. Very important part of this is to avoid serially ineffective treatment. This would include things like repeated interventional pain management with transient results, patient gets an epidural steroid injection, they're better for a week, and then they're right back to baseline. Chiropractic, physical, and occupational therapy without clear functional gains. I'm working on a case right now of a young man that was injured in an automobile accident. He's had 88 physical therapy sessions. There is no change in the physical therapy evaluations. His function is exactly the same. We have to provide valid and accurate assessments and documentation of any functional gain, and this includes in activities of daily living, instrumental activities of daily living, and work activity, including any and all interventions. This also includes the idea of first doing no harm, again, going back to our avoidance of iatrogenicity in all of its different forms. So kind of the bottom line here is that if the patient is not making progress with what the clinician is doing, they need to recalibrate and change their approach and possibly go back and consider some of these biopsychosocial influences that we're talking about. So in some, mental and physical processes are inextricably linked. There's little or no role for mind-body dualism in current practice. It's not working. It's not serving us well. We need to move on. We need greater integration of mental and physical issues with focus on functional restoration. We advocate a combination of compassion or regards for the individual's experience with a clear-eyed emphasis on scientific rigor and appropriate application of valid knowledge about how to best manage what they present to us. This approach is challenging, but we feel it's necessary to move on from the dualistic perspective. Okay, any questions? You had a question. I originally trained family medicine, and our program emphasized the biopsychosocial model approach. And throughout my career, it's reinforced that I think that's the best way to approach care. I think that there's system barriers to doing that. We have a fee-for-service system. You have a 15-minute office visit. You have medical legal pressures to get that MRI and so on and so forth. And so I guess from a practical point of view, insurers don't want us to address that underlying depression, anxiety that we've seen in disability literature is associated with prolonged periods of disability. And so from a practical point of view, how do we emphasize this mind-body-social approach and get buy-in from the stakeholders? I think the beginning of that is to be aware of it. Every patient encounter is just to keep it in mind, be aware of it. And we really, for all the barriers that you're pointing out, we have to chip away at this. We have to take opportunities when we get them and just do whatever we can with them. But you have to constantly keep this in mind, some of the things that we're talking about here. As Les said, we've been working, how long have we been doing this, 15-some years? We've seen progress. Since before the Earth's crust was fully cooled. We can, I mean, we are now getting approval for cognitive behavioral therapy as a pain adjunct. We're getting approval for psychiatric evaluation. So we are making progress with this. But it's a long, hard road. It starts, I think, with awareness. Yeah, the other part, I think, is that we can do, no matter what, is we can pay attention to addressing the person in front of us, which it sounds like you're doing. I also often end up pointing out to people that it takes, mostly, it takes the same amount of time to say things in different ways that have differential impacts. You know, my story that I heard about, you know, someone I know who was in a rollover accident, they had a syrinx, a really serious injury, and at one point the urologist came in the room, looked through the chart, didn't look at her, looked through the chart and said, you know, you're never going to have normal bladder function again, and left the room. Her, the doc who was her primary person came in, found her visibly upset, and his comment was, I don't know if you're going to have normal function again, but we're going to do everything we can to get you there. Now, those two statements took exactly the same amount of time, right? So that's something that we can do, no matter what system that we're in, is really pay attention to the way that we engage with patients and learn that language. And in the meantime, you know, it's essentially subterfuge and, you know, doing whatever you can for people, but it's absolutely a system-wide problem. There's a lot of us in the room, and maybe we begin to make changes, you know, in that way, but I don't want to minimize it either. It is an issue. Up hill room. Is it not all mind, including how we perceive our physical nature? And probably, as I think about it, medicine started off as a philosophical pursuit, so Hippocrates and Galen were philosophers, and then in the last 200 years, the scientific rev, you know, the science of science, which is responsible for a lot of advances, but is still not being able to answer some fundamental questions, which has its limits. So is it not all mind? And working on the mind, even to understand the physical, we're not experiencing everything, including our bodies and the world around us. Well, and we make the assumption that a scientific worldview is not a philosophy, and yet it is, right? My name is Christina, and I am a nurse supervisor of a wellness center that is an OCMED clinic slash lifestyle medicine clinic for firefighters. We view our clients as 30-year athletes, so we are very motivated to, we already embrace this model, and so we are looking for a physician who's interested in this style of medicine already, and what it looks like is all the fire crews come in, and our metrics isn't how many patients you saw, it's did you hit mental, fitness, and medical, and nutrition with the patient, and the whole staff puts in these health interventions, and that is our metrics. We also have a psychologist that they see every time that they come in to their medical visit, so we don't even call it a medical visit, we call it a health visit. So if you are interested in this type of medicine, we operate in that space already, and so we are looking for a physician in September, so just putting that out there. That's great. We're preaching to the choir, and as my wife says, that's because the choir's the only people who listen. I just wanted to comment. One of the things that I see is the dualism is a very effective tool in the commodification and monetization of healthcare, and I think we often look at that from the perspective of insurance companies and units, you get paid per unit, but I know from my own professional experience and my community of providers, we commodify ourselves, especially when we're creating silos and focusing on, we get paid for this and you don't, and I think that, for me, is one of the real challenges, both the way the culture commodifies healthcare and the way internally we do as well. And that was part of that one cell model. Yes. That's from the 2005. We're over time. We're keeping you from lunch, but I want you to have your opportunity. Thank you very much, and maybe this is the other topic, but I'm dealing with population health management where this dualism is also very much present, and it comes to the point that there are mental health strategies, but there are no physical health strategies, and this is a complete confusion what belongs where, because these mental health strategies conclude that physical exercise is good, ergonomics is good, because there is no pain, which is not bad, right, but they are measuring only outcomes related to mental health, while physical health is neglected completely. So, all this effect of physical exercise on hypertension, diabetes, cancer, whatever, is ignored, because psychologists are measuring, are you happy when you lose weight and look better and doing better in social contacts? So this is a big problem, and I don't really know how to resolve it, because it's good to have focus on mental health, but to lose focus at the same time on physical health is really not good. So, what is your... Whole patient. The whole patient. The whole patient is well-trained, but you cannot... Yeah. Concentrate and work. Yeah. We're trying to slow it down. Yeah. Some psychologists will do that, but I won't. All right, we'll hang on. Thank you very much. That's a very great, that's a very good comment.

mind-body duality

medicine

mental and physical processes

dualism in Western medicine

patient care

mental health

functional restoration

iatrogenesis

holistic approach

interconnectedness