Good afternoon, and welcome to today's webinar, Self-Reported Measures and Disability Impairment Evaluations, presented by ACOM's Work Fitness and Disability section. My name is Danielle Feinberg, and I am with the American College of Occupational and Environmental Medicine. There are two features available to communicate with the panelists and other attendees. You may post general messages in the chat feature. Messages can be shared with either the panelists or all participants. Use the drop-down box to select who you want to share your message with. Go ahead and give it a try by introducing yourselves to all the panelists and our attendees. Let us know your role and where you are from. Questions on the other hand should be submitted to the Q&A box. We will address questions at the very end of the presentation. Panelists are monitoring this box for questions, so please be sure to post all of your questions here and not in the chat box. Today's webinar is being presented by Dr. Jennifer Christian, Dr. Ronald Kulik, and Dr. John Burress. Jennifer Christian has spent most of her career in efforts to minimize the impact of health conditions on working people's lives and livelihoods. In recent years, most of Dr. Christian's company consulting projects have involved designing and piloting new processes to identify risks early and find ways to address them. Her clients have included health care delivery organizations, employers, workers' comp and disability insurers, managed care companies, and government agencies. Dr. Christian also treats at-risk patients referred after being identified by a nurse using a screening instrument. In 2018, Dr. Christian developed and taught a full-day course for ACOM entitled Cutting Edge Techniques and Work Disability Prevention, which emphasized risk screening. She has won several awards for her leadership in propagating the work disability prevention model across North America, including a Lifetime Achievement Award from the American College of Occupational and Environmental Medicine. Dr. John Burress, after completing a family medicine residency, then completed his occupational and environmental medicine through the Harvard School of Public Health. He has maintained a clinical focus via community-based clinics, except for a 10-year stint at Boston Medical Center. Since 2015, Dr. Burress has been principal achemed consulting and injury care, an innovative value proposition practice that seeks to address deficits in current MAWC system to improve outcomes, help optimize EMR for client companies. In addition to direct clinical care, Dr. Burress provides disability management consultation for a number of government and non-government organizations in Massachusetts and New Hampshire. Dr. Burress is a senior aviation medical examiner and an HIMS AME. Dr. Burress provides physical leadership for AIM Mutual Insurance and Express Medicine in New Hampshire. He is a past chair of Mass Medical Society Public Health Committee, a past member of the Board of Directors for ACOM, and currently serves as co-chair for the Massachusetts Department of Industrial Accidents Healthcare Services Board Guideline Writing Committee, and a vice chair of the Work Fitness Development Section at ACOM. Dr. Kulik is a full professor and clinical psychologist at the Department of Diagnostic Sciences at Tufts School of Dental Medicine, and holds an additional appointment at Harvard MGH Department of Anesthesia, Critical Care and Pain Medicine. He has published multiple peer-reviewed papers and three books on pain assessment and management, with recent work as a director of the Interprofessional Pain and Headache Grounds, an international educational platform reaching clinicians, scientists, and public policy stakeholders. His recent research and grant funding focuses on controlled substance risk mitigation and improving pain care access. Other academic responsibilities have included an appointment on the Massachusetts Health Service Board and co-chair of the Massachusetts Governor's Committee for the Curriculum on Substance Abuse and Assessment for Dentistry. Fellowship training responsibilities include supervision of anesthesia, pain medicine, and oral facial pain medicine fellows, as well as contributing to the Curriculum for Tufts School of Dental Medicine. We're glad to have all three of you join us today. And I will now turn it over to Dr. Christian. Good morning, everybody. Let me see if I can advance my slides. You've answered maybe no. Okay, Danielle, we're having trouble. I can't advance the slides. Oh, here we go. Okay, here we go. Yay. It's very slow. Welcome, everybody. Welcome, everybody, from ACOM's Work Fitness and Disability section. This is webinar number three in our series this year. We have one more still to be scheduled on the use of PROMIS measures in treatment. Today we're going to be discussing the use of self-report measures to enhance formal examinations, third-party, independent, impartial evaluations, assessments, and examinations. We are not talking about the use of self-report measures today in treatment settings. That will be more our next webinar. There are many, many self-report measures. I want to show you a slide with one of our members' inventory. So today we're not going to be listing, critiquing, or comparing a lot of self-report measures against one another. We're going to be making a few comments on a few particularly notable measures. So today's session is mostly focusing on why and how to use some self-report measures to strengthen your assessment of function, impairment, workability, and disability, and in doing so, strengthen your report and the credibility of your report. Dr. Christian, forgive my interruption. We're unable to see your slides. Okay, so I will see if I can. We've been having trouble with this, dear audience. We've been having trouble seeing my slides. Can you see them now? Yes, we can. Thank you. Okay. So this is an example. We have a colleague, Peter Blumenthal, who does formal evaluations, and he was willing to share his inventory of self-report measures. And the main reason why I'm showing it to you is to point out that there are 90 of them on his list, and that there may be stronger and weaker measures here, but also that he's using measures to figure out about things as different as substance use disorders and the function of individual organs and regional pain and neuropsychiatric, right? So there's a ton of self-report measures out in the world, and we're only going to be focusing on a few today, and I'm having the same trouble advancing my slides. This is just driving me crazy, and it may be driving you crazy. Somebody else, Ron, could you please take over the slides at this point and just back up one? I think I have only one more slide. And I'll stop sharing. Yeah, you'll need to stop sharing. I apologize, everyone. We spent 30 minutes on this technology problem, and obviously we didn't get it solved. Do you want me to keep going one more? Yes, thank you. So the plan for this session is that Dr. Kulik's gonna lead off by discussing the utility of questionnaire instruments in assessing disability in general and identifying some specific tools you can use in your third-party exam practice and review why you should use them with regard to efficiency, accuracy, defensibility in the post-Daubert era and link the use of such tools to impairment rating under the AMA guides. And I believe he's also gonna be talking about how you incorporate the results of those self-report instruments into your report. And then Dr. Baras is gonna discuss why and how he incorporates self-report measures into his formal impairment evaluations procedure and includes them in his reports. And then it'll be your turn to ask questions and please do enter your questions into the Q&A part of the website and I'll be watching very carefully for what your questions are. Thank you so much, everybody. And now let's turn to Dr. Kulik. There's one that we missed that's gonna be important. The educational objectives we set for this webinar, we're gonna look again at the end, is making sure that you can name two ways that including self-report measures can strengthen your formal report, name two risks to avoid because self-report measures can also weaken your formal reports and describe key features that distinguish high-quality versus low-quality self-report measures and describe the main operational challenges to implementing self-report measures. And now, Dr. Kulik, welcome. No, thank you very much. I appreciate the opportunity to do this. Many, many, many years ago, I spoke with the same society live and not on Zoom and I remember a great experience. I love that initial list of Dr. Blumenthal's measures that he has and we're gonna, actually, I was noticing that some of ours that Dr. Buress and I are talking about overlap with those and are on the list. So that's good to see. There are a million measures out there. There's no question we need, from an assessment standpoint or a treatment standpoint, we really need to look at the impact of a work-related injury on emotional factors, disability factors, a whole range of other domains that clearly impact us all. That clearly impact this population. And I don't have to tell anybody in this group that many of our patients, by virtue of the system itself, sometimes are suffering greatly. And I love this quote, which I use with some of my patient lectures. I don't know if anybody can recall from early days of school who gave us this quote and it was, it basically says, life can be solitary, poor, nasty, brutish, and short. And to be honest with you, this is not, that's not the correct Hobbes on the left side. It's Thomas Hobbes on the right. And actually, although they do look kind of similar, actually, having that in the 16th century, he was commenting on the work conditions and other conditions of life-wise, quality of life-wise as the folks at that particular point in time. So there's no question that people suffer. And John has some outstanding examples that he'll relate to you in terms of a couple cases. I'll just mention one case of a young woman who's 26 years old, who had a major crush injury working in an industrial setting, ended up with a diagnosis of CRIPS and her employer essentially threatened her because she was an undocumented immigrant. She threatened with essentially turning her in and she had post-traumatic stress disorder and a number of other psychiatric comorbidities predating some of her injury. And in fact, post-dating her injury as a result of her sort of draconian care. So patients do suffer based upon our system. And I think the idea of assessing these patients is important and self-report instruments play a significant role in this. And there's a few comments I wanna make in terms of what might be important here. I think certainly from a screening standpoint, whether we call them screening or assessment tools, they need to be brief. Ideally, they should have sufficient reliability, predictive validity. They should be somewhat free of bias, although I'll comment, nothing is free of bias. It always amazes me. I saw the Minnesota Multiphasic Personality Inventory on Dr. Blumenthal's list. Just wanted to comment that I had one case where a patient did all 566 items very diligently. The only problem is after the fact, we found out that he couldn't read. So we go on with these challenges in terms of things we might sometimes miss. I'll talk a little bit about flags integration into the assessment is a critical issue because that gives us better data. And we wanna provoke a conversation with the patient, helps us gather data better. So there are disease-specific instruments. Some of these are very familiar to you folks, swestri for back pain, quickdash, hand and arm pain. And John is gonna talk a little bit about those. Roland Morris, pretty famous for back pain. HIT-6 is for headache. So we know there's disease-specific measures as well as general measures. And I'd like to argue for a shout out in a practice for using at least one general measure. Dr. Burress will be talking about the HUDAS, which is great. There's other measures that are general depression, anxiety. The PROMIS measures I'll mention briefly because they're now embedded into the e-records in a lot of settings. So we sort of divide these into both. Sort of chopping this up in terms of what we wanna assess is it can get a little confusing. We can't possibly assess everything. And I'm gonna make the argument that we should assess probably some of the more critical areas that come to us from the flags the patient brings to us. And in some cases we get narrower instruments for those because sort of doing everything for everybody kind of cuts up the pie too much and gives us bad data. So lots of scales available. My argument is please familiarize yourself with a couple of scales or several that you could familiarize yourself with and use. Possibly pick a general multiple domain scale and maybe a couple of short scales based upon a population you most likely see. Recognize the flags and there's new term probably over the last five years we've heard about. Now I'm a pain guy. So a lot of the scales I'm gonna talk about are essentially pain related because it's sort of my research bias and clinical bias. But there's some really great data on what's now called high impact pain and the flags associated with that. So we don't assess everybody but I think there's a subset of patients who are fairly severe that we could use more assessment screeners with. Certainly integrate the measures as I mentioned. Informed consent is important. And I mentioned an example of a patient who apparently couldn't read his MMPI. And some folks do not score scales and I understand that but there's some advantage to scoring the scales. And if you see an individual on two occasions or more repeated measures, even though in your cases you may just get one crack at the patient. Okay, so a few constructs that are worth discussing and these are essentially some of the flags that we wanna talk about the flags before you even perhaps think about a measure, a specific measure for a particular patient. The concept of quote symptom magnification has been thrown around. It's not essentially a construct that has much scientific validity. We like to think of somatization or somatic over concern as less judgmental. Certainly patients perceive disability. The third one, fear avoidance and pain catastrophizing. It's fascinating and it predicts to disability unquestionably. I'm just gonna argue what you'll see in a later slide that physicians themselves and other clinicians have some fear avoidance of making recommendations for patients. And we sometimes fear asking sensitive subjects with some of our patients. So we have some of that on our own as clinicians. And certainly some of the things I've just mentioned mental status, depression, anxiety, and a very important one to not ignore is substance use. Okay, just a quick word on the flags. Chris Main has gone over this. We modified some of Chris's work a few years later and much, much, much by many authors has been written on the flags. I'm just gonna focus on maybe the personal environmental, the psychosocial flags over on the right. Certainly the middle column, fear avoidance, emotional distress. These are predictors of, and particularly with pain in this case, but also with other conditions, predictors of treatment-resistant disability. And these are all the factors that you could see over here on the right. I'll talk in terms of these specific scales a little bit more about those. So who gets assessed? So should you give questionnaires to all patients? Screeners, I'm gonna argue, yes, you should. And these are not necessarily high burden questionnaires, but some like the WHO-DAS are about 15 plus minutes. Again, John will talk a little bit about that, but there are also some general screeners that all patients can get. NIDA quick screen is only four items. It's screens for substance use risk. PHQ is for depression, but I'm gonna argue that maybe even it's too short. We could use the PHQ-9 specific to depression. Relatively short, quick to score. It takes a matter of seconds. And we know with disability, depression is a significant comorbid predictive factor. So those with multiple flags should get other scales. I'll talk a little bit about the COM, which essentially is for patients already on opiates, assessing risk factors. Again, a short scale ranging from eight items to 17 items, depending upon which one you use. So one final slide on the high impact chronic pain, because again, I mentioned I was a pain guy here, and that's a big area of concern that drives disability. It's a subset of patients, not all patients. Essentially, it's very, very predictive if it persists over a period of time, generally associated with the poor outcomes, increased healthcare utilization, and certainly a return to work. It often goes along with psychiatric comorbidities and cognitive impairment comorbidities. So it's, as I said, in the last five, six years, it's a new focus of research with the argument that we should focus on the patients that are the worst challenged, as opposed to those who may need less of an assessment, less of a treatment. Now, I know there's a lot of sort of enjoyment from, if not the word enjoyment, we like to do pain questionnaires and they're great, and they give us a big picture of the patient. Now, the data on some of these is not necessarily great. I haven't looked at this in a few years, but generally the studies don't suggest that scoring these really may help us that much. There are scoring patterns, but just simply adding up the number of patients' pain sites will predict to whether you're gonna have a picture of a treatment-resistant disability. And I was telling John a little earlier, I tend to get referred to patients who have the Xs outside of the body, or with one big X right through the body. But to make a long story short, I won't talk long about pain sites. John will talk a little bit more, and I do think it's important to look at, but I don't have a specific questionnaire for you on that, that I could argue has sufficient reliability and validity. A few minor comments is a very, very important area. We could do six hours on the whole issue of stigma and work-related injury. Certainly we talked a little bit about English literacy with patients, other cultural areas are big predictors. What I'd like to do and strongly suggest on small screeners go through the patient individually with one or two items, or if they do the screener beforehand, when you're interviewing the patient, spend a little time on specific items to make sure they actually could read, understand the items, and there are no significant barriers from the standpoint of cultural factors or other factors. So we can, again, talk at great length about this. Bear in mind all patients really, all questionnaires, and the results are subject to bias. I mentioned healthcare literacy. Certainly if they have psychiatric comorbidities, which we want to assess, the questionnaires are going to be biased. Some patients do lie, and I am not going to talk about a malingering screener or a malingering questionnaire, although it's historically a really popular topic because at least in terms of pain, not much is available. There's some available that can help with malingering in terms of memory assessment, but in general, it's a problematic area to cover, and bear in mind some patients in fact do lie, but they also have a legitimate comorbid problem that they have despite the fact that they may be essentially misinforming us on certain questionnaires. So it's important to note, and this is nothing new. Depending upon who you ask, the carriers will argue it's as high as 39%. A lot of clinicians will argue it's less than 1%, probably somewhere in the middle, but again, this is nothing new. We've done a little bit of work on the history of pain medicine and malingering, and basically this work has gone on since pre-Caesar and the Roman Empire when recruits were malingering in various ways to get out of military service. What I find fascinating is one study suggests that those who are arrogant, those who believe that they can find intentional deception on the part of the patient often are considered the worst judges of detecting deception. So we need to be humble. We're not very good at that, and this particularly in terms of questionnaire assessment, there's quite a bit of data to suggest that at least questionnaire data is not a particularly good focus for this. So I'll not belabor the test. The question is never yes or no. Do they have, are they malingering or not? You cannot find that on a test, but there have been efforts to do so, which some of us find a little disturbing. We did some research about 10 years ago because we found a proliferation of reports in the literature that suggested that we can find out whether a patient was lying about their pain level by doing some fMRI work with the patient. And there were folks all around the country advertising that you could stick your patient in the scanner, in the magnet, and do an assessment on their credibility. And unfortunately, this was going on for a while. It's fortunately likely because of a Daubert challenge has been thrown out and generally is not seen anymore, but there's no shortage of efforts to try to find out what's going on with patients in terms of whether they're lying or not. Again, the caution is be careful. Another example, and since I mentioned Daubert, and I think most in this group are familiar with the Daubert criteria, it's from 1993. Judge Breyer was the person who was the champion of this, perhaps because his wife was a Boston psychologist, but he essentially rode this forward with the Daubert decision. It used to be just a decision based upon peer review and what was generally accepted. But we then now, in terms of some of these questionnaires, we've introduced science into the courtroom, and now theoretically per Daubert, they should be testable and have valid and reliable procedures backing them up. There in fact should be error rate mentioned in terms of the assessment of a patient with some of the questionnaires. And there's some wonderful, in our field, there's some wonderful, great examples of this. And this is from a paper we published some years ago. There's still an attempt to use Waddell signs to assess patients, quote unquote, malingering and other factors, which really can't be assessed by this essentially what some would argue nowadays is a silly little examination measure. There's a great report in 2002, an orthopedic surgeon argued that the patient's soft tissue injuries should have resolved over six weeks. Waddell signs were relied upon without supporting studies, addressing validity and reliability for chronic pain, challenging the validity of the test, the plaintiff referenced content directly from Waddell's writings. So they basically knocked Waddell's, the argument of Waddell signs from lingering out of the box because of Waddell's own writings. And the judge stated, as plaintiffs pointed out, clinical studies show that the signs often appear in patients with no motive towards malingering that is those not involved in anything or like a litigation setting. This is particularly true, notes Waddell, in patients with chronic pain and history of failed treatment. And they really go on, the judge nicely went on to explain the fact that this was an inappropriate use of a test. We see this with a whole range of self-report and screening tests, not just this one. And I can mention a number of other cases. So the judge found that Dr. Riederman's opinion on the causation cannot withstand Daubert scrutiny. This premised on misinterpretations of clinical studies and a scientifically insupportable methodology and a misrepresentation of Waddell signs. So I welcome some of these cases and I love to hear more about them because I think some of the questionnaires we've used inappropriately with our patients often really do not meet criteria for Daubert or any other reasonable assessment. So many scales are available. Familiarize yourself with the scales, possibly select two. And I mentioned some of these other factors here as well, score the scales and consider repeat measures. So just to repeat those statements and look at some specific scales that may be of interest. The GAD-7, PHQ-9, these are standards in the field, enormous numbers of studies in terms of reliability, validity, use with a range of populations who are disabled. Only seven items on a GAD-7 and nine on the PHQ-9. I'll talk a little bit about those. They have some significant advantages. There are others that go into some of the other categories that are really relevant for patients who are presenting with disability. Fear of movement, the tampokinesiophobia scale, very short. It's been normed on multiple populations, low back pain, neck pain, headache patients, and actually it's quite a good scale. As well as the pain catastrophizing scale, only 13 items. So these, particularly the top four, ones you want to consider, I could talk a little bit more about them as time permits. And PHQ-9, I just mentioned briefly, is a somatization scale. We've had, there's some mixed results and we've had with our group mixed feelings about the PHQ-15. We could talk a little bit about that. There are other scales that are available, but we don't have right now a great scale that sort of taps, short scale that taps into somatization. Substance use. Well, I've spent some time training dentists on how to do a NIDA quick screen, which is a four-item assessment of substance use disorder. What's really cool, and it's now, by the way, called a TAPS, that's the new version, through SAMHSA. You could put it on your cell phone and spend a relatively short amount of time with the patient asking them four straight little questions. And depending upon the response to those questions, it'll cue you to the next step to do a little bit in deeper investigation, as well as help you illustrate referral sources. So I'm, again, very bullish on a TAP. You could use it quickly in a whole range of settings. And there may be other short questionnaires. I've seen Audit C on Dr. Blumenthal's list. That's great for alcohol. The nice thing about this, it's quicker. It's a few questions. It's been heavily validated across multiple populations. So consider using it. You could also weave it into your e-record if you want. The COM, which is the Chronic Opioid Misuse Scale, is specifically for patients that are currently on opiates. It assesses risks. It's been used by the Brigham Emergency Room using this, essentially, a protocol where if a patient responds yes to a few of the correct questions, the scale itself does not have to continue. You get a positive for risk of opioid misuse. But I recommend that you use at least the 17th. There's also a 12 item questionnaire that has actually pretty robust validity, reliability. And I think it gets used quite a bit. And we can talk more about that as time permits. Next is the issue of specific scales that address disability. And we won't go into the definitions of disability. Everyone on this call really knows them, likely better than myself or a number of other folks. But there are scales that I think are short, summative, general scales that should be considered as well as scales specifically for the sort of disorder that you're assessing. PROMISE has been widely used. It is embedded into many medical e-records. So as the patient completes it, there's automatic scoring. And I'll talk a little bit more about that. In small practices, it's I think a little more complicated to use. It addresses psychosocial factors as well as perceived disability factors associated with function. It's a general scale. It's not quite as sensitive as specific scales like the NEC Disability Index. And it misses a few things, but I think there's a significant case for using the PROMISE. Joe Schwab at our orthopedic surgery department uses them with all their patients. And what's really cool is he requires that the patient and the fellow review the results of the PROMISE. And so there's a cross-communication again as part of the interview. Oswestry, well-used Roland Morris Disability with back pain. I mentioned the NEC Disability Index. And just a few words before Dr. Burrus talks on the WHODAS, World Health Organization Disability Assessment Scale. Let me get the next slide here. Okay, so this is a nice scale. We've done a little bit of research on it with normative data for a pain population. It has been translated to somewhere in a range of 30 some languages. It's used in multiple settings and it has really some face valid items here. And it's broken into six domains and they're really good. They essentially make sense when you have the patient go through them. It can be scored relatively easily and you get a disability score which has been shown to have predictive validity with regard to a whole range of external disability criteria. And it makes sense to the patient. And I think you could actually document pieces of the WHO WHODAS too in your note. And again, John will probably talk a little bit more about that. Some, just a comment on scoring. I know there are scales that are not scored by some folks. And I think that's perfectly okay under some circumstances if you refer to specific items on a scale, but I would in generally encourage scoring of the questionnaires. Promise is easy because it's embedded in a record. I mentioned the easy score on TAPS for substance use screening. The PHQ-9, the depression scale only has night items. By the way, the PHQ-9 has a couple specific critical items. The last item on the PHQ-9 addresses suicidal ideation. So regardless of the patient's score in a PHQ-9, you wanna look down on the scale and have a conversation about the last item if he or she endorses suicidal ideation. Again, a really nice screener. There are shorter ones. And then I mentioned the WHODAS and I do recommend documenting content on this. And John will talk a little bit more. So the next group is, I've already talked somewhat about the PROMIS. It's the Patient Reported Outcomes Measurement Information System. This was a nationally developed scale with federal funding. And it's used in a lot of healthcare settings at this particular point in time. And it used in occupational medicine settings as well. It's been compared to a number of other scales, neck disability index, and a number of other scales. And again, you need sort of a e-record infrastructure to do it, but I do think it's something to actually consider with your patients. The PDQ is sort of interesting. Bob Gatchell and Tom Meyer, Texas Back Institute Group, they developed this scale as part of their initial assessment and outcomes assessment for their functional restoration work early on. And they've done some wonderful work. And I understand the AMA guides reference the PDQ pretty liberally. And it's a reasonable short 15 item scale, easily scored, adequate reliability and validity. You could score in terms of mild to extreme self-reported disability. Great normative data. The only concern I had about it was the fact that since Bob Gatchell and Meyer haven't been working much on this anymore, it's not really been liberally mentioned in the literature for the last, I would say 10 years or so. So it doesn't have some of the more recent research that some of the other scales have, but it's a good scale. And it certainly makes sense. John most recently alerted me to the QuickDash, which is the short and improved version of the DASH. The DASH was a 30 item tool. They used for arm, shoulder, hand pain. They reduced it to 11. Again, good reliability and validity, easy to score. However, if you really look at it, it's not only 11 items. You have to take the extended items, work or sports if you really want it to be, I think, valuable for its use. So it's a little more than 11 items, but again, I think consideration has been compared to other scales pretty liberally. Okay, here's the PROMIS and the QuickDash being compared. The QuickDash tends to be a little more, better predictive in terms of disability endpoints, measures in contrast to the PROMIS, a little more specific in terms of hand arm as you might suspect. You know, a lot of these are short and we could get too short. And it sort of is very frustrating that we have the PHQ-2, which I think is really too short for assessment of depression. My wife worked in public health and she used to work with the short form 36 and it kept getting reduced to the short form 12 and a short form six and so on and so forth. And it gets to be a joke at some point where all we need to do basically is ask patients how they feel and do you care? And maybe that's our scale. I think we could be a little bit better than that because there are probably more factors we want to look at in terms of our patients. Okay, so a few words on transition to treatment. I know this isn't a topic for today. Archer has done some really cool work in terms of looking at various of the flags and what he does in, he's worked primarily with low back pain patients in terms of a multidisciplinary CBT and rehab program. And the argument is don't take everyone. Everyone does not need a comprehensive assessment of 15 measures. So think about flagging patients, those yellow flags ahead of time, and then maybe cherry pick the scales that make the most sense, some of which I mentioned here. Unfortunately, from an assessment standpoint and even a treatment standpoint, this is Joe Gerstein who reached some fame with some of his anti-interdisciplinary pain rehab efforts that he had undertaking. He was complaining about both clinicians and people who do assessment who throw everything in the toolbox at the patient. And I think we need to be careful with that. We could probably be selective in terms of choosing face valid and predictive questionnaires without throwing everything at the patient, but we should assess. Substance use is important to assess as well as disability. This is a quote from a orthopedic surgeon. I think John and I had met this fellow at one point in time. And in the public setting, he said to me, I would never refer a patient directly for substance use evaluation. I just send them to the pain center. They have people who can take care of it. That sort of horrified me. And I'm thinking to myself, well, no, whether you're in an occupational medicine setting or a primary care setting and so on and so forth, it behooves us to do at least a brief screen for a patient. So I mentioned something as simple as the taps to do a brief screen for patients. Other places are a little bit more diligent. The Baptist Orthopedic Group in Boston does a pretty extensive screening and risk factors, including substance use risk. In fact, they require all their patients prior to going through lumbar fusions to have a reduction in their opiates to 60 morphine dose equivalents. And in fact, the short screenings pick up these patients in addition to other screenings, pick up the high risk patients ahead of time. And lastly, I mentioned Joe Schwab in orthopedics at MGH. And he uses the PROMIS for everything. And maxillofacial surgery is using it as well now. And again, I know of a couple occupational medicine docs who are using the PROMIS as well. That one is directly embedded into your e-record. A little more complicated to embed it, but I think it provides a quick example and an opportunity to talk to a patient. But remember, if I say nothing else, I'm going to say that the best thing is, the best thing is what, sorry, I jumped slides here. The best thing, slides are moving without my permission. The best predictor of future behavior is past behavior. And a good history will probably do better than your questionnaire data. That doesn't mean questionnaire data is not necessarily as well. So a few barriers and operational changes. There is bias and stigma. I mentioned some examples of that. Certainly everyone does not have an e-scoring system that we could use like the PROMIS, but things are increasingly available. The cost is not prohibitive for most of these. We still get a lot of, as I mentioned, in the Waddell signs example, we get a lot of junk science that still goes on. There is some data that if you train a clinician in the risk factors in each of these areas, and you have clinicians be exposed to the short forms, they're more likely to use them. And most of that research is an area in substance use disorder risk assessment. And we found that as we could even train dentists to do substance use risk assessments, and they actually do it on occasion, and which is important since they historically have been one of the highest prescribers of short-acting opiates. So I think the idea of training makes sense, conferences like this make sense, and jumping into screeners that make sense to you and are short and have adequate reliability and validity are a good thing. We've done some work. Some of what goes on in terms of psych screening is not really new. In terms of disability screening, it's not really new risk screening. There were screening questionnaires that were fascinating that were developed in the 1800s, as well as concurrent treatments often for pain. And unfortunately, there was a lot of charlatanism that went on way back then, and it goes on now. John Lozier, who's a neurosurgeon, and I put this paper together almost for fun, suggesting that what is happening, at least in the pain area from an assessment and a treatment standpoint, is not a lot different from what happened in the mid 1800s. And I think we just need to be very, very careful and use the instruments that have sufficient weight with our patients. Otherwise, we have the risk of being called out and being subjective, perhaps, to being dauberted, as it's somewhat said. So last two slides. I think I have a couple of minutes left, if I'm okay. Two minutes. You know, we talk a little bit about screening patients, and I think this is certainly important, but let's not forget about the bias of the clinicians themselves. And certainly, it's easy for me to argue about orthopedic surgeons and pain physicians and so on, but I think some of the same biases likely exist in occupational medicine, and certainly in a lot of the rehab treatment areas. And I love this, because this is a study where they looked at fear avoidance attitudes among clinicians. And it's really great, because those therapists who had the worst fear avoidance scores increased certification of sick leave, advice to avoid return to work, and advice to avoid return to normal activity. And if you look at it, it ain't just the patients. It's the environment that they're in. And that is a critical issue, because the healthcare system certainly can make people more disabled and sicker. So I'm starting to be a fan of the fact that maybe we should spend more time assessing our clinicians and less assessing our patients. And in fact, we're in a process of doing that right now with some of our postgraduate dental folks to make sure they don't essentially disable folks. So anyway, so that's my sort of jaundiced perspective in terms of some of this. So conclusions, yes, pick some short, valid assessment tools, get comfortable with them. There's a lot out there, as you've seen with the prior slide before my talk started. You need to be disease-specific in some cases, pick a scale for hand or arms like the QuickDash, but really pick a general scale. And the HUDAS is good. The PROMIS is good. There are other ones out there. Consider web-based tools. Now, you don't just need an Epic to weave your tool in. TAPS is a really good example, and you could actually just use it on your phone or put it in your, somebody in your office could type it in and you actually get great recommendations, including with the TAPS, they'll actually tell you where to refer the patients. So it's a good resource. Look for flags and then decide based upon that in terms of the prevalence of those particular risk flags. Informed consent is the right word to use when we deal with patients. So we think about informed consent in a variety of ways, particularly in terms of research or engaging in some procedure with the patient. But if you're giving a patient questionnaires, they really need to know why they're getting the questionnaires. And if you want to increase adherence, have a conversation with the patient about why you're giving them these and why you're asking the questions. And whether it's the PHQ-9, and we're talking about depression or HUDAS, I like to have that, and it's not a 20-minute conversation. That's literally a 60-second conversation. And it'll increase adherence and you'll get better data. Certainly integration into the interview and examination process, Dr. Burris, we're talking more about that. And think about scoring and documentation of what you put together. And I think I've wove my way through that, and that is all I have. Thank you, Ron. Good job. Thank you. So now, Dr. Burris. Oh, okay, we're going to go. Yes. You can advance. So within the definition of disability, I point out that there's the word domain. And to me, it fits so nicely with the HUDAS in terms of looking at the patient looking at a person from the standpoint of the domains of their function. And impairment, more about the loss of abnormality or loss or abnormality of structure, physiology, or psychological function. The AMA guide, one of my challenges was to correlate or link the two. If it defines disability as the alteration in capacity to meet the demands or the regulatory statutory requirements due to impairment. But my point is, if there's three components, limitations, restrictions, and tolerance, of the three, tolerance is the most difficult to discern, yet it's often the deciding influence. And I think ignoring tolerance represents an abdication of role. Next slide, Ron. And I'm sorry, my voice is a little bit strained. So the key construct I want to convey, if I can, is to understand the determinants of tolerance allows insight into the human condition and the self-report questionnaires that Ron was kind enough to introduce me to in the context of writing a book chapter. It can really assist in that. And it can help you gain the insight that can afford opportunities. We all do evaluations under different contexts. And sometimes the requesting party doesn't allow you to comment anything off script or other than what they've asked. But sometimes you can, and I often do. For example, I had someone with unstable angina and I made concrete suggestions and the guy sent me a letter that I'd actually saved his life. That insight can afford tertiary prevention. And remember, that's to reduce the impact of existing disease by restoring function and or mitigating disease-related complications. Chronic pain, as Ron suggests, represents a frequent common path for disrupting life and job. The crux of the matter, though, is if a credible disability assessment, once done, can help that person pivot the focus towards improving their human condition. Next slide, Ron. Ron, can you advance? Great, thank you. So just in terms of process, obviously, when you're thinking about doing a disability assessment, you wanna do your record review and your preparation, identify the key questions. The interview, as Ron suggested, and there's so many people on this webinar that have done this and have great experience, but for me, activity tolerance history is very important. I try, as part of a physical exam, to me, assessing function is second nature. I studied ergonomics at Harvard, and that's kind of my background. But I actually really like pain diagrams just so it gives you a visual representation sometimes, not only of where the pain is and the character of the symptoms, but also a little bit of a window into that person's psychology. And I use these self-report questionnaires as an augmentation. I do about 100 of these disability assessments for New Hampshire, for example, and for a number of other different requesting people. And I actually use the WHO-DAS each time. And practically speaking, it's easy in that it's not proprietary, you can print it out, you give it to the worker or the applicant, and they fill it out before you get to them. And then the trick is you look at it, your own self, you read the answers, you look at them, and that helps focus additional questions that you can use during the history taking. And obviously the goal with any disability assessment is to generate a well-substantiated report that details your findings and opinions. And to my thinking, how to exceed expectations is to identify opportunities to restore that person's function and improve that person's quality of life. Next slide. So when you think about the AMA guide, and I'll talk only about the sixth edition, there's a whole section on actual mental health assessment. For the average occupational environmental medicine specialist, you're not going to be asked to do that. To my thinking, you're going to be asked to do stuff underneath musculoskeletal impairment. I want to give you a couple of examples of how that happens. I list some of these questionnaires, and I'm just going to, next slide, Ron. For example, in the spine and pelvis chapter, they use the PDQ, and I'll show you the actual table in a second. Ron mentioned that it's 15 questions and you score it. That score helps you peg where that particular examinee is. Next slide. You're using these questionnaires to build your argument for a percentage of impairment. You're developing a rationale to adjust up or down. That validated self-report questionnaire tool is part of the data being collected. Next slide. The questionnaire does not itself, with one exception, define the impairment percentage. If you read the AMA guide, it talks about how to parse out when you just completely throw out the self-report questionnaire. It really asks the examiner to think about, is this credible in this person? The potential influence of behavioral and psychosocial factors. Next slide. I want to share with you an assessment that I made. This was last summer. This was referred to me by a spine surgeon, in part because he wouldn't do it himself. The individual had what, from a surgical standpoint, is a successful outcome. She had a chance fracture when this 250-pound person fell on her and folded her in half. It gave her a fracture through the vertebral body of T12. Next slide. I used the HUDOS 2.0. This young woman was very reserved. Part of my goal was to tease out the psychological impact that this injury had on her. She was a varsity athlete and had gotten into this Ivy League school because of her sport. This was an important part of her identity. Even though she had a successful surgical outcome, she couldn't compete at her previously high level. To just give you a feel for what I was able to bring out in the interview, I said, well, why don't you just stand in the classroom because she had back pain while she was sitting in class. The woman had the presence of mind to say, no, I don't want to do that because I'll distract the other students. She was physically beautiful. I personally have never had that problem, but for her to articulate that was very interesting. The HUDOS actually brought out the burden of the excessive time on her health issues and the emotional burden on herself and family. With the entire assessment, I was able to opine nine percent whole person impairment. Interestingly, I substituted the word sport for work in the verbiage of the PDQ. I'll show you the slide in just a second. But just to give you an idea, this actually was settled and the settlement that was given to this woman was 1.4 million. I was told that the opposing counsel didn't get an opposing medical evaluation. Next slide. Just to let you know, see where it says modifier 2 and then it lists the score for the PDQ. That's how the AME guides uses the questionnaire. Next slide. Then that's actually the column where the default is nine, and I was able to argue to stay at nine and not adjust lower. Keep in mind, this woman had actually returned to her sport. Another set of eyes might say, well, she's fine, but she wasn't fine. This had a huge impact on our future as a person. Next slide. Our time is limited, but I do want to share with you just a few more thoughts about this. There is a section in the AME guides that uses a questionnaire to actually put forth amount of whole person impairment, and I listed there. This is the quick dash that Ron mentioned. If you rate someone under the AME guides, you'll be asked to use that. What I found interesting was the description of how it's used and how they want you to think about the validity of that questionnaire. I'll leave it at that. Also, inconsistent answers suggest either symptom exaggeration or problems comprehending the questionnaire. What if the person has a low English capability or they've had a traumatic brain injury? So you have to think, is this questionnaire really giving me the information I need? Okay, next slide. So I just want to spend a second on pain diagrams. I think they're simple but powerful, and it's a little bit less evidence-based and more anecdotal, but it should coincide with the verbal history and give some consistency. And on one day, I'll show you these four examples, okay, and just bear with me. Next slide, Ron. So this is the typical one. A fellow has a radiculopathy status post-surgery. He's got residual. His hood ass only had two things marked as severe, but this guy could not do his job, and I said so. I opined that he was disabled. Next slide. This is very interesting. If you notice how he's just circled things, this guy broke down in a sob during the interview, and his wife knew it was coming and looked for Kleenexes. That fellow is depressed. I said, no, no, he's not disabled. That's the worst thing on the planet that could happen to him. If you ask him when was the last time he had two weeks vacation, he said over Christmas. What did you do? I stayed in bed the whole time. What's going to happen if this guy's disabled? Not good. And just the last two slides real quick. You can see all the ink here, and, you know, there's a lot of psychological overlay. Again, in the same day, I got five minutes of a sob. Next slide. And then you see this. The woman has a brain tumor and an evolving process in the context of all these other things. Okay? Okay, next slide. So, yeah, I'm going to close with that and leave plenty of time for questions. Hi, I actually would like to lead off with the question on how are we using the word risk? Because if we're looking at a case that is an episode that has already evolved and looks a particular way, we're not describing with these instruments the risk that something might happen in the future, correct? Are we describing the risk that something exists today? Risk screening, we've had it one seminar already on risk screening, in which we kind of use the word risk to describe that something bad is going to happen. The outcome will be bad because of this. And we're talking, when we're doing evaluations, we're talking about something where the examiner is expected to explain the current situation. So are we using the risk word here to say the risk that these factors explain the current situation? I think it depends on, I would just answer that. I would argue that it depends essentially both. If you're looking at a comm, which is a brief screener for somebody who's on opiates, that questionnaire is designed to predict whether they're going to have a problematic course with opiates. And it doesn't do it perfectly, but it's an added picture of what's going to happen there. If you're looking at a PHQ-9, for example, the last item addresses suicidal ideation. And indeed, it only references current suicidal ideation, but it suggests you're looking forward in terms of risk. So I think both. Okay. I think within our specialty, we're doing a lot of risk screening. And I don't think we've been clear whether we're describing a risk for untoward developments in a case, right? This person, this will turn out poorly. But when we're doing these formal evaluations, we're doing it because it's already turned out poorly. And I'm wondering whether we're using the risks we're discovering to say, this is the likelihood that this is the reason why it looks the way it does. John, do you have any comments on that? No, not specifically. How much time do we have in the Q&A session, by the way? We have 12 more minutes. I see two questions in the list. Okay. Good, you wanna look at them? I see. Amir Wolf has asked that he thinks case law is an important factor to consider, but he would be hesitant to base his clinical decisions just on case law regarding Waddell and Daugherty. Any comments on that? Well, I would comment. I mean, I think you're right. You don't necessarily base things on case law. But I think we are obliged to use assessments that are valid and reliable given the proliferation of junk science that's out there. Yeah, my comment to that is you do the person, the examining no good service by not having a credible, well-substantiated opinion delivered in a way that others can think of it from the standpoint of your rationale and not just how many degrees you have behind your name. So yeah, I think to ignore case law is at our own peril. I know we're medical and not legal, but no, I'm not gonna cite Waddell's signs after hearing Ron talk about that. No way. Well, we did a project for the state of Washington where we did audits of 1,000 IMEs. And part of the conversation we had with the Department of LNI was what is a good IME? And their definition of a good IME is one that answers the questions and also is going to be, lays out a basis for decisions, which is gonna be credible to the reader who is gonna make decisions. And the reader is gonna be a lay reader. So we need to lay out not only our opinion, but the rationale for it in a way that is persuasive to the reader. Because the reason why you've been asked to make that evaluation is because someone else is gonna make a decision. I think that's critically important. For example, in New Hampshire retirement system, there are a group of attorneys that make the final decision called hearing examiners. My job is to create the narrative, to examine the records, to examine the worker, to go over the history and correlate the things. And I think to understand the psychological makeup of that individual and how that overlay impacts the musculoskeletal issue, if that's the case, I think that's important. I think, for example, that case that I cited where the young woman got a pretty good settlement, I think my having done that was something that was useful to the plaintiff attorney. John, in that case, you likely used the words within a reasonable degree of medical certainty, I suspect. Yeah, I use the scientific certainty. But the point I'm making with that is we may be wrong, but to not use the best tools that are available, I think puts the patient and us at peril. Let's see. There was a second question from Joseph Magnania. If I'm ruining your name, I apologize. Are there validated scales that do not directly mention pain or the patient's clinical diagnosis? In other words, that are only focused on lifestyle, behavior, et cetera. Ron? Yeah, sure. Again, I apologize for biasing the presentation. I'm a pain guy. So yes, I mean, we could have had a talk on assessment for post-concussion syndrome-like patients in the absence of pain, memory, and something else, so if I'm understanding the question correctly. The HUDOS doesn't mention pain that much. Exactly. It's not intended for pain. It talks about the domains, which was my point. The domains are what's important. And if you key off of that, you'll have, I think, a more credible report that touches on things that are actually important to the narrative of that person's disability. I think the last question is a good one. You want to go over that, Jennifer? Go ahead. Go ahead. So the question is by Marita Shapiro. Is it best to have patients complete questionnaires on their own or to go through the questions and patient's responses together during the clinical interview? Any studies comparing these approaches? Perhaps Ron knows the studies, but practically speaking, I like to have the person do the questionnaire, I look at it, and then the critical juncture, as Ron taught me some years ago, is go over the results with the worker, and I say, thank you for filling this out. I appreciate your taking the time, and now I want to go over these answers. And so that validates that person's effort, and then we can dive in, get under the hood about certain things. That's the gold standard, John. I think you're spot on. I mean, practically, even if you look at the questionnaires that are done in Epic, the PROMIS questionnaires, those are reviewed after the fact. Now that when the patient doesn't complete them, then you have a few questions to ask. Or, yeah, or if they just refuse. Exactly, yeah. And then there are even more questions to ask. Yeah, I would add, you mentioned the HUDAS to the last, the previous question. I was all, the things we talked about at PHQ-9 has nothing to do with pain, as well as the TAPs and so on and so forth. So most of those are- Real quick, any studies comparing these approaches? Any comment about that? In terms of the different questionnaires? No, in terms of how to actually use them, practically speaking. You say it's a gold standard. Is that- Most of the studies are, most of the studies that I'm familiar with are on adherence, how to get maximized results with a patient and how to maximize adherence, addressing bias and so on. So I guess I would answer yes. There's some interesting, there's an old interesting field of motivational interviewing where you weave some of these questionnaires into the right way to interview a patient and you get, you get better outcomes that are tied to questionnaires. So it's sort of beyond this, but yes, we have a paper, my colleague on, on MI motivational interviewing that kind of increases adherence. I mean, the bottom line is, not to go off script here, but 50% of patients who leave our office don't do what we told them to. And that is in the best case scenario. And there are some studies, if you add in questionnaires and you add in some motivational interviewing techniques, you could actually improve adherence. So there's some stuff, there's some stuff out there. To me, I, the reason why I think I agree that it's the gold standard that you have them complete the questionnaire on their own is one of the things you want to be able to say is I elicited the patient's own opinion. I didn't suggest or lead it, right? And so if they complete the questionnaire first and then you go deeper and get more specific on some of the questions, because actually many of the questionnaires aren't all that, like the WHO-DAS and the SF6 or whatever, they're pretty generic. My condition is preventing me from doing work. Well, then you might want to say, well, what part of your work are you having trouble with? And then now you're going deeper and getting more specific. Yeah, for, let me add, I neglected to mention this, but I actually have a paragraph in my reports that says patient perception. And then I cite either a quoted comment during the interview or, and, or some of their main, where it says severe extreme under the WHO-DAS. In this domain, they describe this. And typically that correlates with the history. I think our time is almost up. Yeah, John and I talked about this. I think we mentioned in a chapter, nothing is better in the world than patient quotes as opposed to assessment of what you think they're feeling. And we've been asked to give the site to download the TAPS again. Oh, okay, so it's on the slide there. And we could put that in the chat if I could get to it. Danielle is going to be sending out the slides to anybody, to everybody that registered for the webinar. So you'll be able to also get it there, Paul. Okay. Putting it in a chat for those. So have we overwhelmed you audience with the data and you can't think of anything to ask or was this so obvious you already knew it all? You're surprisingly quiet, ACOM Work Fitness and Disability section. There it is. I think it's kind of overwhelming to think about the number of tools that are available. And I think the way you two guys have emphasized some sort of core ones to start with, it has been really helpful. And also the way, John, that you described how using the questionnaires to make sure that the patient's perspective is represented and that you're talking about their whole life, the impact on their life and their future is also really good. And what I love is your advocacy for the patient by trying to talk about how to the patient and also in the report about what might make the situation better. It's very kind of the two of you to have been willing to speak. And I don't think we have any other questions. So let's declare success. Danielle, you wanna close us out? Thank you so much, Dr. Christian. And thank you to Dr. Burress and Dr. For joining us today. I do apologize my slide jumped ever so slightly. I just wanna remind everybody that the American Occupational Health Conference is taking place April 16th through 19th of this year in Philadelphia. Please visit acom.org, A-O-H-C for more information or to register. Again, thank you so much to our outstanding presenters today. It's always wonderful to be able to work with all of you. And thank you to all of our learners that joined us today. In order to claim your CME credit, a link will be sent out to everyone who attended live, excuse me, with the evaluation as well as the handouts and an archive link of the presentation. And once you complete the evaluation, if you've attended live, you will be able to claim your CME credits. Thank you to everyone and please stay safe. Have a great day. Thank you, bye-bye. Thank you.

Self-Reported Measures

Disability Impairment Evaluations

ACOM Work Fitness

Dr. Jennifer Christian

Dr. Ronald Kulik

Dr. John Burris

Functional Impairment

HUDAS

PROMIS

PDQ

Patient Questionnaires