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Can i  work 092911
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Can i work 092911

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  • 1. Doctor, Can I Work Despite My…. Heart Attack, Back Pain, Psychosis ???????? What Does Science Say ?? “ To all of the men and women around the world who remain productive despite significant emotional and physical pain.” Presley Reed.
  • 2. Questions ? James B. Talmage MD, Occupational Health Center, 315 N. Washington Ave, Suite 165 Cookeville, TN 38501 Phone 931-526-1604 (Fax 526-7378) [email_address] [email_address]
  • 3. The speaker is the current President of “ The premiere society for the prevention and management of disability” For more information, contact AADEP @ 1-800-456-6095 or visit our website @ www.aadep.org A Component of the SOCIETY FOR DISABILITY PREVENTION AND MANAGEMENT
  • 4. James B. Talmage MD <ul><li>Adjunct Associate Professor </li></ul><ul><li>Division of Occupational Medicine </li></ul><ul><ul><li>Department of Family and Community Medicine </li></ul></ul><ul><li>Meharry Medical College, Nashville, TN </li></ul><ul><li>Private Occupational Medicine Practice </li></ul>
  • 5. James B. Talmage MD Financial “Conflict of Interest” Disclosure <ul><li>“ Reviewer ”, AMA Guides, 5 th Edition </li></ul><ul><li>Associate Editor , the Guides Newsletter </li></ul><ul><ul><li>PAID </li></ul></ul><ul><li>Co-Editor & Co-Author , the Guides Casebook, 2 nd Edition </li></ul><ul><ul><li>PAID </li></ul></ul><ul><li>Co-Editor & Co-Author , A Physicians Guide to Return to Work </li></ul><ul><ul><li>PAID royalties </li></ul></ul><ul><li>Consultant : Guides Impairment Calculator software </li></ul><ul><ul><li>PAID </li></ul></ul>
  • 6. James B. Talmage MD Financial “Conflict of Interest” Disclosure <ul><li>Co-Author , AMA Guides, 6 th Edition </li></ul><ul><ul><li>PAID </li></ul></ul><ul><li>Member , 6 th Edition Errata Committee </li></ul><ul><ul><li>PAID </li></ul></ul><ul><li>PAID consultant : </li></ul><ul><ul><li>Impairment & Disability Products </li></ul></ul><ul><li>Author : Guides Sixth Impairment Training Workbooks: </li></ul><ul><ul><li>Spine PAID </li></ul></ul><ul><ul><li>Lower Extremity PAID </li></ul></ul><ul><ul><li>Neurology, Psychiatry, & Pain PAID </li></ul></ul>
  • 7. AMA Publications <ul><li>AMA Press: 1-800-621-8355 or </li></ul><ul><li>www.amapress.com </li></ul>
  • 8. AMA Publications
  • 9. 2011 <ul><li>2 nd Edition </li></ul><ul><li>I will receive royalties </li></ul>
  • 10. www.mdguidelines.com PAID CHAIR Musculoskeletal Advisory Committee 3 rd , 4 th , & 5 th Editions. Paid CHAIR of the Medical Advisory Board 6 th Edition.
  • 11. Paid Consultant <ul><li>Federal Motor Carrier Safety Administration </li></ul><ul><ul><li>Physician Work Group </li></ul></ul><ul><ul><li>Consultant on medical issues affecting commercial motor vehicle driver safety </li></ul></ul>
  • 12. ACOEM’s Practice Guidelines, 2 nd Edition NO ROLE
  • 13. UNPAID CHAIR: Spine Committee <ul><li>Legally presumed correct treatment for workers’ compensation utilization review in California and Nevada. </li></ul><ul><li>Low Back Chapter 2007 Update </li></ul><ul><ul><li>366 pages </li></ul></ul><ul><ul><li>1310 articles reviewed and referenced. </li></ul></ul><ul><li>Neck chapter 2011 update </li></ul><ul><ul><li>332 pages </li></ul></ul><ul><ul><li>895 articles reviewed and referenced </li></ul></ul>2007
  • 14. Other Professional Activity <ul><li>Peer Reviewer for: </li></ul><ul><ul><li>Archives of Physical Medicine & Rehabilitation </li></ul></ul><ul><ul><li>The Spine Journal </li></ul></ul><ul><ul><li>American Family Physician </li></ul></ul><ul><ul><li>Journal of Occupational & Environmental Medicine </li></ul></ul><ul><li>Editorial Advisory Board : </li></ul><ul><ul><li>The Spine Journal </li></ul></ul><ul><ul><li>Tennessee Medicine </li></ul></ul>
  • 15. <ul><li>I am an optimist. </li></ul><ul><li>Thus, </li></ul><ul><li>“ Can I Work?” </li></ul><ul><li>NOT </li></ul><ul><li>“ Am I Disabled?” </li></ul>
  • 16. “ Work” <ul><li>Etymological analysis : work means trouble, worry, or toil. </li></ul><ul><li>French “travailler” is derived from Latin “tripotium” meaning feared instrument of torture . </li></ul>
  • 17. SSA 2008 Report to Congress
  • 18. SSA 2008 Report to Congress
  • 19. 1978 to 2006 US Population change 222.5 million to 300 million = 35% increase Disability change 2,879,000 to 6,806,000 = 136% increase
  • 20. SSA 2008 Report to Congress
  • 21. SSA 2008 Report to Congress
  • 22. KEY POINT <ul><li>MEDICAL CARE is not likely to significantly impact the back pain disability problem. </li></ul><ul><li>Determinants of low back disability are primarily psychosocial , and are not affected MUCH by medical care. </li></ul>
  • 23. OLBP: Treatment <ul><li>“ Back pain gets better, because back pain gets better ; God made us that way” </li></ul><ul><li>NEJM (Oct 5, 1995), 333(14); 913-917 1555 patients, 228 practitioners of 6 types: Urban/Rural Family Practice MDs, Urban/Rural DCs (Chiropractors), Urban Orthopedists, Urban HMO MDs </li></ul>
  • 24. North Carolina Back Pain Study <ul><li>Family Practice MD, treated with medication. </li></ul><ul><li>Chiropractors, treated with manipulation. </li></ul><ul><li>Orthopedists treated with a Physical Therapy referral and a CT scan. </li></ul><ul><li>HMO MD treated with a pamphlet, </li></ul><ul><ul><li>and no return visit. </li></ul></ul><ul><li>Treatment vastly different, but recovery/results the same (Ortho/DC > $) </li></ul>
  • 25. 6 Different “Recovery Curves” For 6 Different Types of Practioners Treating Low Back Pain
  • 26. Am J Public Health 1994; 84: 190-196 Washington State Workers’ Comp experience with 28,473 claims “ Recovery Curve Has NOT changed since the 1950s when it was first published.
  • 27. Recurrence: N.C. Study Medical Care 1999; 37 (2): 157-64 <ul><li>Same study as NEJM 1995 (prior slide) </li></ul><ul><li>Recurrence of LBP : (functionally disabling) 8 - 14 % @ 3- 6 months 20 - 35 % @ 6-22 months </li></ul><ul><li>Only statistically significant difference was slight increase in recurrence in HMO group @ 6 - 22 months </li></ul><ul><li>88 % chose care from same type practitioner as original episode </li></ul><ul><li>Care seeking and satisfaction were highest in Chiropractor group </li></ul>
  • 28. Surgery Rate , Same cohort Spine 2000; 25 (1): 115-120 <ul><li>46 of 1246 patients ultimately had spine surgery </li></ul><ul><li>Rate of Surgery was not significantly related to type of practioner, (p = 0.38), despite a trend. </li></ul><ul><li>Overall 3.7 % HMO MD 1.8 % Chiropractor 2.8 % Primary Care MD 4.4 % Orthopedic Surgeon 5.2 % </li></ul><ul><li>Surgical Outcome = Moderate continuing Impairment </li></ul>
  • 29. Change from Acute to Chronic LBP Spine 2000; 25 (1): 115-120 <ul><li>Same cohort (study) as last 3 slides (N. Carolina) </li></ul><ul><li>7.7 % of original acute low back pain group developed chronic pain </li></ul><ul><li>Level of back disability was “moderately severe” </li></ul><ul><li>Type of initial care did not change incidence of chronic pain. </li></ul><ul><li>Best predictor of ultimate “chronic pain” was failure to improve in the first one month. </li></ul>
  • 30. Effect of Medical Treatment on Low Back Disability Spine 2000; 25 (23): 3055-64 <ul><li>Prospective study by International Social Security Association . </li></ul><ul><li>2080 subjects, all “sick-listed” for low back pain for > 90 Days, from 6 different countries: Denmark, Germany, Israel, Netherlands, Sweden, United States (N. Jersey and California) </li></ul><ul><li>Interviewed @ baseline and @ 1 & 2 years later. </li></ul><ul><li>Multiple validated scales used to measure outcome. </li></ul>
  • 31. Effect of Medical Treatment on Low Back Disability Spine 2000; 25 (23): 3055-64 <ul><li>Medical treatments that DID NOT influence the “return to work” rate, or back function, or pain: Visits to physicians (G.P., Company MD, or Specialist), visits to physiotherapists, Hospitalization, Bed Rest, Heat and Cold, TENS, Ultrasound, Acupuncture, Massage, Manipulation and Traction, Zone therapy, Medical Baths, Exercise (strength, fitness, aerobics), Analgesics, Pain-relieving Injections, Braces, Walking Aids and Supports, </li></ul>
  • 32. Effect of Medical Treatment on Low Back Disability Spine 2000; 25 (23): 3055-64 <ul><li>Surgery: Only effective treatment </li></ul><ul><li>Sweden had the lowest rate of back surgery @ 6 % (almost all were discectomy), and surgery was associated with improved pain, function, and return to work. </li></ul><ul><li>Surgery rate was 3 times higher in the Netherlands and 5 times in the US. Surgery in those countries relieved pain, but was NOT associated with improved function, health perception, or with increased “return to work rate”. </li></ul>
  • 33.
  • 34. 1926 Article 19 2 6 is NOT a typo
  • 35. JBJS 1926 ; 8: 137-170 <ul><li>“Physicians in general are too quick to make a diagnosis and then look for corroborative findings…” page 137 </li></ul><ul><li>“ Lawyers and judges appear to have a pretty generally formed opinion that a doctor’s statement concerning disability of the lower back is largely a matter of guesswork.” p 138 </li></ul>
  • 36. Joe Jim Talmage MD
  • 37. “What is Joe’s…” <ul><li>Pulse Rate ? </li></ul><ul><li>Blood Pressure ? </li></ul><ul><li>Weight ? </li></ul><ul><li>Measurable, with fairly good scientific precision </li></ul><ul><li>Functional Capacity ? </li></ul><ul><li>Chance of re-injury if “Joe” returns to heavy labor ? </li></ul><ul><li>Measurable ? </li></ul><ul><li>Predictable ? </li></ul>
  • 38. Requesting Source Assumes that Physicians Can Answer those Questions Scientifically <ul><li>We can replace a hip </li></ul><ul><li>We can insert an artificial disc (fusion cage) </li></ul><ul><li>We have developed Prozac (fluoxetine) </li></ul><ul><li>Therefore: “Doctors must know scientifically how to answer questions about work capacity” -John Q. Public </li></ul><ul><li>Send the doctor a form asking “What can Joe do?” </li></ul>
  • 39. BOTH Patients and employers want “ Notes from the Doctor”
  • 40. The “dreaded” form: What can Joe do ?? 9 % of all primary care visits require an opinion from the MD on work ability. - J Rainville, et al; The Physician as disability advisor for patients with musculoskeletal complaints. Spine 2005; 30 (22): 2579-2584
  • 41. How many hours/day can he lift, sit, stand, walk, climb, kneel, bend, twist, pull, push, simple grasp, fine manipulation, reach above shoulder, drive a vehicle, operate machinery, temperature extremes, high humidity, fumes, noise, OTHER
  • 42. http:// www.myexcusedabsence.com / Accessed November 01, 2007
  • 43. www.myexcusedabsence.com www.junkbrosnews.com/Docnote.htm
  • 44.
  • 45.
  • 46. Return to work formula My Fantasy: “To sit at the feet of Dr. Einstein and learn the formula for filling out Return to Work forms”
  • 47. Joe Requesting Source Treating or IME DOC
  • 48. 3 Major Considerations: Terms to Understand <ul><li>Risk </li></ul><ul><li>Capacity </li></ul><ul><li>Tolerance </li></ul><ul><li>But First Why is Work Important ? </li></ul>
  • 49. Work Improves Life Expectancy
  • 50. Canadian Medical Association Policy Summary <ul><li>“The Physician’s Role in Helping Patients Return to Work After Illness or Injury” </li></ul><ul><li>CMAJ 1997; 156 (5): 680A-F </li></ul><ul><li>“ Prolonged absence from one’s normal roles, including absence from the workplace, is detrimental to a person’s mental, physical, and social well being . Physicians should therefore encourage a patient’s return to function and work as soon as possible …”: </li></ul>
  • 51. 2000 Ontario, Canada Workplace Safety and Insurance Board (WSIB) <ul><li>“ Prolonged absence from one’s normal role is detrimental to physical, mental, and social well being. Long term umemployment post-injury is itself a health problem.” </li></ul><ul><ul><li>Injury/Illness and Return to Work/Function: A Practical Guide for Physicians. </li></ul></ul><ul><ul><ul><li>http://www.wsib.on.ca/wsib/wsibsite.nsf/LookupFiles/DownloadableFilePhysiciansRTWGuide/$File/RTWGP.pdf </li></ul></ul></ul>
  • 52. AAOS Position Statement September 2000 <ul><li>AAOS supports safe, early RTW …help(s) improve performance, regain functionality, and enhance quality of life . </li></ul><ul><li>As patient advocates, … early RTW … benefits …including prevention of deconditioning and psychological sequels of prolonged time off work. </li></ul><ul><li>AAOS believes that safe, early RTW programs are in the best interest of patients . …improves quality of life for the injured worker. </li></ul>
  • 53.
  • 54. AMA Policy and Directives 2004 Adopted June 2004 <ul><li>The AMA encourages physicians everywhere to advise their patients to return to work at the earliest date compatible with health and safety and recognizes that physicians can, through their care, facilitate patients’ return to work. (Policy) </li></ul><ul><li>http://www.ama-assn.org/ama/pub/article/print/2036-8668.html assessed 06/26/04 </li></ul>
  • 55. August 2004 UK Department of Work and Pensions <ul><li>“ As a certifying doctor you will need to consider and manage your patient’s expectations in relation to their ability to continue working . In summary, you should always bear in mind that a patient may not be well served in the longer term by medical advice to refrain from work, if more appropriate clinical management would allow them to stay in work or return to work.” </li></ul><ul><ul><li>Reference on the next slide </li></ul></ul>
  • 56. Reference for preceding slide’s quote <ul><li>Medical evidence for Statutory Sick Pay. Statutory Maternity Pay and Social Security Incapacity Benefit purposes. A Guide for Registered Medical Practitioners. </li></ul><ul><ul><li>http://www.dwp.gov.uk/medical/medicalib204/ib204-june04/ib204.pdf </li></ul></ul>
  • 57. 2005 UK: Next Two slides <ul><li>The Health and Work Handbook </li></ul><ul><ul><li>Patient Care and Occupational Health: a Partnership Guide for Primary Care and Occupational Health Teams . </li></ul></ul><ul><ul><li>http:// www.facoccmed.ac.uk/library/docs/conf_haw.pdf </li></ul></ul><ul><li>Joint statement by : </li></ul><ul><ul><li>Faculty of Occupational Medicine </li></ul></ul><ul><ul><li>Royal College of General Practitioners </li></ul></ul><ul><ul><li>Society of Occupational Medicine </li></ul></ul>
  • 58. UK 2005: “Worklessness” <ul><li>“ ‘ Worklessness’ (being unemployed or economically inactive and in receipt of working age benefits) causes poor health and health inequality, and this effect is still seen after adjustment for social class, poverty, age, and pre-existing morbidity.” </li></ul><ul><ul><li>“ People who are out of work experience poorer mental health …” </li></ul></ul><ul><ul><li>“ Anxiety and depression are two to three times more common …” </li></ul></ul><ul><ul><li>“ Being out of work can lead to increased smoking, consumption of alcohol, use of illicit drugs, and risk taking sexual behavior.” </li></ul></ul><ul><ul><li>“… worklessness leads to increased mortality rates .” </li></ul></ul>
  • 59. UK 2005: “Worklessness” <ul><li>“ The negative effects of unemployment are reversible on re-entry to work .” </li></ul>Key Point
  • 60. 2008 Revision
  • 61. Waddell and Burton <ul><li>Free download of pdf of 257 page book </li></ul><ul><li>http://www.workingforhealth.gov.uk/documents/is-work-good-for-you.pdf </li></ul>
  • 62. False Perceptions Are Common
  • 63. Work Improves Life Expectancy
  • 64. Unemployment and Mortality <ul><li>CMAJ 1995; 153 (5): 529-540 </li></ul><ul><li>Jin et al, The impact of unemployment on health: a review of the evidence. </li></ul><ul><ul><li>Review article </li></ul></ul><ul><ul><li>46 original studies </li></ul></ul><ul><ul><li>Most aggregate-level studies and large, census based cohort studies report positive association between unemployment and overall mortality , suicide, and cardiovascular disease. </li></ul></ul><ul><ul><li>Workers laid off because of factory closure have more symptoms and illnesses. </li></ul></ul><ul><li>Conclusion : “Evaluated on an epidemiologic basis, the evidence suggests a strong, positive association between unemployment and many adverse health outcomes. </li></ul>
  • 65. “Is Unemployment Pathogenic?” <ul><li>Int J Health Serv 1996: 26 (3): 569-589 </li></ul><ul><ul><li>Review article : Shortt, Is unemployment pathogenic? A review of current concepts with lessons for policy planners </li></ul></ul><ul><ul><li>“ The most common disorders documented are emotional and cardiopulmonary disease .” </li></ul></ul><ul><li>Med J Aust 1998; 168 (4): 178-182 </li></ul><ul><ul><li>Mathers and Schofield, The health consequences of unemployment: the evidence. </li></ul></ul><ul><ul><li>Review article </li></ul></ul><ul><ul><li>“… longitudinal studies with a range of designs provide reasonably good evidence that unemployment itself is detrimental to health and has an impact on health outcomes – increasing mortality rates, causing physical and mental ill-health , and greater use of health services.” </li></ul></ul>
  • 66. P.T. Martikainen: Unemployment and Mortality among Finnish men, 1981-1985 BMJ 1990; 301 (sep): 407-411 <ul><li>9810 deaths among 2.7 million person-years . </li></ul><ul><li>Controlled for background variables affecting mortality. </li></ul><ul><li>Total Mortality : </li></ul><ul><ul><li>unemployed have a relative risk (RR) of 1.93 (95% CI = 1.82-2.05) </li></ul></ul><ul><li>Accidental and violent death : </li></ul><ul><ul><li>RR 2.51 (2.28-2.76) </li></ul></ul><ul><li>Circulatory Diseases : </li></ul><ul><ul><li>RR 1.54 (1.40-1.70) </li></ul></ul>
  • 67. P.T. Martikainen: Unemployment and Mortality among Finnish men, 1981-1985 BMJ 1990; 301 (sep): 407-411 <ul><li>“ Effects of unemployment on mortality were more pronounced with increasing duration of unemployment.” </li></ul><ul><li>“ Conclusion : The relative excess mortality of unemployed men in Finland cannot be explained by demographic, social, and health variables preceding unemployment. Unemployment therefore seems to have an independent causal effect on male mortality.” </li></ul>
  • 68. BMJ 1994;308:1135-1139 (30 April) <ul><li>Objective : To assess effect of unemployment and early retirement on mortality in a group of middle aged British men. </li></ul><ul><li>Design : Prospective cohort study (British Regional Heart Study). Five years after initial screening, information on employment experience was obtained with a postal questionnaire. </li></ul><ul><li>Setting : One general practice in each of 24 towns in Britain. </li></ul><ul><li>Subjects : 6191 men aged 40-59 who had been continuously employed for at least five years before initial screening in 1978-80: 1779 experienced some unemployment or retired during the five years after screening, and 4412 remained continuously employed. </li></ul><ul><li>Main outcome measure : Mortality during 5.5 years after postal questionnaire. </li></ul><ul><li>Results : Men who experienced unemployment in the five years after initial screening were twice as likely to die during the following 5.5 years as men who remained continuously employed (relative risk 2.13 (95% confidence interval 1.71 to 2.65). </li></ul>
  • 69. BMJ 1994;308:1135-1139 (30 April) <ul><li>After adjustment for socioeconomic variables (town and social class), health related behaviour (smoking, alcohol consumption, and body weight), and health indicators (recall of doctor diagnoses) that had been assessed at initial screening the relative risk was slightly reduced, to 1.95 (1.57 to 2.43). </li></ul><ul><li>Even men who retired early for reasons other than illness and who appeared to be relatively advantaged and healthy had a significantly increased risk of mortality compared with men who remained continuously employed (relative risk 1.87 (1.35 to 2.60)). </li></ul><ul><li>The increased risk of mortality from cancer was similar to that of mortality from cardiovascular disease (adjusted relative risk 2.07 and 2.13 respectively). </li></ul><ul><li>Conclusions: In this group of stably employed middle aged men loss of employment was associated with an increased risk of mortality even after adjustment for background variables, suggesting a causal effect . The effect was nonspecific, however, with the increased mortality involving both cancer and cardiovascular disease. </li></ul>
  • 70. “Is Unemployment Pathogenic?” <ul><li>Scand J Prim Health Care 1996; 14 (2): 79-85 </li></ul><ul><ul><li>Sundquist et al, Underprivileged area score, ethnicity, social factors, and general mortality in health district authorities in England and Wales. </li></ul></ul><ul><ul><li>Sex standardized mortality ratios computed for all 192 health districts in England and Wales . </li></ul></ul><ul><ul><li>“… social deprivation, UNEMPLOYMENT , and overcrowding were related to mortality …” </li></ul></ul>
  • 71. Martikainen & Valkonen: Excess mortality of unemployed men and women during a period or rapidly increasing unemployment. Lancet 1996; 348: 909-912 <ul><li>2.5 million people age 25-59 at 1990 census, data from employment roles from 1987-1992. </li></ul><ul><li>Mortality in Finland during 1991-1993 </li></ul><ul><li>Unemployed had increased mortality ratio : </li></ul><ul><ul><li>During low unemployment 2.11 </li></ul></ul><ul><ul><ul><li>(95% CI = 1.76-2.53) </li></ul></ul></ul><ul><ul><li>During high unemployment </li></ul></ul><ul><ul><ul><li>Men 1.35 (1.16-1.56) </li></ul></ul></ul><ul><ul><ul><li>Women 1.30 (0.97-1.75) </li></ul></ul></ul>
  • 72. Unemployment and Specific Diseases <ul><li>IARC Sci Publ 1997; 343-351 </li></ul><ul><ul><li>Lynge, Unemployment and Cancer: a literature review. </li></ul></ul><ul><ul><li>Danish Cancer Society review </li></ul></ul><ul><ul><li>“ Unemployed men have an excess cancer mortality of close to 25 % compared with that of all men in the labour force.” </li></ul></ul><ul><ul><li>“ The available data from various countries indicate that this excess risk is found both in periods when the unemployment rate is about 1% and when it is about 10 %.” </li></ul></ul><ul><ul><li>“ Furthermore , it persists long after the start of unemployment and it does not disappear when social class, smoking, alcohol intake, and previous sick days are controlled for .” </li></ul></ul>
  • 73. Unemployment and Specific Diseases <ul><li>Scand J Work Environ Health 1997; 23 (supplement 3): 79-83 </li></ul><ul><ul><li>Janlert. Unemployment as a disease and diseases of the unemployed. </li></ul></ul><ul><ul><li>Swedish review: Dept of Epidemiology and Public Health, Ume å University, Sweden </li></ul></ul><ul><ul><li>“ There is a causal link between unemployment and the deterioration in health status…” </li></ul></ul><ul><ul><li>“ Losing, or gaining, employment has clear effects on psychiatric symptoms and on well being. The death rate is increased among unemployed persons.” </li></ul></ul>
  • 74. Unemployment and Specific Diseases <ul><ul><li>Acta Physiol Scand Suppl 1997; 640: 149-152 </li></ul></ul><ul><ul><ul><li>Brenner. Heart disease mortality and economic changes: including unemployment; in West Germany 1951-1989 </li></ul></ul></ul><ul><ul><ul><li>Cardiovascular mortality rates in the United States, United Kingdom, and Scandinavian countries influenced by economic indicators, including unemployment . </li></ul></ul></ul><ul><ul><ul><li>“… similar tests were undertaken using Western German heart disease mortality rate data over 1951-1989. Time-series regression analysis showed that, holding constant the effects of tobacco, animal fats and alcohol, increased income and social welfare expenditures are related to heart disease mortality rate declines, whereas increased unemployment and business failure rates are related to heart disease mortality rate increases over more than a decade.” </li></ul></ul></ul>
  • 75. Unemployment and Suicide <ul><li>J Stud Alcohol 1998; 59 (4): 455-461 </li></ul><ul><ul><li>Caces and Harford. Time series analysis of alcohol consumption and suicide mortality in the United States, 1934-1987 </li></ul></ul><ul><li>Conclusions : “… unemployment was significantly related to suicide and was shown to confound the relationship between alcohol and suicide.” </li></ul>
  • 76. Unemployment and Premature Mortality <ul><li>Am J Public Health 1999; 89 (6): 893-898 </li></ul><ul><ul><li>Mansfield, et al. Premature mortality in the United States : the roles of geographic area, socioeconomic status, household type, and availability of medical care. </li></ul></ul><ul><li>Multiple regression analysis : premature mortality predicted by </li></ul><ul><ul><li>Female headed households </li></ul></ul><ul><ul><li>Black race </li></ul></ul><ul><ul><li>Low education </li></ul></ul><ul><ul><li>American Indian race </li></ul></ul><ul><ul><li>Chronic unemployment </li></ul></ul>
  • 77. “Is Unemployment Pathogenic?” <ul><li>Occup Environ Med 2001; 58 (1): 52-57 </li></ul><ul><ul><li>Nylen, et al Mortality among women and men relative to unemployment, part-time work, overtime work, and extra work: a study based on data from the Swedish twin registry. </li></ul></ul><ul><ul><li>Swedish Twin Registry , births 1926 - 1958 </li></ul></ul><ul><ul><li>9500 women & 11,132 men </li></ul></ul><ul><ul><li>Unemployment in 1973 associated with mortality </li></ul></ul><ul><ul><li>RR 1.98 (1.16-3.38) women, 1.43 (0.91-2.25) men </li></ul></ul><ul><ul><li>“ Conclusion : Unemployment and some time aspects of work were associated with subsequent mortality , even when controlling for social, behavioral, work, and health related factors. The idea that losing a job may have less importance for women than men is not supported by this study. </li></ul></ul>
  • 78. “Is Unemployment Pathogenic?” <ul><li>Scan J Public Health 2002; 30 (3): 216-222 </li></ul><ul><ul><li>Quaade, et al. Mortality in relation to early retirement in Denmark: a population-based study. </li></ul></ul><ul><ul><li>Compared “early” retirees vs. disability retirees </li></ul></ul><ul><ul><li>Standardized mortality ratios </li></ul></ul><ul><ul><ul><li>Employed 0.59 men 0.51 women </li></ul></ul></ul><ul><ul><ul><li>Disability retirement 2.31 men 1.66 women </li></ul></ul></ul><ul><ul><ul><li>“ Early” retirement 0.88 men 0.72 women </li></ul></ul></ul><ul><ul><li>“… the increasing mortality of the early retirement recipients is consistent with an adverse effect on health of retirement itself…” </li></ul></ul><ul><ul><li>Mortality during 1987-1996 of the entire population of Denmark, in folks born 1926-1936 who were alive in 1986. </li></ul></ul>
  • 79. “Is Unemployment Pathogenic?” <ul><li>J Health Economics 2003; 22 (3): 505-518 </li></ul><ul><ul><li>Gerdtham & Johannesson. A note on the effect of unemployment on mortality. </li></ul></ul><ul><ul><li>10-17 year follow up of 30,000 Swedes age 20-64 </li></ul></ul><ul><ul><li>Matched employed with unemployed </li></ul></ul><ul><ul><li>Unemployment increases risk of death by 50 % </li></ul></ul><ul><ul><ul><li>Employed = 5.36 % died, vs. 7.83 % in unemployed </li></ul></ul></ul><ul><ul><li>Unemployment increases death from suicide and “other diseases” </li></ul></ul><ul><ul><li>No increased rate of death from cancer, cardiovascular disease, or trauma </li></ul></ul>
  • 80. Unemployment and Vascular Disease <ul><li>Am J Ind Med 2004; 45: 408-416 </li></ul><ul><ul><li>Gallo, et al. Involuntary job loss as a risk factor for subsequent myocardial infarction and stroke: Findings from the Health and Retirement Survey. </li></ul></ul><ul><ul><li>Compared 457 workers with involuntary job loss to 3763 employed control workers in the USA. </li></ul></ul><ul><ul><li>Risk of Myocardial infarction almost significant </li></ul></ul><ul><ul><ul><li>1.89 ( 95% CI = 0.91-3.93) </li></ul></ul></ul><ul><ul><li>Risk of Stroke significantly increased </li></ul></ul><ul><ul><ul><li>2.64 (95% CI = 1.01-6.94) </li></ul></ul></ul><ul><li>Conclusions : “… involuntary job loss should be considered as a plausible risk factor for subsequent cardiovascular and cerebrovascular illness among older workers.” </li></ul>
  • 81. J Epidemiol Community Health 2004;58:501–506. <ul><li>Objectives: To assess the relation of the incidence of, and recovery from, limiting illness to employment status, occupational social class, and income over time in an initially healthy sample of working age men and women. </li></ul><ul><li>Methods: Cox proportional hazards models. </li></ul><ul><li>Results: There were large differences in the risk of limiting illness according to occupational social class, with men and women in the least favourable employment conditions nearly four times more likely to become ill than those in the most favourable. Unemployment and economic inactivity also had a powerful effect on illness incidence. Limiting illness was not a permanent state for most participants in the study. </li></ul><ul><li>Employment status was also related to recovery. </li></ul><ul><li>Conclusions: Having secure employment in favourable working conditions greatly reduces the risk of healthy people developing limiting illness . Secure employment increases the likelihood of recovery. These findings have considerable implications for both health inequality and economic policies. </li></ul>
  • 82. Age at Retirement and Mortality <ul><li>Tsai et al. Age at retirement and long term survival of an individual industrial population: prospective cohort study. British Medical Journal 2005; 331: 995-997 </li></ul><ul><li>Study of Shell Oil 3668 employees in Texas 1973-2003 </li></ul><ul><li>Mortality of employees who retired at 55 was greater than those who retired at 65 </li></ul><ul><ul><li>( RR = 1.37 , 95% CI = 1.09-1.73). </li></ul></ul><ul><li>Mortality of those who retired at 55 , who were still alive at 65 , was still increased: </li></ul><ul><ul><li>RR = 1.89 (95% CI = 1.58-2.27) </li></ul></ul><ul><ul><li>Attempt to control for early retirement due to “bad disease” </li></ul></ul><ul><ul><li>Assumes “bad disease” at age 55 would produce mortality by age 65 </li></ul></ul>
  • 83. BMC Public Health 2006; 6: 103 doi:10.1186/1471-2458-6-103 <ul><li>Methods : Data from five longitudinal cohort studies in Sweden, including 6,887 men and women less than 65 years old at baseline were linked to disability pension data, hospital admission data, and mortality data from 1971 until 2001. Mortality odds ratios were analyzed with Poisson regression and Cox's proportional hazards regression models. </li></ul>This article is available from: http://www.biomedcentral.com/1471-2458/6/103
  • 84. BMC Public Health 2006, 6:103 doi:10.1186/1471-2458-6-103 <ul><li>Results: 1,683 (24.4%) subjects had a disability pension at baseline or received one during follow up . 525 (7.6%) subjects died during follow up. The subjects on disability pension had a higher mortality rate than the non-retired, the hazards ratio (HR) being 2.78 (95%CI 2.08–3.71) among women and 3.43 (95%CI 2.61–4.51) among men . HR was highest among individuals granted a disability pension at young ages (HR >7), and declined parallel to age at which the disability pension was granted. </li></ul><ul><li>The higher mortality rate among the retired subjects was not explained by disability pension cause or underlying disease or differences in age, marital status, educational level, smoking habits or drug abuse. There was no significant association between reason for disability pension and cause of death. </li></ul>This article is available from: http://www.biomedcentral.com/1471-2458/6/103
  • 85. BMC Public Health 2006, 6:103 doi:10.1186/1471-2458-6-103 <ul><li>Conclusion: Subjects with a disability pension had increased mortality rates as compared with non-retired subjects, only modestly affected by adjustments for psycho-socio-economic factors, underlying disease, etcetera. It is unlikely that these factors were the causes of the unfavorable outcome. </li></ul><ul><li>Other factors must be at work. </li></ul><ul><li>[Could it be that unemployment is itself a toxin?] </li></ul>This article is available from: http://www.biomedcentral.com/1471-2458/6/103
  • 86. Bamia, et al. Age at Retirement and Mortality in a General Population Sample. Am J Epidem 2008; 167 (5): 561-569 <ul><li>The Greek EPIC Study. </li></ul><ul><li>Greek segment of European Investigation into Cancer and Nutrition. </li></ul><ul><li>16,827 adults , enrolled 1994 - 1999. </li></ul><ul><ul><li>Assessed in 2006 </li></ul></ul><ul><ul><li>Cox regression models to control confounders </li></ul></ul><ul><li>NO prior history of stroke, cancer, coronary heart disease, or diabetes. </li></ul>
  • 87. Bamia, et al. Age at Retirement and Mortality in a General Population Sample. Am J Epidem 2008; 167 (5): 561-569 <ul><li>Retirees had a 51% increase in all cause mortality (95% CI = 16 to 98). </li></ul><ul><li>A 5 year delay in retirement was associated with a 10% decrease in mortality (95% CI=4 to 15). </li></ul><ul><li>Major increase in cardiovascular mortality, lesser increase in cancer mortality, and no increase in trauma mortality. </li></ul>
  • 88. 2009 Rand Study <ul><li>http://www.rand.org/content/dam/rand/pubs/working_papers/2009/RAND_WR711.pdf </li></ul><ul><li>Mental Retirement Susann Rohwedder RAND and NETSPAR Robert J. Willis University of Michigan </li></ul>
  • 89. 2009 Rand Study <ul><li>Some studies suggest that people can maintain their cognitive abilities through “mental exercise.” This has not been unequivocally proven. Retirement is associated with a large change in a person’s daily routine and environment. In this paper, we propose two mechanisms how retirement may lead to cognitive decline . For many people retirement leads to a less stimulating daily environment. In addition, the prospect of retirement reduces the incentive to engage in mentally stimulating activities on the job. We investigate the effect of retirement on cognition empirically using cross-nationally comparable surveys of older persons in the United States, England, and 11 European countries in 2004. We find that early retirement has a significant negative impact on the cognitive ability of people in their early 60s that is both quantitatively important and causal . Identification is achieved using national pension policies as instruments for endogenous retirement. </li></ul>
  • 90.  
  • 91.  
  • 92. Realizing the Health Benefit of Work: A Position Statement <ul><li>As physicians, we see firsthand the personal tragedies that long term work absence, unemployment and work disability wreak on individuals, families and communities. </li></ul>2010
  • 93. Realizing the Health Benefit of Work: A Position Statement <ul><li>We see marriages end , capable individuals excluded from employment, breadwinners become reliant on pensions , and mental health problems like anxiety and depression develop . </li></ul>http://www.racp.edu.au/page/ policy-and-advocacy/ occupational-and- environmental-medicine
  • 94. <ul><li>In Australia and New Zealand the available evidence suggests that the message that ‘work is generally good for health’ has not yet achieved widespread acceptance. </li></ul><ul><li>Instead, we see : </li></ul><ul><ul><li>A decline in durable return to work rates following illness or injury; </li></ul></ul><ul><ul><li>Increases in requests for sickness certificates and disability support pensions driven by people with common, treatable health problems being permanently certified as unfit for work; </li></ul></ul>
  • 95. Realizing the Health Benefit of Work: A Position Statement <ul><li>Rubbing salt in the wound, extended time off work often sees a worsening rather than an improvement in symptoms and conditions it is supposed to ameliorate. </li></ul>
  • 96. AFOEM 2010 <ul><li>The evidence is compelling: for most individuals, working improves general health and wellbeing and reduces psychological distress. </li></ul><ul><li>Even health problems that are frequently attributed to work —for example, musculoskeletal and mental health conditions—have been shown to benefit from activity-based rehabilitation and an early return to suitable work. </li></ul>
  • 97. AFOEM 2010 <ul><li>Waddell and Burton’s review and other studies show that the influence of unemployment extends to the children of those not working. </li></ul>
  • 98. AFOEM 2010 <ul><li>Research into the impact of parental unemployment on children has found: </li></ul><ul><ul><li>A higher likelihood of chronic illnesses , psychosomatic symptoms and lower wellbeing for children in families where neither parent has worked in the previous six months; 40 </li></ul></ul><ul><ul><li>Children living in households where the parents are not working are more likely in the future to be out of work themselves , either for periods of time or over their entire life; and </li></ul></ul>
  • 99. AFOEM 2010 <ul><li>Research into the impact of parental unemployment on children has found: </li></ul><ul><ul><li>Psychological distress may occur in children whose parents face increased economic pressure, sometimes resulting in withdrawal, anxiety and depression in the children or aggressive or delinquent behaviour and substance abuse . 41, 42 </li></ul></ul>
  • 100. Roelfs et al. Losing life and livelihood: A systematic review and meta-analysis of unemployment and all-cause mortality. Social Science & Medicine 2011:72; 840-854 <ul><li>The study is a random effects meta-analysis and meta-regression designed to assess the association between unemployment and all cause mortality among working-age persons. </li></ul><ul><li>We extracted 235 mortality risk estimates from 42 studies , providing data on more than 20 million persons . </li></ul>
  • 101. Roelfs et al. Social Science & Medicine 2011:72; 840-854 <ul><li>The mean hazard ratio (HR) for mortality was 1.63 among HRs adjusted for age and additional covariates. </li></ul><ul><li>The mean effect was higher for men than for women. </li></ul><ul><li>Unemployment was associated with an increased mortality risk for those in their early and middle careers , but less for those in their late career. </li></ul>
  • 102. Roelfs et al. Social Science & Medicine 2011:72; 840-854 <ul><li>The risk of death was highest during the first 10 years of follow-up , but decreased subsequently. </li></ul><ul><li>The mean Hazard Ratio was 24% lower among the subset of studies controlling for health-related behaviors . </li></ul><ul><li>Public health initiatives could target unemployed persons for more aggressive cardiovascular screening and interventions aimed at reducing risk-taking behaviors. </li></ul>
  • 103. Social Science & Medicine 2011:72; 840-854
  • 104. Social Science & Medicine 2011:72; 840-854
  • 105. Social Science & Medicine 2011:72; 840-854
  • 106. Mortality in Perspective <ul><li>Jacobs DR, Adachi H, Mulder I, et al Cigarette Smoking and Mortality Risk: Twenty-five–Year Follow-up of the Seven Countries Study Arch Intern Med. 1999;159:733-740 </li></ul>Person Smoking Unemployment Men < 40 1.95 Men 40-50 1.86 Smoke > 10 cig/day 1.8 Women < 40 1.73 Women 40-50 1.34 Smoke < 10 cig/day 1.3
  • 107. Semi-Retirement, or “Bridge” Employment <ul><li>Zhan Y, et al. Bridge Employment and Retirees’ Health: A Longitudinal Investigation. Journal of Occupational Health Psychology 2009; 14 (4): 374–389 </li></ul><ul><li>Hierarchical regression analyses showed that compared with full retirement, engaging in bridge employment either in a career field or in a different field was associated with fewer major diseases and functional limitations , … better mental health. </li></ul>
  • 108. Some Jobs Are NOT Fun
  • 109. Aphorisms <ul><li>“ Love and work are the two things that give life meaning and purpose.” </li></ul><ul><ul><li>Sigmund Freud </li></ul></ul><ul><ul><li>Actually, there are three, but Freud was an atheist, so he missed THE BIG ONE. </li></ul></ul><ul><li>“No other technique for the conduct of life attaches the individual so firmly to reality as laying emphasis on work; for his work at least gives him a secure place in a portion of reality , in the human community.” </li></ul><ul><ul><li>Sigmund Freud </li></ul></ul>
  • 110. Partnership for Workplace Mental Health, a Program of the American Psychiatric Foundation <ul><li>Work is central to a person’s identity and social role. It provides income, but more than that, it is often an important source of self-esteem. </li></ul><ul><li>For many people, lack of work equates with lack of meaning. Thus, loss of work capacity is a life crisis, one that demands an immediate and focused response. </li></ul>http:// www.workplacementalhealth.org/employer_resources / disabilityresources.aspx
  • 111. http://www.workplacementalhealth.org/employer_resources/disabilityresources.aspx
  • 112. Aphorisms <ul><li>“ Employment is nature’s physician, and is essential to human happiness.” </li></ul><ul><ul><li>Galen ( 130-203 AD) </li></ul></ul><ul><li>“ Without work all life goes rotten .” </li></ul><ul><ul><li>Albert Camus (1913-1960 AD) </li></ul></ul><ul><li>“ An unemployed existence is a worse negation of life than death itself . Because to live means to have something definite to do – a mission to fulfill – and in the measure in which we avoid setting our life to something, we make it empty … Human life , by its very nature, has to be dedicated to something .” </li></ul><ul><ul><li>Jos è Ortega y Gasset (1883-1956 AD) </li></ul></ul>
  • 113. Happiness: It’s NOT the money <ul><li>1 year after winning the lottery or being left permanently disabled by an injury, people return to their previous level of happiness. </li></ul><ul><ul><li>P Brickman, et al; Lottery winners and accident victims: is happiness relative? J Pers Soc Psychol 1978; 36: 917-927 </li></ul></ul><ul><li>Ghana, Mexico, Sweden, UK, & US have similar life satisfaction scores despite per capita income varying 10 fold. </li></ul><ul><ul><li>E Crooks, et al; How to be happy: eat plenty of Brussels sprouts, take up gardening, quit smoking, and move to Iceland. Financial Times 2003 (Dec 27) </li></ul></ul><ul><li>Per capita income in most developed countries has quadrupled in the past 50 years, yet subjective well being has NOT changed. </li></ul><ul><ul><li>JF Helliwlll, et al; The social context of well being. Phil Trans R Soc Lond B 2004; 359: 1435-1446 </li></ul></ul><ul><li>“ Most folks are as happy as they make their minds up to be.” </li></ul><ul><ul><li>Abraham Lincoln </li></ul></ul>
  • 114. Work is central to happiness <ul><li>Features of Work that correlate highly with happiness: </li></ul><ul><ul><li>Autonomy over how, where, and at what pace work is done </li></ul></ul><ul><ul><li>Trust between employer and employee </li></ul></ul><ul><ul><li>Procedural fairness </li></ul></ul><ul><ul><li>Participation in decision making </li></ul></ul><ul><ul><li>A Overall; A working recipe for the quality of life. Financial Times Jan 24, 2002 </li></ul></ul>
  • 115. Work as “Life’s Purpose” <ul><li>Evolutionist: Man has evolved by working (or with work) for thousands of years. </li></ul><ul><li>Creationist : The Bible </li></ul><ul><ul><li>“Then the Lord God took the man and put him in the garden of Eden to cultivate it and to keep it .” (work) Gen 2:17 </li></ul></ul><ul><ul><li>When man’s sin causes him to leave the garden of Eden, “Cursed is the ground because of you; in toil you shall eat of it all the days of your life.” (work) Gen 3:17 </li></ul></ul><ul><ul><li>Man was created to work by a benevolent God. </li></ul></ul><ul><ul><li>Work was created for man by a benevolent God. </li></ul></ul>
  • 116. Even if the patient doesn’t want to return to work, it is usually in his/her best interest to do so.
  • 117. Pharmaceutical Rep with New Antibiotic “Cephawhatsit” <ul><li>Doc : “Literature looks good, kills everything. Are there any side effects I should know ?” </li></ul><ul><li>Rep : “The FDA requires I tell you about a Black Box Warning.” </li></ul>This drug is detrimental to a person’s mental, physical, and social well being. Would you prescribe this antibiotic?
  • 118. 3 Major Considerations: Terms to Understand <ul><li>Risk </li></ul><ul><li>Capacity </li></ul><ul><li>Tolerance </li></ul><ul><li>“ When I use a word,” Humpty-Dumpty said, “It means just what I choose it to mean – neither more nor less.” Lewis Carroll, Alice’s Adventures in Wonderland, Chapter 6 </li></ul>
  • 119. Words on Forms <ul><li>Risk : basis for physician imposed “ work restrictions” (line on forms). What the patient should NOT do, based on risk. </li></ul><ul><ul><li>MAY NOT drive a commercial vehicle with epilepsy. </li></ul></ul><ul><li>Capacity : basis for physician described “ work limitations” (line on forms) What the patient is NOT able to do. </li></ul><ul><ul><li>CANNOT flex or abduct right arm at the shoulder more than 80 º, thus cannot reach overhead controls on a factory press. </li></ul></ul>
  • 120. Words on Forms <ul><li>Tolerance : basis for patient decision as to whether or not the rewards of work are worth the “cost” of the symptom. </li></ul><ul><ul><li>What the patient can do , but dislikes doing, or will not do, because of symptoms. </li></ul></ul><ul><ul><li>No place to describe this on most return to work forms. </li></ul></ul><ul><ul><li>Unique to each patient . (Not predictable by the objective findings) </li></ul></ul>
  • 121. Risk
  • 122. Hill’s Criteria for Causation Proc R Soc Med 1965; 58: 295-300 <ul><li>Strength of the association </li></ul><ul><li>Temporality </li></ul><ul><li>Consistency among studies </li></ul><ul><li>Biologic Gradient </li></ul><ul><li>Experimental evidence </li></ul><ul><li>Plausibility of a biologic mechanism </li></ul><ul><li>Coherence of evidence </li></ul><ul><li>Analogy to a similar effect, from a similar agent </li></ul><ul><li>Specificity of outcome. </li></ul>
  • 123. Hill’s Criteria for Causation Proc R Soc Med 1965; 58: 295-300 <ul><li>Strength of the association </li></ul><ul><li>Temporality </li></ul><ul><li>Consistency among studies </li></ul><ul><li>Biologic Gradient </li></ul><ul><li>Experimental evidence </li></ul><ul><li>Plausibility of a biologic mechanism </li></ul><ul><li>Coherence of evidence </li></ul><ul><li>Analogy to a similar effect, from a similar agent </li></ul><ul><li>Specificity of outcome. </li></ul>Unfortunately, many physicians jump to conclusions about causation, and therefore Work Risk, by thinking ONLY about 2 of the 9, and the two that do NOT require a Knowledge of the medical literature.
  • 124. Temporal Correlation does NOT prove Causation
  • 125. Temporality <ul><li>Post hoc ergo propter hoc </li></ul><ul><li>The rooster crows , then the sun rises . </li></ul><ul><ul><li>Perfect temporal correlation </li></ul></ul><ul><ul><li>Therefore, the rooster crowing CAUSES the sun to rise. </li></ul></ul><ul><ul><li>ERROR: “When” does not equal “Why” </li></ul></ul><ul><ul><li>“As I turned into the discount store parking lot, a part broke on my 6 year old car; therefore , the store is liable for injuring my car. </li></ul></ul>
  • 126. Temporality <ul><li>ERROR: “When” does not equal “Why” </li></ul><ul><ul><li>“As I bent over to pick up a pencil at work , I felt a ‘pop’, and pain in my back; therefore, I have been injured at work, and my employer is liable for a workers’ comp claim. </li></ul></ul><ul><ul><li>BUT, what if I bent over to get a pencil in my neighbor’s house? </li></ul></ul><ul><ul><ul><li>Would I have a successful claim against his homeowner’s insurance? </li></ul></ul></ul><ul><ul><li>What if I bent over to get a pencil in my lawyer’s office? </li></ul></ul><ul><ul><ul><li>Would I have a successful claim against his office liability and umbrella insurance policies? </li></ul></ul></ul>
  • 127. Risk Assessment BASED on Anecdotal Temporality <ul><li>Joe bent over at work to pick up a pencil and hurt his back ? </li></ul><ul><li>What if I send Mary back to work despite her back pain? She might have to pick up a pencil at work ? </li></ul>
  • 128. Risk : At work or at home, “Risk” is part of everyday life. “No Risk” is NOT an option !
  • 129. Cohen JT, and Neumann PJ; What’s More Dangerous, Your Aspirin or Your Car? Thinking Rationally About Drug Risks (and Benefits) Health Affairs 2007; 26 (3): 636-646 FATALITY RISK: DRUGS Treatment Mortality Cause Fatality Rate per 100,000 person-years Smallpox vaccine Smallpox 0.07 First generation antihistamines, 4 months/year Increased deaths from NON-motor vehicle accident related injury 2.8 Prophylactic Aspirin in a 50 year old man CVA, GI bleed, etc. 10.4 Clozapine for schizophrenia Agranulocytosis 35. Natalizumab (Tysabri) for multiple sclerosis Progressive multifocal leukoencephalopathy 65. Rofecoxib (Vioxx) for arthritic pain Cardiovascular events 76.
  • 130. Cohen JT, and Neumann PJ; What’s More Dangerous, Your Aspirin or Your Car? Thinking Rationally About Drug Risks (and Benefits) Health Affairs 2007; 26 (3): 636-646 OCCUPATIONAL FATALITY RISK Job Employees (thousands) Annual Fatalities (2004) Fatality rate per 100,000 person-years Office and Administrative 23,907 91 0.4 Total, ALL OCCUPATIONS 145,612 5,724 3.9 Firefighters 282 30 10.6 Transportation and material moving 10,098 1,511 15.0 Construction laborers 1,009 296 29.3 Taxi drivers and chauffeurs 188 68 36.1 Truck drivers 1,738 779 44.8 Logging workers 75 85 114.0 Tree Fallers 15 55 357.6
  • 131. Cohen JT, and Neumann PJ; What’s More Dangerous, Your Aspirin or Your Car? Thinking Rationally About Drug Risks (and Benefits) Health Affairs 2007; 26 (3): 636-646 TRANSPORTATION FATALITY RISK Mode of transportation Fatality risk per 100 million miles Fatality risk per 100,000 person-years Train 0.03 0.11 Commercial air travel 0.03 0.15 Bus 0.05 0.19 Cell phone while driving 2.3 1.3 Passenger car or light truck 0.7 11 motorcycle 30 450
  • 132. Cohen JT, and Neumann PJ; What’s More Dangerous, Your Aspirin or Your Car? Thinking Rationally About Drug Risks (and Benefits) Health Affairs 2007; 26 (3): 636-646 RECREATIONAL FATALITY RISK Activity Annual fatalities # of participants Annual risk per 100,000 person-years High school and college football 5 8,600,000 0.058 Downhill skiing 38 7,800,000 0.49 Swimming 412 47,000,000 0.88 Bicycling 762 36,000,000 2.1 Boating 703 24,000,000 2.9 Rock climbing 36 100,000 36 Climbing in the Himalayas - - 13,000
  • 133. Guides to the Evaluation of Disease and Injury Causation <ul><li>J. Mark Melhorn MD </li></ul><ul><li>William Ackerman MD </li></ul><ul><li>AMA Press </li></ul><ul><li>2008 </li></ul><ul><li>https://catalog.ama-assn.org/Catalog/product/product_detail.jsp?productId=prod980016 </li></ul>
  • 134. Guides to the Evaluation of Disease and Injury Causation <ul><li>“ Work relatedness , in the context of industrial injuries, involves concepts of medical and legal causation .” </li></ul><ul><li>“ Definitions of medical causation and legal causation arise from different sources -one from science and the other from the desire for social justice.” </li></ul><ul><li>“For physicians treating injured workers, understanding the differences between the two concepts is essential.” P 14 </li></ul>
  • 135. Guides to the Evaluation of Disease and Injury Causation <ul><li>“The courts did not have their origins in science, and, therefore, the laws developed are not scientifically derived .” P 15 </li></ul><ul><li>“ Judges and legislatures have the power to substitute convenience for science . One common method for doing so in workers’ compensation cases is the establishment , by legislative or judicial decree, of presumptions that institutionalize societal choices.” P 17 </li></ul>
  • 136. Guides to the Evaluation of Disease and Injury Causation <ul><li>Example </li></ul><ul><ul><li>Many states have laws that create the presumption that cardiovascular disease in a policeman or fireman was caused by work stress and/or chemical exposure , and thus any heart attack is covered by workers’ comp. </li></ul></ul><ul><ul><li>The presumption of work relatedness may, or MAY NOT be rebuttable . P 17 </li></ul></ul>
  • 137. Guides to the Evaluation of Disease and Injury Causation <ul><li>Level of Proof needed to establish work relatedness by AGGRAVATION of a Pre-existing condition for workers’ compensation VARIES GREATLY among jurisdictions. </li></ul><ul><ul><li>Kansas: one iota </li></ul></ul><ul><ul><li>Tennessee: any anatomic or physiologic change </li></ul></ul><ul><ul><li>California: 1% </li></ul></ul><ul><ul><li>Florida, Arkansas, Missouri: > 50% </li></ul></ul>KANSAS: > 50% of Causation OKLAHOMA: > 50% OF Causation TENNESSEE: > 50% of Causation
  • 138. Risk: <ul><li>If alcohol is causing cirrhosis , more alcohol should cause more cirrhosis . </li></ul><ul><li>If cigarettes are causing emphysema, more cigarettes should cause more emphysema. </li></ul><ul><li>If repetitive work is causing *_____, more work should cause more *_____ . * = back pain, or shoulder pain, or … </li></ul>
  • 139. Risk : At work or at home, “Risk” is part of everyday life. “No Risk” is NOT an option !
  • 140. Risk: Legal Standard Americans with Disabilities Act <ul><li>Employer may require that the worker Not pose a direct threat to Self or Others High Probability (not clearly defined) of specific Substantial Harm (not  symptoms) that is imminent (  3 months, not future) </li></ul><ul><li>Based on Objective Medical Evidence related to the particular individual </li></ul><ul><li>Law & Definitions will differ in different counties </li></ul>
  • 141. The OTHER side of the coin <ul><li>If the ADA specifies when an employer can not stop a patient/employee from doing a job, the logical application is that in the disability arena a physician should not attempt to prohibit that same patient from doing the same job. </li></ul>
  • 142. Risk with Return to Work: Of What Consequence ?? <ul><li>Objectively verifiable, Serious, single incident . Examples: Disc Herniation, Myocardial Infarction </li></ul><ul><li>Objectively verifiable, but less immediately serious. Example: Increase in Pre-existing Hypertension </li></ul><ul><li>Subjective: Not verifiable , Example: Increase in current Back Pain </li></ul>
  • 143. Psychological Problem Psychological Risk <ul><li>Dx = Paranoid Schizophrenic Risk in question, </li></ul><ul><li>“ What is the risk of Joe killing coworker’s ?” </li></ul><ul><li>Dx = Major Depression (or Panic Attacks) Risk in question, “What is Joe’s risk of Suicide ?” </li></ul><ul><li>Our Ability to Predict human behavior is VERY limited </li></ul><ul><li>Little Science, but clear objective end point (Permitting Scientific Studies) </li></ul>
  • 144. NEJM 2006; 355 (20): 2064-2066 Data from Swanson: 1994 text edited by Monahan & Steadman Violence and mental disorders: Developments in risk assessment. University of Chicago Press, 1994: 101-136
  • 145. Example of Psychological Risk: Suicide Rates JAMA 2003; 290 (11): 1515-1519 Condition Suicide Rate % per year Normal population 0.012 – 0.017 Bipolar, NO treatment 0.116 Bipolar, Lithium Rx 0.066 Bipolar, Anticonvulsant Rx 0.155
  • 146. Again: Physical Problem Physical Risk <ul><li>Dx = Known Coronary Artery Disease Risk in question, “What is the risk of myocardial infarction if Joe does a Heavy Job ?” </li></ul><ul><li>Dx = Prior Discectomy Risk, “What is the risk of recurrent disc herniation if Joe does a Heavy Job ?” </li></ul><ul><li>Some Science (unfortunately, very few studies), Clear objective end point (consequence) </li></ul>
  • 147. Apparently Physical Problem Apparently Physical Risk, BUT <ul><li>Problem : Mild Coronary Disease “If Joe returns to a work, What is the risk that he will experience exertional, but non-anginal chest pain and file for disability ?” </li></ul><ul><li>Problem : Back Pain, Or Carpal Tunnel Syndrome “If Joe returns to work, what is the risk that his back, (or hand) pain , will increase, and he will file for disability ?” </li></ul><ul><li>Subjective End Point </li></ul>
  • 148. Capacity:
  • 149. Ouch !
  • 150. Capacity : Scientifically Measurable
  • 151. Considerations in Return to Work Decisions: Capacity <ul><li>Strength, Endurance </li></ul><ul><li>Measurable , but Rarely Measured, fairly scientific </li></ul><ul><li>Assumes training to maximal ability has occurred Example : competitive athlete, or worker fully trained & acclimated to job </li></ul><ul><li>Usually measure “ current ability ”, Not Capacity </li></ul>
  • 152. Capacity <ul><li>Current ability is usually capable of increasing up to “ Capacit y” with training. </li></ul><ul><li>Strength, Flexibility, & Endurance are measurable (now), but can be increased through exercise, or can decrease with inactivity. “Use it or Lose it !” </li></ul><ul><li>Principal of training for a marathon race, or of “Work Hardening” or “Work Conditioning”. </li></ul>
  • 153. Progressively tougher exercise builds capacity Return to Work with restrictions that progressively decrease Will Also Build Capacity
  • 154. Progressively Decreasing Work Guidelines <ul><li>By weight: </li></ul><ul><ul><li>Lift ≤ 20 lbs for weeks 0-2 </li></ul></ul><ul><ul><li>Lift ≤ 40 lbs for weeks 2-4 </li></ul></ul><ul><ul><li>Lift ≤ 60 lbs for weeks 4-6 </li></ul></ul><ul><ul><li>Then full duty </li></ul></ul><ul><li>By time: </li></ul><ul><ul><li>Do regular job 2 hours/day for weeks 0-2 </li></ul></ul><ul><ul><li>Do regular job 4 hours/day for weeks 2-4 </li></ul></ul><ul><ul><li>Do regular job 6 hours/day for weeks 4-6 </li></ul></ul><ul><ul><li>Then full duty </li></ul></ul>
  • 155. Work can be the progressive exercise that builds capacity.
  • 156. Tolerance
  • 157. Considerations in Return to Work Decisions: Tolerance <ul><li>Psycho physiologic concept </li></ul><ul><li>Ability to tolerate sustained work at a given level. Not scientifically measurable </li></ul><ul><li>Generally less than capacity </li></ul><ul><li>Symptoms like pain and/or fatigue limit performance, thus “not very scientific” </li></ul><ul><li>Influenced by Rewards available and Personality </li></ul><ul><li>May or May Not be similar to “current ability” </li></ul>
  • 158. Tolerance for symptoms while at work is the real issue
  • 159. Restrictions ?? What if my chronic LBP Patient Applies to Work ? <ul><li>“Joe” has Strain or Backache </li></ul><ul><li>“Can’t do full duty” (dislikes his job) </li></ul><ul><li>Stays and stays and stays on restrictions… </li></ul><ul><li>Until , he comes for a Pre-Placement Exam for another company that pays much more </li></ul><ul><li>Now he wants a “Full Duty” release ?? </li></ul><ul><li>“Restrictions”, that disappear with change in employment, are they Scientific ?? </li></ul>
  • 160. Restrictions ?? What if LBP Pt Applies to Work <ul><li>ADA/EEOC limit MD at Pre-Placement Exam </li></ul><ul><li>“ No basis to restrict employment” “Mere increase in pain from a painful condition is NOT ‘Significant Harm’” </li></ul><ul><li>“Restrictions”, that disappear with a desired change in employment, are they Scientific ?? </li></ul>
  • 161. The Problems with Tolerance Based Work Restrictions <ul><li>This anecdote shows that tolerance is not measurable by a physician. </li></ul><ul><li>Joe won’t do an easy job despite backache for $ 7.00/hour, but will do a much more physically demanding job for $ 25.00/hour. </li></ul><ul><li>Dr A says Joe can’t work at this job, or has “restrictions” based on tolerance , while Dr B says Joe can work and does NOT need restrictions (fit for full duty): </li></ul><ul><ul><li>Neither doctor has sound science behind his/her opinion </li></ul></ul><ul><ul><li>To “requesting sources” doctors look biased , and their testimony is believed to be “for sale”. </li></ul></ul>
  • 162. Physician Agreement: Reliability Necessary for Validity <ul><li>If science or consensus exists on risk , most physicians will agree on work restrictions . </li></ul><ul><li>If testing shows a lack of current capacity , most physicians will agree on work limitations. </li></ul><ul><ul><li>At least temporary limitations </li></ul></ul><ul><li>If patient tolerance for symptoms is the issue </li></ul><ul><ul><li>With severe pathology there will be fair agreement </li></ul></ul><ul><ul><li>With mild or moderate pathology , there will be little or no agreement . </li></ul></ul><ul><ul><ul><li>J Rainville, et al; The Physician as disability advisor for patients with musculoskeletal complaints. Spine 2005; 30 (22): 2579-2584 </li></ul></ul></ul>
  • 163. Physician agreement (??) on work recommendations <ul><li>Studies with family practioners, internists, physiatrists, spine surgeons, and social security examiners. </li></ul><ul><ul><li>Vignettes : elicit ideal responses, NOT necessarily the actual response to real world cases </li></ul></ul><ul><ul><li>Striking lack of consistency among physicians </li></ul></ul>
  • 164. References on MD agreement <ul><li>D Patel, et al; National variability in permanent partial impairment ratings. Am J Phys Med Rehabil 2003; 82: 302-306 </li></ul><ul><li>EMH Haldorsen, et al; Musculoskeletal pain: Concepts of disease, illness, and sickness certification in health professionals in Norway. Scand J Rheumatol 1996; 4: 224-232 </li></ul><ul><li>TS Carey, et al; Medical disability assessment of the back pain patient for the Social Security Administration: The weighting of presenting clinical features. J Clin Epidemiol 1988; 41: 691-697 </li></ul><ul><li>JT Chibnall, et al; Internist judgment of chronic low back pain. Pain Med 2000; 3: 231-236 </li></ul>
  • 165. Tolerance: 4 physician choices <ul><li>Play Secretary (Doctor not really necessrary ) </li></ul><ul><li>Try to assess tolerance </li></ul><ul><li>Gestalt (Educated Guess or “gut feeling” </li></ul><ul><li>Abstain : leave tolerance decisions to the patient </li></ul>
  • 166. Tolerance : 4 physician choices Choice 1 : Play Secretary <ul><li>Play Secretary (Doctor not really necessrary ) </li></ul><ul><ul><li>Form asks: “How much can he lift?” </li></ul></ul><ul><ul><li>Patient: “I can lift 10 pounds.” </li></ul></ul><ul><ul><li>Doctor writes on form “restriction: no lifting over 10 pounds” </li></ul></ul><ul><ul><li>No need for patient to pay the doctor to fill out a form. Patient could have filled the form out. </li></ul></ul><ul><li>Primary care providers rely mainly on patient input for disability assessement. </li></ul><ul><ul><li>G Pransky, et al; Improving the physician role in evaluating work ability and managing disability: A survey of primary care practioners. Disabil Rehabil 2002; 24: 867-874 </li></ul></ul>
  • 167. Choice 2 : Try to assess tolerance <ul><li>Functional Capacity Evaluation : </li></ul><ul><ul><li>“Reader’s Digest Version” </li></ul></ul><ul><ul><li>No proven reliability or validity </li></ul></ul><ul><ul><ul><li>Physical Therapy 1998; 78 (8): 852-66. </li></ul></ul></ul><ul><ul><ul><li>Spine 2004; 29: 914-19 & 920-924. </li></ul></ul></ul><ul><ul><li>Only 1 study ignoring the FCE and sending workers with back pain to Full Duty when the FCE said they are not capable, and doing so IMPROVED the long term results. </li></ul></ul><ul><ul><ul><li>Spine 1994; 19: 2033-2037. </li></ul></ul></ul>
  • 168. More Recent Systematic Review <ul><li>Search for articles in English, French, and Dutch. </li></ul><ul><li>4 FCE systems predominate in the Netherlands </li></ul><ul><ul><li>Blankenship System (BS) </li></ul></ul><ul><ul><li>Ergos work simulator (EWS) </li></ul></ul><ul><ul><li>Ergo-Kit (EK) </li></ul></ul><ul><ul><li>Isernhagen work system (IWS) </li></ul></ul>Gouttebarge V, Wind H, Kuijer P, et al. Reliability and validity of Functional Capacity Evaluation methods: a systematic review with reference to Blankenship system, Ergos work simulator, Ergo-Kit, and Isernhagen work system. Int Arch Occup Environ Health 2004; 77: 527-537
  • 169. More Recent Systematic Review: Reliability: 12 published studies <ul><li>Reliability has not been demonstrated for: </li></ul><ul><ul><li>Blankenship System (BS) </li></ul></ul><ul><ul><li>Ergos work simulator (EWS) </li></ul></ul><ul><ul><li>Ergo-Kit (EK) </li></ul></ul><ul><li>Isernhagen work system (IWS) has good reliability : 5 studies </li></ul><ul><ul><li>ICC (Intra-Class Correlation Co-Efficient) 0.75-0.95 </li></ul></ul>Gouttebarge V, Wind H, Kuijer P, et al. Reliability and validity of Functional Capacity Evaluation methods: a systematic review with reference to Blankenship system, Ergos work simulator, Ergo-Kit, and Isernhagen work system. Int Arch Occup Environ Health 2004; 77: 527-537
  • 170. More Recent Systematic Review: Validity: 12 published studies <ul><li>Validity has not been demonstrated for Any of these 4 FCE systems. </li></ul><ul><li>There are studies correlating FCE with: </li></ul><ul><ul><li>Questionnaires (e.g. VAS, Oswestry, PDI, etc) </li></ul></ul><ul><ul><li>Whether the examinee will choose to return to work </li></ul></ul><ul><ul><li>Worse FCE performance somewhat predictive of worse status on questionnaires and lower return to work rate. (kappa 0.4-0.7) </li></ul></ul>Gouttebarge V, Wind H, Kuijer P, et al. Reliability and validity of Functional Capacity Evaluation methods: a systematic review with reference to Blankenship system, Ergos work simulator, Ergo-Kit, and Isernhagen work system. Int Arch Occup Environ Health 2004; 77: 527-537
  • 171. More Recent Systematic Review: Validity: 12 published studies <ul><li>Validity has not been demonstrated for Any of these 4 FCE systems </li></ul><ul><li>Only studies of Construct Validity (correlation with outcome once patient returns to work) are those of Gross and Batti é, and these have a negative Pearson correlation co-efficient . </li></ul><ul><li>Construct “FCE predicts safe return to work” has NOT been proven. </li></ul>Gouttebarge V, Wind H, Kuijer P, et al. Reliability and validity of Functional Capacity Evaluation methods: a systematic review with reference to Blankenship system, Ergos work simulator, Ergo-Kit, and Isernhagen work system. Int Arch Occup Environ Health 2004; 77: 527-537
  • 172. Recent Studies Showing FCE does NOT Predict SAFE Return to Work <ul><li>Gross & Battie </li></ul><ul><ul><li>The Prognostic Value of Functional Capacity Evaluation in Patients with Chronic Low Back Pain, Part 1 Spine 2004; 29(8): 914-919 AND Part 2, Spine 2004; 29(8): 920-924 </li></ul></ul><ul><ul><li>Functional Capacity Evaluation Performance Does Not Predict Sustained Return to Work in Claimants with Chronic Back Pain. Journal of Occupational Rehabilitation 2005; 15 (3): 285-294 </li></ul></ul><ul><ul><li>Does functional capacity evaluation predict recovery in workers’ compensation claimants with upper extremity disorders? Occup. Environ. Med. 2006;63;404-410; </li></ul></ul>
  • 173. Hamilton Hall MD , et al; “Effects of discharge recommendations on outcome.” Spine 1994; 19: 2033-2037 <ul><li>@ 12 Canadian Back Institute locations. </li></ul><ul><li>Acute LBP, still in pain and off work 0-70 days. </li></ul><ul><li>Work Conditioning 4 hours/day, 5 days/week, for 30 days - both groups had weekly FCE’s. </li></ul><ul><li>Control group , Dec 91-Apr 92, 857 patients, with 669 available for follow up. </li></ul><ul><li>Study group , June 92-Oct 92, 1070 patients, with 769 available for follow up. </li></ul>
  • 174. H Hall continued <ul><li>Treatment identical in both groups, until return to work recommendation @ discharge. </li></ul><ul><li>Control group : return to work restrictions based on measured capacity, and pain (the FCE). </li></ul><ul><li>Study group : Return to work Unrestricted Unless: objective nerve root irritation, sciatic scoliosis, ROM < job requirement, or Recent fracture. ( FCE ignored , pain ignored) </li></ul><ul><li>“Success” of treatment measured @ 4 months defined by return to work. </li></ul>
  • 175. H Hall continued <ul><li>Patients returning to work Control group: 82 % (444/543) Study group: 81 % (551/679) </li></ul><ul><li>Patients @ full duty , @ 4 month follow up Control group 48 % (262/543) Study group 77 % (524/679) </li></ul><ul><li>Increased success (defined as unrestricted work) by ignoring pain and measured capacity. </li></ul><ul><li>“ Restrictions”are a self-fulfilling prophecy , and patients see themselves as no longer able to perform their normal work-related activities. </li></ul>
  • 176. H Hall continued <ul><li>“Return to work may be influenced by factors other than physical ability. Factors such as motivation, emotional reaction, economic and cultural impact, unemployment rate, job satisfaction, and WCB benefits may override improved physical function in the patient’s decision to return to work. The added barrier of a return to work restriction appears to be another negative factor affecting outcome . Conversely, the added impetus of an unrestricted return to work recommendation may be a positive factor in the decision to resume an active life-style and return to work.” </li></ul>
  • 177. Why FCEs don’t help me: 6 Outcomes <ul><li>FCE cures the patient. </li></ul><ul><li>Valid FCE & “Capacity” > I thought. </li></ul><ul><li>Valid FCE & “Capacity” = I thought. </li></ul><ul><li>Valid FCE & “Capacity” < I thought. </li></ul><ul><li>INVALID FCE. </li></ul><ul><li>Injured during testing. </li></ul>
  • 178. Functional CAPACITY Evaluation ? Functional TOLERANCE Evaluation ? <ul><li>“ The FCE should be terminated by either the examiner or examinee at will.” (Lechner, Sourcebook of Occupational Rehab, in press). </li></ul><ul><li>Patient advised in pre-test instructions to “ stop if pain experienced” and “not to knowingly be re-injured.” </li></ul><ul><li>Most reports of “FCE”s state that “examinee self-limited due to pain”, or TOLERANCE. </li></ul>
  • 179. Choice #3
  • 180. How then does the “Real World Doc” decide if Joe can work After his Heart Attack ? Despite his backache ? Gestält (Choice 3) “ Based on My Anecdotal Experience, Patients like Joe Usually Do … Or Usually Do Not… WORK, at this type Job”
  • 181. Gestält Psychology (Choice 3) <ul><li>“… affirms that all experience consists of Gestälten, and that the response of an organism to a situation is a complete and unanalyzable whole rather than a sum of the responses to specific elements in the situation.” Webster’s New Universal Unabridged Dictionary, 2nd Edition, 1983 </li></ul><ul><li>Intuitive or “Gut” Reaction </li></ul>
  • 182. Gestält is based largely on Anecdotal Experience Which is Colored by Our Biases <ul><li>Medical/Scientific Training has a role </li></ul><ul><li>Each Physician has a different experience, although hopefully fairly similar </li></ul><ul><li>Explains how 2 different MD’s, each honest and competent, can have opposite opinions on the question “Can Joe Work Despite His… ?” </li></ul>
  • 183. “ Opinions are like Noses, Everyone has One, And We each Blow It Frequently” Old Tennessee Aphorism
  • 184. Aesop's Fable The Blind Men and the Elephant <ul><li>Each man has a blindfold (Bias) </li></ul><ul><li>Each man has a piece of the elephant (anecdotal experience) </li></ul>5 IME doctors examine This patient
  • 185.
  • 186. Differing Opinions Based on Anecdotal Experience Plantiff’s Lawyer: “Joe, Go see Dr A” Defense Lawyer: “Joe, Go see Dr B”
  • 187. Anecdotal Experience Leads to Self-Fulfilling Prophecies <ul><li>Dr A: “I usually declare patients like Joe ‘disabled’ . They usually don’t go back to work, and don’t any get better, so I must be correct .” </li></ul><ul><li>Dr B: “I usually declare patients like Joe fit to work . They usually go back to work and do fine, so I must be correct .” </li></ul><ul><li>Both are honest, well trained, and yet, they have very different anecdotal experiences </li></ul>
  • 188. Real World Data on MDs Certifying Disability <ul><li>W Zinn, et al; Physician perspective on the ethical aspects of disability determination . J Gen Intern Med 1996; 11 (9): 525-532 </li></ul><ul><li>Survey : </li></ul><ul><ul><li>184 Internists and FPs (Random Sample, RS ) (53 % of 347), and </li></ul></ul><ul><ul><li>76 “Neighborhood Health Center” ( NHC ) MDs (76 % of 100). </li></ul></ul><ul><li>Physician willingness to exaggerate clinical data to help a patient he/she thought was deserving of disability : </li></ul><ul><ul><li>39 % of Random Sample MDs </li></ul></ul><ul><ul><li>56 % of NHD MDs </li></ul></ul>Euphemism for “lie”
  • 189. J Gen Intern Med 1996; 11 (9): 525-532 MD perceptions on Visual Analog Scale Question RS NHC Confidence in ability to assess disability ( 0 = confident, 10 = not confident) 4.4 4.6 “ Burdened” by disability assessment (0 = more burdened, 10 = less burdened) 2.8 2.5
  • 190. J Gen Intern Med 1996; 11 (9): 525-532 MD perceptions Question RS NHC Filling out disability form can compromise the physician patient relationship 82 % 86 % Filling out disability form is a conflict of interest for the physician 62 % 62 % “ Better” if an independent physician determines disability 80 % 80 %
  • 191. Similar to prior study <ul><li>41 % of family physicians </li></ul><ul><ul><li>felt pressured to write unwarranted work excuses , and </li></ul></ul><ul><ul><li>felt manipulated by their patients. </li></ul></ul><ul><ul><li>Mayhew HE & Nordlund DJ; Absenteeism certification: The physician’s role. J Fam Pract 1988; 26: 651-655 </li></ul></ul>
  • 192. Similar to prior study <ul><li>87 % of cases in which primary care physicians could not justify “sick-listing” certification, a certificate was issued anyway . </li></ul><ul><ul><li>L England & K Svardsudd; Sick-listing habits among general practioners in a Swedish county. Scand J Prim Health Care 2000; 18: 81-86 </li></ul></ul>
  • 193. Would Doctors LIE ?????
  • 194. Ethics ? JAMA 2000; 283; 1858-1865 <ul><li>Random sample questionnaire of 1124 MDs. </li></ul><ul><li>Use of 3 “tactics” to help patient get health insurance coverage/permission: </li></ul><ul><ul><li>Exaggerated complaint severity </li></ul></ul><ul><ul><li>Changed billing diagnosis </li></ul></ul><ul><ul><li>Reported signs or symptoms patient didn’t have </li></ul></ul><ul><li>39 % of MDs had used at least one “tactic” “sometimes” or more often in the last year. </li></ul><ul><li>Use unrelated to worry about prosecution for fraud. </li></ul><ul><li>54 % reported using these tactics more frequently than 5 years ago. </li></ul>Euphemism for “lie”
  • 195. Other Similar Articles <ul><li>Freeman VG, et al. Lying for Patients: Physician Deception of Third-Party Payors. Arch Int Med 1999; 159: 2263-3370 </li></ul><ul><li>169 Internists, 6 vignettes, to determine willingness to deceive a third-party payor. </li></ul><ul><li>Percentage willing to deceive: </li></ul>Coronary artery bypass 57.7 % Arterial revascularization 56.2 % Screening mammography 34.8 % Emergency psychiatric referral 32.1 % Cosmetic rhinoplasty 3 %
  • 196. Other Similar Articles <ul><li>Alexander CG, et al. Support for Physician Deception of Insurance Companies among a Sample of Philadelphia Residents. Ann Intern Med 2003; 138: 472-475 </li></ul><ul><li>Convenience sample of 700 prospective jurors . </li></ul><ul><ul><li>Public perception of doctor’s role </li></ul></ul><ul><li>In response to a health care restriction, a physician should: </li></ul>Accept the restriction 4 % Appeal the restriction 70 % Misrepresent the patient’s condition to get the desired service 26 %
  • 197. AMA Code of Ethics <ul><li>First Edition, 1847 </li></ul><ul><ul><li>“ The life of a sick person can be shortened not only by the act, but also by the words or manner of a physician . It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have the tendency to discourage the patient and depress his spirits.” </li></ul></ul>
  • 198. AMA Code of Ethics <ul><li>2000-2001 Edition: </li></ul><ul><li>Patient-Physician Relationship </li></ul><ul><ul><li>(Last section in the book) </li></ul></ul><ul><ul><li>“ The patient has the right to receive information from physicians and to discuss the benefits, risks, and costs of appropriate treatment alternatives. </li></ul></ul><ul><ul><li>Patients are also entitled to obtain copies or summaries of their medical records , to have their questions answered , to be advised of potential conflicts of interest that their physicians might have, and to receive independent professional opinions.” </li></ul></ul><ul><ul><ul><li>Page 231 </li></ul></ul></ul>
  • 199. Ann Intern Med 2005; 142: 560-582
  • 200. Page 566
  • 201. Explains “Why Judges, Attorneys, Insurance Companies, etc. think Doctors Opinions and Testimony are for Sale” ($$)
  • 202. Choice 4 : Leave decision about tolerance to the patient. <ul><li>Not an issue for physician imposed work restrictions (risk). </li></ul><ul><li>Not an issue for physician described work limitations (capacity). </li></ul><ul><li>Tolerance issues are decisions only the patient can make . </li></ul><ul><ul><li>Usually NO line on the return to work form for patient tolerance. </li></ul></ul>
  • 203. Tolerance: What to say ?? <ul><li>“ You do not appear to meet the Social Security Administration’s criteria for total disability. Thus, in our society, there is some job you’re expected to be able to do. Since there is no medical evidence that you are at high risk of significant harm by working, I can not state that you’re disabled for this job. There is no need for work restrictions based on risk. Whether the rewards of working are sufficient for you to choose to remain at work, or whether the pain/fatigue you feel is sufficient for you to choose a different type of work, or not to work at all, is a question only you can answer. I can record on this form what you feel to be your current activity tolerances, but not as “work restrictions” or as “work limitations”. These tolerances are not scientific, and they may change in the future.” </li></ul>
  • 204. “ Disclaimer” for Return to Work Compliments of Gary Freeman <ul><li>You can sue the Pope for being Catholic. </li></ul><ul><li>But, this disclaimer may help prevent you from being sued successfully. </li></ul>
  • 205. <ul><li>The above statements have been made within a reasonable degree of medical certainty or probability. The opinions rendered in this case are mine alone. Recommendations regarding treatment, work, and impairment ratings are given totally independently from the requesting agents. These opinions do not constitute per se a recommendation for specific claims or administrative functions to be made or enforced. </li></ul><ul><li>This evaluation is based upon the history given by the examinee, the objective medical findings noted during the examination, and information obtained from the review of prior medical records presented, with the assumption that this material is true and correct. If additional information is provided to me in the future, and additional service/report/reconsideration may be requested. Such information may or may not change the opinions rendered in this evaluation. </li></ul><ul><li>Medicine is both an art and a science, and although an examinee may appear to be fit to return to duty (work), there is no guarantee that he/she will not be injured or sustain an additional new injury once he/she returns to work. </li></ul><ul><li>If further information is required, please contact me. </li></ul>
  • 206. Conclusions “ Can I Work Despite My …?” Heart Attack ? Back Pain ? (Fill in any medical problem)
  • 207. Conclusions <ul><li>Capacity : Rarely attained. </li></ul><ul><li>Current Ability : Measurable, with some degree of validity. </li></ul><ul><li>Risk : Little Science, Not measurable in Joe, Patients are rarely harmed by a return to work release. </li></ul><ul><li>Tolerance : In the real world, what usually determines return to work. </li></ul><ul><li>Motivating , (“Cognitively Restructuring”) the Impaired individual to improve tolerance is the “Art of Medicine”. </li></ul>
  • 208. Return to work formula My Fantasy: “To sit at the feet of Dr. Einstein and learn the formula for filling out Return to Work forms”
  • 209. How then does the “Real World Doc” decide if Joe Can Work After his Heart Attack ? Or Despite His Back Pain ? Or Despite ___________ ? Gestält Or Secretary method Or by FCE FTE NOT by Science
  • 210. Some day We Will Know More About Back Disability
  • 211. The End Thank You

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