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Reliably Determining Occupational Causation

April 21, 2010

Dan Rafael Azar MD MPH QME

Medical DirectorAlliance Occupational Medicine

Santa Clara & Milpitas

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Identifying Causation is Critical

• Impacts claim management • Impacts source of medical treatment • Impacts employee health• Impacts liability for treatment• Impacts future costs• Impacts profitability• Impacts morale

Make the right decision as early as possible

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Evaluation and Treatment is a Partnership

– Employee-Patients– Employers– Carriers (adjusters)– Utilization Review– Medical Case Managers– Attorneys– WCAB judges– Legislature

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Evaluation and Treatment is a Partnership

• We share goals (some of us)– Get the EE

• as well as possible• as quickly as possible • for the lowest cost

– Goal: MMI (maximal medical improvement)– Goal: P&S (Permanent & Stationary)

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Why use an Occ. Med. Clinic?• Measure our success by case management

– Causation determination– Disability management– Claims management– Cost effectiveness

• Responsible for quality of ancillary services• In-house specialists are held to higher

standard• Personalize treatment for local employer• Typically best choice for initial treatment

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First Visit “Basics”

1. Diagnosis

2. Causation

3. Treatment

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Treatment Philosophy• Attitude of provider

– Neutral in mind– Positive in attitude– Not pro-EE – Not pro-ER

• Thorough history taking – Fact finder – Active listener

• Thorough exam• Thorough documentation

– Fact organizer• Synthesize treatment plan• Lead, Communicate and Coordinate to Implement Plan

– “It takes a team”– Define roles– Problem solve– Educate stakeholders generously

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Treatment Philosophy• Always strive to do the “right thing” = Speak the truth

– WC serves a specific purpose– WC is not a safety net– Treating a non-occupational illness under WC is not “doing

the EE a favor”• Establish causation as AOE/COE

– Arising Out of Employment– (occurring in the) Course Of Employment

• Probable cause– Not just “a possible cause”

• Significant contributor– Not trivial

• No patient-physician relationship exists until causation is resolved and treatment is started

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First Visit

• Goal: put together a unbiased narrative that tells a believable story

• Fact collecting and organizing

• Develop a relationship with patient

• Dispel bias against “company doc” – Reflect comprehension– Express compassion

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Thoroughness at First Visit IncludesReviewing All Available Information

• Authorization form from employer

• Patient description of injury mechanism

• Anatomic illustration of injured areas

• Basic current and past work history

• Clarify prior relevant medical history

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History: Establishing Diagnosis, Causation and Pre-Injury Baseline

What happened? No problems before then? What makes it worse? Ask for specific responses. Ask questions until it makes sense Check for non-occupational contributors Check for consistency of causation:

Worse at End of Day? Week?How does it feel on weekends, vacation?

Organize a time line for current injury– Include treatment received since onset of sx’s

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History: Why now?It Should Make Sense:

• What changed in this EE’s life (at work or home) to trigger this injury?

– Increased work volume?– Increased work hours (OT)?– Increased work pace?– Coworker laid off?– Coworker maternity/disability leave?– Relocating offices without correct ergonomics?

• Is there a clear causative relationship?

If it doesn’t “make sense” its non-occupational until proven otherwise

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Identify Non-Industrial Contributors?• Personal Medical Illnesses (diabetes, thyroid,

degenerative)• Hobbies: knitting, sewing• Gardening / Home Projects / Remodeling• Sports • Family / Small Children / Dependent Adults• School / Second Job• Over-committed

– Just too much – Many working mothers & homemakers– Unrealistic personal expectations – Poor interpersonal boundaries,

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During History Listen for • Anger

• Blaming

• Self pity

• Passive attitude

• Poor coping

• High perceived stress

• Poor boundaries (at work and home)

– Excessive sense of responsibility

– Inadequate rest and recovery

– Life out of balance

• Poor self-care

– Lack of regular exercise

– Smoking

– Diet

(Skip to Slide 23)

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Establish Impact on Function

• Activities of Daily Living (ADL’s)• Impact on Work Duties?• Clarify work functions• These are additional clues to causation• Look for association between painful

activities and causation• “What were you doing when you first

noticed symptoms?”

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History > Subjective Section of DFR / Report

• What?• When?• Where?• Injury-relevant medical history

– Prior treatment history– What worked?– Rate of recovery

• How is work impacted by injury? • How is injury impacted by work?• Contemplate

– Differential Diagnoses– Causation & Apportionment– Treatment Plan

• Set stage for upcoming physical examination

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Physical Examination:Confirm Diagnoses

• Define physical boundaries of injury• Thinking: Differential Diagnoses = “Probable and Possible

Dx’s”• Identify medical red flags

– Expedite care – Contact ER/Adjustor, ED, PMD, Specialist)

• Identify case management red flags:– Exam doesn’t fit history/mechanism– Exam suggests non-occupational pathology– Exam suggests supra-tentorial amplification

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Objective / Examination• Visual Observation during history

– Pain with movement– Movement to relieve pain – Signs of excessive anxiety

• Active Range of Motion (AROM)• Visualize painful area

– Discoloration – Edema– Asymmetry

• Palpation– Tenderness– Bogginess (edema)– Fibrosis

• Provocative Testing– Tinel’s– Phalen’s– Impingement test– Signs of malingering– Symptom Exaggeration (conscious vs. unconscious)

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During Examination Look for:

• Lack of aerobic fitness

• Lack of muscular development

• Advancing age– likelihood of injury increases as capacity

and rate of healing decreases

• Poor general health

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A = Assessment = Diagnoses

Identify: • Pathology (what’s wrong?)• Extent of problem (define anatomic areas

involved)• Severity (mild, moderate, severe)

– based on exam findings & impact on function

• Chronicity (acute, cumulative, pre-existing)• Cause (non-occupational, degenerative)

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Plan = Discussion & Treatment• Discussion:

– Describe how I arrived at diagnoses– Synthesis of Subjective and Objective– Differential Diagnosis– Differential Causation– Explain pathology and relationship to most

reasonable mechanism of injury– Acknowledge all relevant diagnoses– Acknowledge impact of non-occupational dx’s – “What it isn’t” (e.g. not CTS, not C-radiculopathy)

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Causation: Entirely Non-Occupational

• “You need to see your own doctor; I cannot treat you under WC”

• “Friendly” first aid advice• End on positive note

– Less conflict with me– Less disruption for employer at workplace

• Document on Work Status – Non-Industrial– See Own MD

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Treatment Plan: Plan Ahead

• Plan A

• On recheck…– If it works…typically finish Plan A– If it doesn’t work initiate Plan B

• Check for non-compliance with plan A• Consider alternative diagnoses• Consider Diagnostics – if they will impact care• Discuss injection or alternative treatment

• Where ever possible use MTUS/ACOEM Guidelines for treatment plan

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Treatment Plan:Patient-Centric Goals

• Actively listen to patient’s concerns

• Define most disruptive diagnoses

• “I get it and I’m competent “

• “I can help with your injury and the problems its causing you – trust me”

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Treatment Plan: Educate the Patient

• Anatomic posters• Explain biomechanics and provocative test results• Demonstrate knowledge and credibility • Answer questions• Dispel common disbeliefs• Reinforce with printed handouts

– Pathology– Basic exercises

• Reassure you will communicate with employer – Work recommendations– To follow restrictions as written– Injury is “real”

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Treatment Plan: Talk to the Patient

• Explain multi-pronged treatment approach• Expectation:

– “Its your job to get better”– Outcome depends on patient effort– “No change = no gain”

• Outcome depends on severity of illness• Outcome depends on delay in seeking care• Reassure:

– think positive– take action– be realistic

• Make yourself available to patient

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Specific Treatment Plan for an Acute Injury

• Mild / Minimal Injury:– First Aid Only (OSHA – not labor code)– Non-Rx meds if sufficient– No Physical Therapy

• Or option of “instruction only” by therapist• No modalities or procedures

– Full Duty (if safe) – Depends on severity

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Treatment Plan for anModerate to Severe Acute Injury

• Start Physical Therapy ASAP• Recheck 2 – 7 days• Restrictions if medically necessary

– Only if necessary – Specific to injury– Specific to job duties– Safety driven

• Prescription meds if medically necessary– Avoid narcotics or muscle relaxants where possible– Use OTC’s or topicals – Limits pain or sedation as an excuse for not working

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Goals of Physical Therapy

• Recover full function

• Establish healthy habits

• Minimize risk of recurrence

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Physical Therapy

During early phase of treatment: • Decrease pain & inflammation

– TENS– Ultrasound– Phonophoresis/Iontophoresis– Myofascial release– Teach proper use of ice and heat

• Improve active range of motion (AROM)• Reduce injury-related anxiety

– Educate about pathology – Encourage movement

• Teach proper technique

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Physical TherapyLate Phase of Treatment: • Focus on increased flexibility, strength & endurance• Teach self-care and personal responsibility• Provide home exercise equipment (if needed) and

instruction– Theraputty– Theraband– Home exercise ball– Foam Roll

• Limit TENS unit to specific cases for pain management• Limit home traction unit to radicular cases • Prescribe one month trial• Re-evaluate for demonstrated use and benefit before

refill

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Cumulative Trauma Injury

• Defined by mechanism – not anatomy.• Work Related Musculo Skeletal Disorders

(WRMSD’s) Includes many different tendinopathies, myofascial pain syndrome and sometimes peripheral nerve entrapment (CTS)

• Identify specific diagnosis– Extensor tendinitis bilateral wrist (R>L)– Lateral epicondylitis R elbow – mild, chronic

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4 Major Causes of Cumulative Trauma Injury

• Excessive force

• Awkward positions

• Static muscular tension

• Insufficient conditioning for job requirement

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Cumulative Trauma Injury Challenges:

• Gradual onset

• Delay in seeking care

• Multifactorial cause

• Prone to “Injury Creep”

• Typical treatment guidelines geared to single, acute conditions under ideal conditions

• High risk of recurrence

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Cumulative Trauma Injury Challenges

• Milder cases: an absence of objective symptoms

• Subjective symptoms such as pain influenced by mood, attitude and job/life satisfaction

• Response to treatment impacted by personality– The mis-educated and over-educated– Fear, anxiety and frustration

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CTI: Treatment Plan

• Ergonomics - evaluate & adjust• Self-care

– Microbreaks hourly?– HEP: flexibility, strength, endurance and

reduce pain

• Technique at work and home• Splints?• Work Habits (hours, pace, days,

location)

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Call Designated Employer Representative (DER)

• Diagnoses• Why I consider it occupational• Treatment plan• Establish Communication• Early intervention if there are discrepancies in history • Insider information

– back story– pre-claim conflict – workplace issues

• Re-examination of causation

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Case Management at MD Recheck

• Before you walk in…– Always check previous note and if needed DFR– Always check PTx flow sheet for # of visits and

exercise compliance– Stay on track with treatment plan– Check for new reports, diagnostics, consults,

correspondence and status of certification

• Reinforce patient-physician relationship

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Case Management at MD Recheck:

• “How is it going?”

• Get specific about injury– Patients wants to talk about pain– I want to talk about function– Get specific about functional capacity

• Check compliance– Home Exercises / Microbreaks– Meds– Splints

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Case Management at MD Recheck:

Reinforce:• To change outcome we need a change in

behavior• Monitor for passivity, blaming non-

compliance, sabotage, inconsistencies“The Lecture”: “Ultimately this is going to be

your problem if…• Restrictions become permanent• Fact: Impairment / Disability ratings have

changed• Chronic pain is chronic and can ruin your life

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Case Management (cont.)• If responding to PTx/HEP consider 2nd Rx if

– Not ready for independent self care– Not ready for trial of full duty

• If not responding consider – Certified Hand Therapy (CHT) – Chiropractic– Acupuncture– Myofascial release

• Discuss treatment options with patient – Placebo effect– Sense of control– Not appropriate for all patients

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Especially Challenging Cases

• Low Back Pain from prolonged sitting

• Depression/Anxiety from work (“Stress claim”)

• Depression from chronic pain, etc.

• Sick Building Syndrome / Chemical Sensitivity

• Noncompliance with treatment plan

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Low Back PainFrom Prolonged Sitting

• History• Look for prior injury or alternate causation• Check Ergonomics• Check Work Volume• Thorough examination• “The talk”:

– The human body and prolonged static posture– Microbreaks– Overall fitness / balance

• Poor Job Fit : this is your problem

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Stress Claim / Psych. Claim• “So how did you get hurt?” • Basic history about circumstances

– Relationships– Work volume

• Doesn’t meet >50% occupational causation:– See your own MD– Call employer and advise

• Strong case for legitimate claim:– Make referral for psych. referral– Continue care through personal health plan until

claim accepted (we are not mental health specialists)

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Depression

• Pre-existing?

• Identify early because this will impact coping and recovery.

• Refer to personal MD for treatment because not occupational causation.

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Depression “due to injury”

• Chronic Pain • Disability• Financial Impact• ImpairmentReassure – • “Normal” response to consequences of any

illness or disability• Depression is situational and will resolve with

physical recovery or emotional adjustment

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Depression “due to injury”• Recommend patient see PMD• WC not designed to manage depression• Patient probably predisposed to

depression/anxiety – check history• Do not automatically accept as secondary to

original injury• If denies prior hx of depression consider

psych. consult• PTP cannot ignore patient psych complaints

associated with injury• While consult being certified (?) refer back to

PMD.

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Sick Building SyndromeChemical Sensitivity Syndrome

• History, history, history• Investigate thoroughly before accepting claim• Review MSDS (if applicable)• Discuss with DER or Safety Manager• Review Industrial Hygiene report• Toxic response must make sense• Causation is EE’s duty to establish• Toxicology consult if highly plausible/probable

Chemical Sensitivity is ultimately a job fit problem

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Problematic Patients• Passive / Depressive / Anxious personality• Borderline personality• Type A personality• Never feel ready for trial of full duty

– Proceed with trial of full duty– Call employer

• If fails trial of full duty:– Mis-diagnosis?– Consult?– Diagnostics?– Work Capacity Evaluation (WCE)?

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Other Problematic Patients• I don’t ever want my case “closed”

– “It might come back”– “What if I need to find another job” – “I won’t continue to treat you if…”

• you are not responding to care, or• stable and don’t need regular medical care.

– Reassure and describe Future Medical• “I got laid off…”

– Often a secondary gain issue– If on full duty see above– If on modified duty request WCE

• Figure out what is blocking MMI

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Closing Cases as P&S

Depends on outcome:

• Cured?

• Residual symptoms?

• Residual impairment?

• Residual disability?

• Permanent work restrictions?

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Other Issues to be Resolved at P&S

• AMA Guides Whole Person Impairment Rating

• Causation: Is residual WPI Occupational?• Apportionment: Is the WPI of mixed

causation?• Future Medical: What? How much? How

specific about type? Indefinite?• Permanent Work Restrictions?

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Common WCE Results

• Most IW’s are “full duty capable” despite pain and behaviors

• Many identified as having inadequate “Chronic Pain Coping Skills”

• Very sore after testing strongly suggests non-compliance with HEP

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Thank You

Alliance Occupational Medicine315 South Abbott Ave., Milpitas

2737 Walsh Ave., Santa Clara

Please visit us at

www.AllianceOccMed.com