Another Long COVID View

The potential for multiple possible causes of many of these perhaps helps us all understand the physician's struggles. So many maladies might cause stomach pain, joint pain, headache, or fatigue (examples only, from the list above). A physician evaluating a patient might attribute such complaints to a vast array of underlying disease, malady, or pathology. Thus, there is challenge here for the scientist and the patient. As we focus on the workers' compensation, there is then challenge for the risk manager, and in a variety of contexts for the human resource manager. In all, many challenges, questions, and few definitive answers as yet. 

Dr. Beaudoin stressed that there are critical emotional health issues related to the complaints patients report. This is likewise similar to Dr. Kertay's comments and perceptions in the ACOEM program. Dr. Beaudoin explained that these complaints and symptoms are reasonably new, this pandemic is new. She explained that there are perceptions that patients are being extensively tested in regards to complaints and symptoms, and these pathways of testing are perceived by some patients as "being dismissed by the medical community." That is, essentially, that more testing is a way of doing something when there is frustration over not being able to provide definitive treatment.

"if the receiving physician cannot provide a more effective therapy than can the transferring physician, medical residents consider the transfer inappropriate, and call the patient a turf." J Gen Intern Med. 1999 Apr; 14(4): 243–248.

That is not new to workers' compensation. It is concordant with some perceived challenges of soft tissue injury, which are legend in the field of occupational medicine. Patients often present with complaints of pains and discomforts that are perceived as discordant with other medical signs and symptoms, exaggerated, or otherwise questionable. In some instances, there is an incomplete or inaccurate description of the mechanics of injury that can be of interest or distraction. 

It is not uncommon for a patient to be initially treated with conservative care and then receive referrals to a parade of specialists in search of anatomical and physiological explanation for symptom(s).  The root cause of symptoms and complaints in soft tissue and orthopedics can be elusive, and there are instances in which doctors may be perceived as disbelieving or dismissing a patient. In the long run, it is likewise not uncommon for some persistent physician to ultimately identify some pathology that is then addressed, often leading to symptom improvement. Some readily lament the delay that is at times seen in the process of reaching an ultimate diagnosis and instigating specific and focused medical care for it. 

Dr. Beaudoin stressed that patient groups are interested in being believed and receiving treatment beyond testing and investigation. At this moment, only two years into this pandemic, the science is just beginning and there is likely some academic curiosity about each and every symptom, constellation, and presentation. But, as worthy as the efforts at research and measurement are in terms of future patients, doctors must remember that each present patient is in need and is seeking relief or amelioration, not merely study and evaluation. 

Patients are said to be frustrated with the lack of definitive treatment specific to the "Long COVID-19" as opposed to more generic treatments and care usual for the spectrum of symptoms being reported such as respiratory challenges. They may benefit from generalized symptom amelioration, but want to be confident that the constellation of COVID-19, their perceived cause, is being addressed.

Dr. Beaudoin added that the Americans With Disabilities Act (ADA) now contemplates Long COVID being "a disability," in that it may "substantially limit one or more major life activities." It is important to focus on the word "may." The ADA has published a guidance on this topic. Remember that diabetes is listed as potentially being an ADA disability, but that millions live with that disease and are not necessarily disabled. It is not the diagnosis of a condition that equates to disability, but the impact of that diagnosis or disease. The government has an extensive publication of COVID-19 considerations as regards disability. 

Dr. Beaudoin noted that the issues of disability are complicated by the lack of empirical data regarding whether a particular patient was or was not even infected (see above, the best way to avoid "Long COVID is to avoid infection). She opined that antibody testing is not yet of significant assistance in differentiating between a patient that has been affected by the disease/infection as opposed to one that has antibodies from vaccination efforts. She describes how the challenges of differentiation are further frustrated by the early periods of the pandemic when testing availability and reliability were challenging, a situation that may have even persisted during more recent pandemic times in certain areas and communities. Without a test to authenticate the initial infection, the proof of relationship of ongoing symptoms may be challenging. 

Employer groups have been concerned with disability, but also with issues around the legal constraints of vaccination requirements, the ADA, and more. There is a desire for clearer understandings of the potential legal exposures, the operational processes that are appropriate, and the determination of both diagnosis and impairment or disability. The mention of these challenges was an appropriate adjunct to this presentation, but in all sincerity the legal challenges are as broad and difficult as the medical and could easily overwhelm the full time of a separate seminar dedicated to them. 

Of interest, there are seemingly issues with the need for documentation and accommodation of the impacts of COVID. These are not necessarily different challenges than workers' compensation experiences in a variety of maladies and conditions, including even the most common orthopedic or soft-tissue issues. The differentiation of effects of current trauma from the potential pre-existing maladies, conditions, and effects has been part of the diagnosis and treatment challenge in various workers' compensation cases forever. There have long been forensic evaluation challenges to make such determinations in the context of "major contributing cause" and other similar statutory standards. That this is not different in "Long-COVID" is likely neither surprising or encouraging from any perspective. 

Teasing the cause of current symptoms from a spectrum of complaints that may relate to COVID or a variety of comorbidities and pre-existing conditions is seen as a medical challenge. Dr. Beaudoin opined that differentiating will be dependent upon critical analysis of prior medical history, various testing, and study. Her discussion seemed to make reference to a forensic approach to differentiating former symptoms, diagnoses, testing, and the current symptom universe in a particular patient. In that context, it is notable that the volume of patients appears significant and the population of available physicians really has no potential for expansion (the existing profession will perhaps have to divert attention to "Long-COVID" to the potential detriment of other maladies and conditions). 

The doctor noted there are "knowledge gaps today." There is more that remains unknown about COVID-19 than is known. This is frustrating for all involved, and is likely impacting the emotional function and recovery of the patient. The patient, at a minimum, believes her/himself to be suffering from the long-term impact of this viral assault. With all of the questions and unknowns, much remains to be studied, catalogued, documented, and analyzed. 

And, it is possible that medical progress may be years in addressing some issues related to COVID-19 just as there have been long challenges with a variety of human ailments including the previously mentioned diabetes, as well as cancers, lupus, Parkinson's, and the list goes on. To further frustrate matters, there are questions of the impact that various COVID variants may cause and how changes in the virus itself may impact the progress of individuals and the medical reactions to those symptoms and challenges. 

Dr. Beaudoin concludes that the situation overall is not under control, and that science and medicine are struggling with "Long-COVID." Her perspective and comments had parallels to the ACOEM conclusions, but bring a somewhat different perspective and focus. The presentation is well worth viewing. As the scientists bring more study and results, it is probable that future presentations will bring further edification and progress. However, for now, the information in such programming is a fundamental necessity for those in claims, employee relations, and more. 

By Judge David Langham

Courtesy of Florida Workers' Comp