It’s COMPlicated – The Importance of Choices

Comments from last week illustrated the substantial difference that the choices about physicians can make in workers’ compensation.

This point was also made in a presentation at the recent IAIABC Forum.  Dr. James Talmage, a well-known authority on medical care for workers’ compensation injuries, spoke about “Working with Physicians to Achieve Return to Work.”  His talk included some of the complexities of medical care that plague workers’ compensation.  He also called for careful selection and relationship-building with physicians who provide care to injured employees. 

A surprising point Dr. Talmage made was that diagnosis errors can result from physicians’ overreliance on an MRI, a favorite target of utilization reviewers.  Without considering that aging causes deterioration in a body without symptoms, pain complaints can be misinterpreted as being caused by a new injury instead of changes due to normal aging.

This point was made in a study done on a group of 294 employees who worked for an “opt-out” employer in Texas who filed claims for injuries either to their shoulder or knee.  In the study, MRI scans were performed on both employees’ shoulders or knees, depending on their complaints of pain.  More than half of employees had more physical abnormalities on the asymptomatic side than on the symptomatic side.  The study is available here.

Dr. Talmage commented that this dependence on MRI scans is understandable.  When physicians were medical students, they equated the objective findings of an MRI with evidence of an injury.  That reasoning would be logical in cases where a person has a persistent cough, and the CT scan shows lung cancer.  The medical student could safely conclude that the cough was caused by the cancer.  

So, if an MRI scan on the symptomatic knee or shoulder showed an abnormality, it would be logical for the physician to suspect a pathology of the knee unless they did an MRI of both knees or shoulders and found the symptomatic knee or shoulder had less abnormality than the asymptomatic knee.  In these cases, the physician would have to consider whether the problem was aging rather than a specific incident. 

This demonstrates the importance of selecting physicians who understand the possible sources of the symptoms, so they can provide the correct medical treatment.  

In selecting physicians, a critical decision is to choose a doctor who approaches a workers’ compensation patient differently than a group health patient.  Doctors are accustomed to using the biomedical model that only considers anatomy and physiology ̶ but outcomes can be improved by using a biopsychosocial model that includes an understanding of a patient’s co-morbidities, job satisfaction, quality of family life, history of opioid use, childhood adverse events, and the patient’s understanding or misunderstanding of workers’ compensation.  Consideration of all these factors will help the physician to focus the patient on recovering and returning to a normal life and work in their unique circumstances.  

The importance cannot be overstated of a focus on recovery from the first encounter with a patient until they have successfully and safely returned to work.  As Dr. Mark Melhorn, Editor of the AMA Guides to Disease and Injury Causation said, “Physicians should practice effective, empathic communication strategies to help injured workers understand the benefit of early return to work.”

These are two of the many examples of why it matters which physician is selected to treat injured employees.  Employers can make a difference in workers’ compensation systems by using physicians who understand the unique considerations of work comp patients. 

To help employers find the right physician for their workers’ compensation programs, the State of Tennessee has developed a toolkit that includes information on how to select and establish effective relationships with physicians.  In the toolkit are sections on how to pick the right panel physician, including:

• Information the employer should provide to the treating physician,
• Tips to facilitate an effective flow of information between the employer and physician, 
• A list of transitional jobs available for recovering employees, 
• Sample job descriptions/analyses written to provide the specific information needed by a physician, and 
• Templates for transitional work letters that can be used when the employee is able to come back to work within restrictions.

The toolkit is just what one state has done, but there are 49 other states and countless employers who’ve been proactive about providing the medical care that offers injured employees the best chance for recovery.  

This blog is here to provide a forum where forward-thinking ideas can be shared.  Will you share yours?

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