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6.1 Epidemiological and Prevalence of Psychosocial
on which the patients self-report symptoms and function. While these questionnaires (Oswestry Disability Index, DASH, Knee Society rating scale, SF-36, etc.) have been validated in populations not seeking compensation, their use in compensation patient populations has not been scientifically validated. Thus, something (psychosocial issues) other than biomedical issues causes the treatment results to be worse, as assessed by patient self-report, in workers’ compensation patients.
Many workers’ compensation patients do not have significant psychosocial confounding issues, and these patients recover like the noncompensation patients. There is no postulated biological reason for delayed or poor recovery in these compensation patients; therefore, logically, those patients with psychosocial confounders are those who have delayed recovery and poor outcomes.
Compensation status also affects the outcomes of vocational rehabilitation efforts (Drew et al., 2001).
This conclusion is supported by studies on the prevalence of psychosocial issues in compensation patients. Dersh found that 64% of 1,595 patients in a tertiary reha- bilitation program had major (Axis I) disorders (other than pain disorder associated with psychological factors), compared with 15% of the general population (Dersh, Gatchel, Polatin, & Mayer, 2002). In addition, 70% had a recognizable Axis II personality disorder, compared with a literature estimate for the general population of 6–14%. Psychological and personality factors are an important issue in those with upper limb work-related disorders. Ring and colleagues found that compared to patients with specific diagnoses, those with idiopathic arm pain had a much higher prevalence of psychological issues, and that upper extremity ill-health correlated with depression (Ring, Kadzielski, Malhotra, Lee, & Jupiter, 2005; Ring et al., 2006).
In summary, psychosocial confounders are common in occupational medicine in workers’ compensation patients, and these issues seem to explain the poorer outcomes noted in treating these patients. This has recently been reviewed with a conclusion that comprehensive biopsychosocial treatment is more effective than isolated traditional biomedical treatment (Vranceanu, Barsky, & Ring, 2009).
6.2 Discussion of Usual Care Treatment Process: Strengths and Weakness Within Occupational Medicine
Many physicians manage musculoskeletal disorders within the biomedical model, as this was how they were trained. Most orthopedic and neurosurgeons, who provide the majority of specialist care for workers’ compensation injuries, did not have a psychi- atric rotation during residency training, and psychologists and psychiatrists are not part of the traditional teaching faculty in these residency programs. Most orthopedic and neurosurgeons have strong obsessive compulsive personality traits, which makes them perfectionists who are very detail oriented (critical for surgeons), good with differential diagnosis, and hardworking/goal oriented. However, this personality style is uncomfortable with emotions – their own, their significant others, and their patients’ emotions (Oldham & Morris, 1990). Thus, the same personality traits that
make many orthopedic and neurosurgeons good surgeons give them “blinders” to the psychological makeup of their workers’ compensation patients. While this “unemotional”
personality hinders their perception of psychosocial issues, it allows them to remain calm while treating critical medical illness and in surgery.
Occupational Medicine physicians vary. Some have been residency trained in occupational medicine, and some of these may have had exposure to psychologists and psychiatrists during residency training. The majority of private practice occupa- tional medicine physicians were residency trained in some other field, and evolved into an occupational medicine practice over time after their formal medical education was complete. Most occupational medicine physicians, however, have done multiple
“fitness for duty” exams for employers in which the issues were psychiatric or psychosocial, so as a group they may be more perceptive in recognizing and more comfortable dealing with the psychosocial issues of workers’ compensation patients.
In addition, occupational medicine physicians may allot more time per patient visit compared to surgeons, since their hourly practice overhead is less. There is evidence that spending additional time with back pain patients can significantly improve outcomes (Indahl, Velund, & Reikeraas, 1995).
6.3 Determining Current Psychiatric Functioning: Strengths and Weakness Within Occupational Medicine
One barrier to the recognition of psychosocial issues within the workers’ compensa- tion system is the workers’ compensation system itself. Most states have “fee schedules”
that determine how much physicians are paid for seeing patients in the office. For a practice to be economically viable, physicians must budget appointment time commensurate to what they are paid for the visit and the expenses to the practice of providing the care. Exploring psychosocial issues takes time to build the necessary rapport, and this exploration of psychosocial issues is in addition to the time required for the purely biomedical aspects of injury or illness treatment. The expense to the practice to treat a workers’ compensation patient is considerably higher than the expense incurred by the practice to treat any other type patient (Brinker, O’Connor, Woods, Pierce, & Peck, 2002). This is because of extra paperwork detailing causation and work status, obtaining treatment authorization, resolving collection disputes, rebilling, etc. Thus, workers’ compensation patients really need more physician time to permit the biopsychosocial issues to be addressed, and yet these are the very patients for whom the physician has the greatest economic incentive to limit the time spent in the exam room. There is evidence that insurers paying physicians more to provide quality care improves outcomes (Atcheson et al., 2001).
A second issue in the workers’ compensation system is that workers’ compensa- tion insurance companies many times have a strong bias against having any psychi- atric diagnosis recognized. In the workers’ compensation system, diagnoses that are recognized as work related are eligible for free medical treatment (possibly lifetime medical treatment), and in many systems they are also eligible for lump sum or
monthly payment financial awards for diagnoses that are permanent impairments.
Thus, workers’ compensation insurers may have a financial interest in directing cases to doctors who do not recognize psychological issues. In addition, in some states workers’ compensation systems do not recognize “mental-mental” claims (psychological disorders with psychosocial stressors, but no physical workplace injury). This may predispose both the patient and the physician to “medicalize”
stressors, by labeling them as if they were physical disorders.
A third issue is that patients in a compensation setting have been shown to fail to accurately reveal their past history of psychiatric/psychological illness. Don and Carragee (2009) found that 68% of motor vehicle accident victims seeking care for neck or back pain denied having any preexisting history of spine pain, drug or alcohol abuse, and psychological diagnoses, but these problems had been docu- mented in their prior medical records. In those seeking compensation for the motor vehicle accident, the rate of false reporting of preexisting problems was 80%.
Lees-Haley, Williams, and English (1996) found that workers’ compensation claimants describe their preinjury function on questionnaires as significant superior to average individual’s function, again suggesting that being in the compensation system changes patients in a way that makes it harder for physi- cians to obtain the needed information about psychosocial issues to be able to deal with these issues. (Lees-Haley et al., 1996 and 1997). The reluctance of patients to admit to preexisting psychological or alcohol or drug use disorders makes the use of self-report questionnaires problematic in detecting these issues. Nonforensically oriented psychologists and psychiatrists may have trouble detecting these issues if they use the traditional nonforensic mental health professional approach of accepting whatever the patient says and trying to work within the patient’s conception of reality.
Thus, the current system incentivizes the patient to conceal, consciously or uncon- sciously, the existence of psychosocial factors so that the injury or illness is accepted as compensable; the current system incentivizes the physician to spend less time with the patient than with patients with other funding sources; and the insurer has financial incentives to steer patients to doctors who ignore the psychosocial issues.
Obviously, one way to determine current psychiatric or psychological functioning is to refer the patient for formal evaluation by a mental health professional. Simpler ways to screen for psychosocial issues exist.
Physicians frequently note symptoms and exam findings that are out of proportion to the objective findings (e.g., Waddell’s signs and Waddell’s symptoms for back pain patients) in cases of biologically unexplained delayed recovery (Waddell, 2004).
This should suggest the need for the assessment of psychosocial issues. Waddell developed these signs and symptoms lists to help physicians recognize when a psychosocial problem exists in addition to a biological problem. These signs may also be present in malingering, but malingering is much less common than are psychoso- cial confounders that delay or prevent recovery.
When recovery is occurring as predicted by the biologic model, the exploration of psychosocial factors is usually neither done nor needed. When recovery or outcome is inconsistent with the biomedical model and tolerance for symptoms, not risk of
harm or objectively documented lack of capacity is the issue (Sect. 6.8), physicians should recognize that unevaluated and untreated psychosocial issues are present.
Asking opened ended questions that screen for psychosocial issues may reveal
“yellow flags” suggesting that psychosocial issues are present (Kendall, Burton, Main, &
Watson, 2009). Examples of these questions would be:
What do you think is the cause of your pain?
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Do you worry that something bad is causing your pain, but has not been found?
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When your pain increases, do you think you are harming yourself, and you must
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stop what you are doing?
Do you think you will never get better?
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Have you been feeling stress or depressed lately?
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What tasks do you do at work?
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What do you like about your job, and what do you dislike about your job?
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Are there parts of your job you fear you will never be able to do again?
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When do you think you will return to work?
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What could your employer do to help you return to work?
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Another method of assessment is to have the physician’s office staff to have patients complete pain drawings or questionnaires that screen for psychosocial issues. Pain drawings that show symptoms in places that are not easily explained biomedically are an indication for the assessment of psychosocial factors (Mooney, Cairns, & Robertson, 1976). A fear avoidance beliefs questionnaire (FABQ) (Waddell, Somerville, Henderson, Newton, & Main, 1993) and Distress Risk Assessment Method (Main, Wood, Hillis, Spanswick, & Waddell, 1992) are questionnaires the patient can complete before the physician enters the exam room. These are easily scored, and they help make physicians aware of psycho- social issues. Another “yellow flag” questionnaire is contained in the New Zealand Acute Low Back Pain Guide (http://www.nzgg.org.nz/guidelines/0072/
acc1038_col.pdf).