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Navigating Disability Benefit SystemsAn Introduction to the Basics

Learning Objectives
1. Describe the relationship between work and health outcomes
2. Apply effective communication and documentation strategies to streamline the claims process
3. Navigate requirements for disability claims with greater proficiency
1 Credit CME

Health care professionals who do not have specialized training in evaluating patients with diminished work capacity often find themselves facing patients who they believe are unable to work because of a health condition. This video explores essential information that front-line health care professionals need to know about disability benefit systems to help patients navigate this complex system.

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Video Transcript

Zach Hochstetler: [00:00:00] All right, let's get started. I'm Zach Hostettler. I'm the director of CPT Editorial and Regulatory Affairs at the AMA. And I'm really happy to be the host for this webinar today. Our webinar is entitled The Navigating Disability Benefits Systems and Introduction to the Basics.

[00:00:20] We're excited to put this program together with two leading experts in the disability benefits system. Here's a quick slide on CME. The American Medical Association is accredited by the Accreditation Council of Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this live CME activity for a maximum of one AMA PRA Category 1 (TM) credits.

[00:00:48] Physicians should claim only the credit commensurate to the extent of their participation. And the activity. Successful completion of the CME activity, which includes participation in the evaluation component, enables the participant to earn up to the following credits that you will see listed in the bullet points below.

[00:01:08] CME credit can be redeemed on the AMA Ed Hub. Participants will receive a follow-up email with additional details. All right, so let's get to our presenters. First off, Dr Les Kertay is an advisor on the AMA Guides editorial panel. He is the Senior Vice President for Behavioral Health for Axiom Medical and is an Adjunct Professor of Psychology at the University of Tennessee Chattanooga.

[00:01:38] Dr Doug Martin is the co-chair of the AMA Guides editorial panel. He's the Medical Director for the Center for Neurosciences, Orthopedics, and Spine Occupational Medicine in Sioux City, Iowa. He is also the immediate past president of the American College of Occupational and Environmental Medicine. Dr Martin, let me turn it over to you.

Douglas Martin, MD: [00:02:00] Thanks very much, Zach, and I want to offer my welcome to everybody that's participating today in this webinar. Dr Kertay and I have been at this a long time but I think that it's important to look back at why this whole issue of understanding various different disability systems is important. And then also, furthermore, to explore what roles that we have as physicians in that whole process. I think my experience is fairly similar to most that I had no idea what this meant in medical school. I had no introduction to it in my family medicine residency and only learned about these things once I was out in practice, which of course is not the best way to learn things.

[00:02:44] A lot of mistakes along the road. I don't mind admitting that. But this all culminated Dr Kertay and you forming this book, which I think was monumental in trying to get information about the various different disability systems together in one place, and then also obviously talking about the importance of the role of the physician in the whole disability determination process, and then also trying to make a difference in people's lives so that we try to prevent those things from happening.

[00:03:19] I just want to summarize a little bit about what is in the book and I know Director Kertay will expand on a lot of these types of things. So the book is actually put together in a really nice format. The first couple of chapters actually talk about why the whole issue of work is important. And I think a lot of times we don't think about that from the perspective or context of that being a medical treatment, but it really is, and I think a lot of times it's underestimated as far as how much power that has Yeah. In the actual treatment process for whatever condition, whether that be an ill injury or an illness that individual might have.

[00:03:58] The third chapter is a really important one, and that talks about the risk capacity tolerance paradigm. And I know that. Unless you're going to talk a little bit more about that in detail. That's something that again I didn't learn about until I was probably in my sixth or seventh year of practice as an occupational medicine doctor, but how important it is to understand what those three different words mean.

[00:04:20] And actually what we as physicians are good at and also admitting maybe what we're not good at is important. And then of course you cannot have a discussion about disability benefit systems without talking about causation. And I know that you have a chapter that's devoted to causation analysis and of course that's extremely important in this whole process-- try to figure out which bucket applies. If you have a problem, it's really important, at least in the systems that we have in the United States, that we align those things correctly so that the right players are able to get involved at the right time.

[00:04:58] The other parts of the book... you have a whole chapter devoted to communication, how incredibly important that is. I think as physicians, oftentimes we don't, understand how important it is to involve all the stakeholders in the communication process, but when we're interfacing with these disability systems, it's incredibly important to make sure that all players understand what's going on. And oftentimes the physician is looked at as the quarterback of that team.

[00:05:24] Then we go through in your book, of course, the various different benefit systems of which the United States is somewhat unique in that regard. We have multiple different benefit systems. We have Social Security. We have Work Comp. We have the VA benefit system. And all of those things have their own little intricacies and unusual parts about them. And it's really important to understand what those things are because they're clearly not the same. There are different things that occur.

[00:05:49] And then the last chapter, of course, in your book is really hits the nail on the head with regards to that whole issue of why work is good and why as physicians that we should be supporting work activities just as an overall health phenomenon, for sure.

[00:06:03] Just to go over the learning objectives as far as what we're going to cover today, we're going to describe the effect of worklessness on health outcomes. We'll have some statistical information to share with you about that. Another thing is to how to deploy effective communication and documentation strategies to streamline the process. Try to make it as simple as we can for people, for sure. And then lastly, to be able to navigate those requirements for disability claims with greater proficiency, so that we understand how to weave through that with a little bit better ease, I think.

[00:06:36] So with that, Les, I'll turn it over to you.

Les Kertay, PhD: [00:06:38] Thank you. Thanks, Dr Martin. And welcome everyone. And needless to say, in a little less than an hour, we're not going to do all of that in a great deal of detail, but I do want to hit the high points. This question: has this happened to you?

[00:06:53] I'm going to assume, if you're here, that this or something like it has happened to you, and this is generally how people begin to learn about benefit systems. You have a patient who walks in and hands you a form and tells you what they want to have done, and the question is that the right medical decision for that patient? And if you don't have any familiarity with the process or the systems, then sometimes it's easy to just default to the easy thing to do and fill out the form the way the patient wants it. And that may turn out to be a really bad thing for the patient in terms of their health.

[00:07:38] That's why we wrote the book. We wrote this book specifically as a primer for people who are on the front lines of medicine, primary care either psychologists or physicians or, perhaps in a specialty, but not doing evaluations of function, but we're faced with this all the time.

[00:08:03] And so that's what we wrote the book for. So here's your question. The patient's got a lot of pain. It's very—work's really stressful. And he needs, feels like he needs some time off, hands you a family medical form. And, oh, by the way, so short term disability is going to be sending you some forms to fill out.

[00:08:22] I'm going to complicate it a little bit. Because the first question is, OK now what do I do? Look like deer in the headlights. So some things that add color to this that are, by the way, it wasn't that hard to make up this scenario because it's a pretty common one. I've been working at the same place for 20 years. It's a pretty heavy demand job. And over the last six months. I've been complaining to you about pain and, sent me to see somebody and I might need a hip replacement. I do have type 2 diabetes. It's not very well controlled. And I've been taking, just for my mood, I've been taking some fluoxetine for a long time and it seems to be working okay.

[00:09:07] Lately, though, I'm not sleeping that well, and I'm spending a lot of time arguing with my family, and I'm feeling a lot more irritable and argumentative. Now, two questions that I want you to ask yourselves. What was your first response when, I gave you that first little bit of information, and then how did think, how did your thinking evolve as you got a little more of the story?

[00:09:34] Did it change things? Are those facts that I gave you, they're certainly facts that might be inclined to make us more sympathetic toward the patient? But the question is, does it change anything about what we're going to do about those forms? Is that relevant information? So those are the kinds of things and today what we're going to have time to do basically is raise a lot of questions and hopefully start you thinking about some of these things and how we address it.

[00:10:04] Here's what I think you should know before you answer the question. right? The first thing is that being out of work has terrible health consequences. It has morbidity associated with it. It has mortality associated with it. People who are out of work die sooner. This is not the health out.... When I first started talking about the importance of being at work from a health perspective 25 years ago, the best that I could say was that we have no research anywhere that being out of work is good for people. We now have definitive research that being out of work has terrible health outcomes.

[00:10:44] So that's the question that I think that we have to start with, right? Is this the right thing for this person? There are other factors, work relevant injuries and illness have a huge, are a huge part of health care costs in general. There, we could get into statistics about the difference between someone who is injured and the work and work related versus those who aren't and how much that costs the health care system.

[00:11:13] People who are either out of work or they have a problem physically and they're less. productive at work, that has a huge impact on, we're now talking, approaching a trillion dollars a year. If you factor in decreased productivity as well as absence costs this is a, not a small impact on the economy.

[00:11:39] And so And I'm going to come back to this toward the end. But, one of the things that I want everybody to take away from this is to think of work as a health behavior. It is one of the health behaviors. Okay, so let's go back to our scenario here. The short term disability forms come and they want to know these questions.

[00:12:01] What's the diagnosis? What's the relevant diagnosis for this particular claimant in this moment? What are his restrictions and limitations? I'm going to spend some time talking about those words because I don't know about you, but most everyone that I talked to who went to medical school or got trained in psychology never encountered those words in the course of our training.

[00:12:28] And then they want to know, in some way, they want to know, can he work? Some forms will ask that question directly and some forms won't, but it's, it is the implied question. And, your question is what do you do? Is it a disabling condition for someone to come in whose back is bothering them, who has some other complaints?

[00:12:52] Is it a diagnosis that in turn they will keeps them from being able to do their job. That's the fundamental set of questions that we've got to ask.

Martin: [00:13:01] And then, oh, by the way, Les he drops this off at 4 30 pm and wants it done by tomorrow at 8 o'clock so he can pick it up.

Kertay: [00:13:09] Exactly, of course, exactly, of course.

[00:13:12] And having worked inside of disability carriers over the years, one of the things that I'm aware of is that would send out these forms as part of the process--claims people, not the, the medical staff didn't make claim determinations, but they'd send out a form, ask you to tell us what the restrictions and limitations were, and then you send it in, you do your best answering it, you send it in, and then the you begin to argue with someone at the carrier about whether what you said is good enough or not.

[00:13:46] I'll say this just so that I don't, so that I don't forget it. I'll probably come back to this again, but the statement, no work is neither a restriction nor a limitation. It's actually an occupational statement, right? You're saying that person is incapable of functioning in any meaningful work capacity.

[00:14:06] That's not what they mean. So we'll get to that in just a second. In this a place to start is what's your role? How are we going to think about work as part of a health, the health condition of our patients, which has psychosocial factors, it has medical factors, which is what we're trained to take care of, and it has economic impacts. And our piece is the middle, but it's a really critical piece. It's not up to physicians to make the disability determination, but they're certainly going to be influential in how it turns out. You're, you, along with restrictions and or limitations. As I always like to say, restrictions and limitations is not a single eight syllable word.

[00:15:01] You're going to encounter language that is familiar, but used in different ways. When we talk about different systems for just a couple of minutes one of my favorite examples of this is the word disability. In a context of social security disability or private disability means that the person is unable to work.

[00:15:25] In the context of the Americans for Disabilities Act, and its, it has the opposite meaning. It has, you have a condition when accommodated allows a person to work. Same word, but it has very different applications in those two systems. Things that seem familiar are actually arcane. And I think that we all can agree that we don't want to do...first, do no harm. And then the second thing is promote health. And the question is, in this setting, what's the thing that's going to promote health? So we'll probably spend most of our energy right here in talking about, how do we think about Joe's request?

[00:16:16] And I want to go back to those words, restriction and limitation, because I think it's really helpful if we use a very specific set of definitions for that. A restriction really should be something that a person should not do because doing so might cause them harm, like actual harm. And I want to be clear about that, that I'm not only talking about increased discomfort, because that increased discomfort may or may not be an indication of harm that's happening.

[00:16:55] Doug knows this, that I, a couple of years ago, I had a serious bicycle accident and I had a significant fracture to my pelvis and ended up with a hip replacement and fixing it. It's great. It's all well. I went back for a year of follow up and I asked my surgeon, my trauma surgeon, is there anything I shouldn't do?

[00:17:17] And he said, yeah, don't fall, which made me laugh, right? It was great comic relief. And he said, I know it sounds funny, but seriously, if you fall hard enough to break anything, it's going to break around the screws. And then I don't have anything to put back together. So don't fall. That's the restriction. And I actually, I complimented him and I said, you may be the first person that I've encountered in this process who actually understands what a restriction is. That's a restriction. Don't do that because doing so might cause more specific harm.

[00:17:58] A limitation is something that a person cannot do, no matter how much they want to. I am incapable of doing those things. That can be... I can, we can make this trivial, right? I can't fly but that's not a meaningful limitation because I never could. What am I limited? I have certain, in my case, I have some limitations in my range of motion. Not particularly relevant to anything that I do, so it doesn't get in my way. I'm pretty capable of doing anything that I want to, but it is a limitation. It's an actual limitation. I can't make myself do things that my hip won't do.

[00:18:41] And then everything beyond those two things is a question of tolerance. And I want to take a couple of minutes here talking about tolerance because it's important to, to note. I didn't use the phrase just tolerance. I use the term tolerance, right? If I do something that causes me pain. I am going to self limit that activity, right? And that's, that is a tolerance question. I'm probably not doing any physical harm, if, especially if it's chronic. And in our case, in Joe's case we're talking about back pain. One of the things we know about back pain is that staying active actually has better outcomes than being inactive.

[00:19:31] So in that case, that pain might actually be something to put up with. Nevertheless, it is a tolerance issue that your patient is going to have to put up with a certain amount of discomfort in order to get better. Is that fair? The important thing here, is, and I'll say in just a minute, I'll say a few things about what your options are in terms of what do you do with tolerances as an issue?

[00:19:57] How do you assess it? We're in medicine, we ought to be really good at restrictions. We're pretty good at limitations. We should have objective measures for what people can and can't do. Tolerance is... that's where we get into biopsychosocial issues and issues of motivation and literally what am I willing to put up with, right? If I like my job, I'm willing to put up with some things that I might not be willing to put up with if I don't like it.

Martin: [00:20:29] So one of the things that I it took me a while to figure this out was, but you can probably understand that those of us that think in terms of what we can measure objectively but then comparing and contrasting that to what is subjective. When you talk about the restriction, we are pretty good about that. We can look at a scenario as physicians and we can We're pretty decent at being able to predict when something's going to be bad for somebody, right? And the limitation part, we can measure that. We can measure a joint range of motion.

[00:20:59] You brought that up in your particular case with your accident. We can measure somebody's strength. I can put somebody on a treadmill and see what their cardiac endurance is like. I can figure those things out, but the tolerance is the problem because that's subjective. And I, I can't plug a motivation meter or a pain meter on somebody and make that mean anything for me. So that's where the struggle is for sure.

Kertay: [00:21:25] Yeah. Yeah. And I, in, in our book, we repeat this and it's also in AMA Guides to return to work, they're you have four choices when you're dealing with tolerance. You can either take dictation. You can put down on the paper what the patient tells you they can or can't do. And frankly, that's probably the most common thing that I see. Most of the time, that's what we do. We put down what our patients tell us they can and can't do. Not really thinking about the potential health consequences of that activity.

[00:22:06] And also, I can't tell you how many times I've seen examples where the physicians tells me that their patient cannot do their job, and it turns out that the patient told their physician that they have to like regularly throw, pick up, turn, and throw 50 pound bags of whatever. And in fact, that's not their job. It may feel like that, but that's not actually what they need to be able to do. So that's an important piece of that. But I, the temptation to take dictation, I think we have to back up from that and start to figure out what else am I going to do? What's my, what's my other choice here? I can try to assess tolerance. Good luck with that. Because I can't do anything except take your word for it, right? Here's what I feel like I can do. There isn't a measure for it you can guess based on your experience, yeah, it's probably going to hurt when you go like that. Question is, does that actually get in the way of you being able to function?

[00:23:19] Or you can call it like it is. You can say here, based on the examination, my examination of you, my knowledge of you from your history here's what I know that I can say that you can and can't do. And here's what you really shouldn't do because that might cause you some harm.

[00:23:40] And beyond that, it's really a question of what are we, what can we do to help you? Here's the way I'd put it. What can we do to help you tolerate your symptoms better so that you can be as functional as possible? That's the way that I would approach it. That's the communication style that I have. People have different ways of going about that, but it's essentially, you need to tell people the differences between those two things. No, in fact, When you do that, yes, it hurts, but you're not really doing damage. And I'm sure that you encounter that on a regular basis, right? The big one that I would suggest, the big two that I'd suggest staying away from is don't take dictation and don't try to assess it because it's not possible.

[00:24:29] There is in the book, and I won't do it in a ton of detail here, but we have a seven So it's really an eight step process, but seven's an A or a B, right? It's important to understand...actually, the way that we have it written in the book, is it's important to understand the job. I'm going to actually expand that, given that I'm currently semi-retired. It's important to understand what a person needs to be able to do. And work is a really important part of that, but that might not, that might not be the issue, right? In my case, bike riding is not part of my job. If it's, but if it's relevant, that's something I need to know about, right? It's important for you to understand what the actual tasks are that a person needs to be able to do in order to function effectively in their life. I'm going to say all of that, right? Work is shorthand for that, is the way that I mean it, when I'm talking about it.

[00:25:31] I think that it's really important that we have an accurate diagnosis. Physicians are really, are and should be good at this. I, speaking about mental health diagnoses, I sometimes feel like we apply criteria in a sloppy way, which is problematic. Nevertheless, we're trained to do that. We are trained to make a diagnosis. Make sure you make it, and make sure you have, you understand the reasons that you made the diagnosis. So far we're in pretty... We're in pretty good medical tradition here. Then it's important to ask the question, is there objective evidence whether you can, you have clinical findings, signs or known medication effects that make it reasonable that this person should take a brief period of time out of work to complete their assessment? Because we don't always know. Right on the spot. We don't know necessarily. Is it reasonable? I'm going to encourage you really strongly not to simply decide to keep somebody out because it's easier to have that conversation. brief conversation.

Martin: [00:26:51] It's only one box to check on the form.

Kertay: [00:26:53] That's right. It's easy, but and it's easy because your patient won't argue with you. So give it some consideration, but it's important to recognize that there are circumstances in which that's important to do. Is there treatment for-- Number four, is there treatment for the condition that you diagnosed and what's the prognosis if you did that treatment effectively? Is that, and now we get to the questions that we're not necessarily, that we weren't trained to do, but I think is intuitively should make sense.

[00:27:31] The next question is there a risk of harm if a person does a particular activity? And if there is, then you assign that as a restriction. That's a restriction.

[00:27:43] Immediately following that, are there limitations? Are there incapacities that this person has, things that they just cannot do? It's important to, to to note that. Now comes part seven, which has two parts. So one of those is, nope, yes, they have a diagnosis, Yes, they don't really require time out of work to, for further assessment, or they, we can continue the assessment while they're functioning. They're we think there's treatment. We think that a person's likely to continue to be on a good course, and they won't harm themselves, and they're not incapable of working. I certify ability. You can do these things. And that's the way that it is. It is possible.

And I'm pretty sure that everyone on this call has had the experience that patient then says, but my, it hurts too much. I can't do that. I can't do this anymore. Right now, your choice is really, and now we're coming down to communication. How are you going to have that conversation with the patient, to say, I can't really say that you can't do it. I can't say that you shouldn't do it, but I can say that doing it will cause you discomfort. So stick to the facts. That's a tough one, but I'm encouraging us to think about that because it's really important in terms of that person's health, right?

[00:29:30] This is my favorite question to ask other treating providers, but I also ask it of myself when I have a patient. If this person wanted to go to work, would I let them? I would say that 95 times out of 100, the answer to that question ends up being yes. And what does that tell me? That tells me two things. If my answer to that question is yes, if they wanted to do it, would I let them? That tells me that they're not at risk of harm, because if they were, I would restrict them from doing it. I would tell them not to. And they're, and I don't believe that they're incapable of doing it. And so there are no restrictions. There are no limitations. Now we're talking about motivation, tolerance. Is that the right thing? It's, this question sounds a little flippant, but I've actually found it really helpful to apply to myself when I'm seeing a patient or if I'm evaluating a file or doing an IME, if this person wanted to do what they can do, what, do their job, would I prevent them from doing it? And if, by the way, if the answer is yes, I almost immediately know why, if, or I'm sorry, I said that backwards. If the answer is no, I wouldn't let them do it. Even if he wanted to, I generally know why, right? I know what the problem is.

Martin: [00:31:04] It's all context, right? The context of this is incredibly important. And I, there's probably others on the call that have had this experience where you have the same individual that maybe has an injury or an illness at the workplace and you're treating them through that. And, they have this discussion about, oh, I don't think I can go back. It's going to hurt too much, et cetera, et cetera.

We have those discussions and decisions with the patient and whatever that outcome might be. And then, oh, by the way, they're in your office a month later for a new post job offer physical. And the person is there and says, oh, I'm fine. I don't have any problems with that at all. Has the pathology changed? The pathology has not changed one bit. The concepts of looking through the restrictions and the limitations hasn't changed. It's all about their perspective, their motivation, and their tolerability.

Kertay: [00:31:56] Yep, yep. And I want to use an example here also that, to, this is not a heartless application of this question. We had a case in which a there was surveillance in a claim. The man's job was essentially construction and surveillance caught him up on the roof. fixing his roof. And, so we were ready to say the orthopedist who worked for us was ready to say that's, that's obvious evidence that he can do it.

[00:32:30] He called up the claimant's provider and asked about that. And his comment was, yeah, I know he did that and I yelled at him for it because he could have really hurt himself. That was not a smart thing for him to be doing. I can't remember the specific orthopedic condition, but that perspective is also important. Sometimes we do things that we really shouldn't do because it might cause harm, but we do it anyway, right? I think it's just important to have that whole context and understand it, and your job as a physician is to help determine what a person can and can't do and what they should and shouldn't do.

[00:33:17] And that's really why we wrote this book, was to get that focus. I mentioned earlier that your answers to all of these questions might vary depending on the system. Medical leave tends to be more forgiving in terms of its rules. If a person needs some time off to get to go to physical therapy, it's job protection, essentially.

[00:33:40] I do want to say that, that doesn't make it entirely benign because one of the things we know is that taking family medical leave in one year, whether it's for yourself or for someone else, actually is predictive of increased risk for filing a short term disability claim in the following year.

[00:33:59] So it's not entirely benign. It still needs these rules, but nevertheless, it's a little less exacting than the rules for private disability, which is all determined by contract. Social security disability, which is controlled by the law and administrative law, or workers compensation, which is controlled by regulation, right?

[00:34:23] And in workers compensation, causation becomes an issue that really doesn't matter in private, in a private disability claim. So I can't, the book has several chapters that go through these different systems and some of the ways in which they are similar and different but that would be another webinar and you guys don't want to stay for that one, right?

[00:34:49] I'm just going to say just a word about how some, a few words about how we're communicating This is the question, like, how are you going to talk to your patient? You might notice, and I suppose I'm guilty of being a psychologist, I tend to have an approach that's supportive, that's pretty straightforward, but I'm not going to be unsympathetic.

[00:35:15] Nevertheless, I'm going to say what the facts are. That's the question. Those take some time. It takes a couple of, it takes a few extra minutes to do that, but I do want to be clear, I, and I hear this a lot that, I've only got six or seven minutes with a patient.

[00:35:35] Okay, but I can say the same thing and say the truth in a sentence that takes me just the same amount of time as it does to agree to what they want and sign the form. It doesn't take a long time. It does take some practice, and it also takes some trust with your patient. We'll come back to that in a minute. Are you going to talk to his workplace? If he, if they accommodated, if they made an accommodation, could he do the job? Would that be the right thing for him? How are you going to talk to the insurer? Are you going to assume that it's adversarial? Are you going to assume that we're trying to do the right thing for my patient?

[00:36:18] And we all have biases about this. Are you going to talk to his attorney if he hires an attorney? How is that going to go? These are all important things. I, a more important question is it really your job? Your job is to take care of your patient. If your patient has brought you forms, your job is to take care of your patient in the context of whether or not you're going to fill out those forms and how you're going to fill them out.

[00:36:47] Physicians can't do everything. When we looked at in the ACOM guidelines for disability and return to work, one of the things that we found was consistently that, excuse me, consistently that the most, the best predictor of return to work was the a relationship between the employee and the employer and whether the employer was willing to accommodate, to make an accommodation. Physicians actually didn't have that much to do with it most of the time, other than don't mess it up. So I think, you'll hear a lot about this and we could go into great detail about all of these communication styles, but I also want you to ask that question what's your job? Your job is to take care of your patients in the context of what they've brought to you.

[00:37:39] I'm only going to say a word about causation. This is a whole, this is a whole day seminar, at least, to try and get into causation. When causation is an issue, there is a science to how you go through the process of determining medical causation. Medical causation isn't necessarily the same as legal causation. And it, what it isn't for sure is just because it happened at work, it's because of work. I bent over to pick that, pick up that object on the floor at work, and my back hurt, and therefore work caused my back injury. Probably not.

[00:38:29] But in our patient's mind, it happened there. That's got to be the, that's got to be the issue. And I think we fall into that as well, right? Something happens in a certain order, then it's automatically called causal. It doesn't take into account risk factors, the epidemiology, the base rate in the population of this particular, what's the base rate of our, guy who's worked in this at the same, medium to heavy OCK for 20 years, what's the base rate of back pain? Probably pretty high. Those are all things that we take into account and I, we can't do it all here.

[00:39:09] So I'm going to, before we go into some conversation in Q&A, I want to just summarize with this last slide. This, if I, if you don't, If you haven't heard anything other than this in the course of this seminar, the thing I really want you to take away from this is work is a health behavior, and to the extent that you can promote work as a part of normal life function... So you're promoting life function, work is a part of that. To that extent, at least think about it as a health behavior. And, we don't base our determinations for what somebody wants to do based on their tolerance. I like smoking, doc, so write me a script that says that, I can smoke. We wouldn't do that, right? So I, I think that's the thing I really want you to take away from this, and since our role is to promote health, we can make a difference in this process, and we can keep people from being needlessly out of work, but we can't do everything there. Some of this is we have to enlist our patients in the process and we can't do all of the work.

[00:40:34] So we'll get to some discussion and I don't know if we have questions from the audience or okay. Doug, I'm going to put this question, the first question to you, in Joe's, in Joe's situation, if you were inclined not to keep him out of work, what might have changed your mind?

Martin: [00:40:54] Yeah.

Kertay: [00:40:54] I'm assuming, by the way, that you would have been not, based on those simple facts, you probably wouldn't have been inclined to keep him out of work.

Martin: [00:41:01] Sure. So I think what you said about communication is incredibly important. And I think if there are questions that come up, it becomes incumbent upon the physician to explore further, especially with regards to the workplace issues. And I've had multiple examples that I could share with you. But as you indicate, a lot of times the report that you get from the patient isn't exactly accurate. So that's important. I had an instance one time where somebody told me that at their work, they had to actually move 500 pounds across this floor. And they had to do this like 20 times a day, right? So I thought this is really strange. So I'm going to go out there and I'm actually going to watch what this person does. They pushed a button that had a machine that pushed the 500 pounds across the board. So it's all about, making sure that you understand what the thing, obviously, that person doesn't have a lot of risk involved with whatever their condition is.

[00:41:53] Obviously, they don't really have any limitations, unless they couldn't punch the button with a finger or something, right? So those are the types of things that become really important. But you look at it in the context of, as you said what would be dangerous to the person? What actually would create a concern? And I would expand on what you said. It's not just a risk to themselves, but it's also a risk to their coworkers.

[00:42:14] Thank you. That's right.

[00:42:16] And I know many times we lose sight of that sort of thing, but I'll just give you an example. Like in my world, and you know this, and I take care of a lot of folks in the meatpacking world. Okay, these are people that are wielding really sharp objects that are right next to each other. So it's not just about whether they could injure themselves doing that, but the person that's next to them that becomes important. So I'm really glad you brought that up. All about the context of the work environment.

[00:42:42] And, you think about, okay, does the person move? Are they static? Do they operate machinery that could somehow go awry if the right decision wasn't made or the right thing didn't happen? So those are the types of things that I think really changed the perspective and would change my answer if I knew more specifics about those things.

Kertay: [00:43:01] That's a really great point. In, in the example that we had somebody who, has been taking an antidepressant for a long time. and they've generally been stable on it, but they've told us that they're getting more argumentative, right? They're having trouble sleeping. I may have a situation in which someone has is, is at increased risk around other people, right? Because right now they need some additional attention. Now, just because someone's depression has gotten worse doesn't mean that I'm going to keep them out of work because I never thought it was a good idea for me to keep my depressed patients at home staring at the wall. That didn't seem like a good strategy.

[00:43:44] Nevertheless, it might make a difference to me in a safety sensitive setting on a temporary basis until I was sure that this person was safe. So I'm really glad you brought that up. I got to ask the last question what, what if Joe tells you that you're, what, you're a terrible doctor, how could you do this to me?

Martin: [00:44:04] As you probably know, as an occupational medicine doctor, this has happened to me more than once. And if you're in that role, of course, you know that is something that you have to deal with. And you have to be prepared with an answer. And I'll tell you the way that I do it is... And it all goes back to the communication. I will sit down with a patient when I am given these forms and so forth. And I go through the forms with the patient because often times the patient hasn't read them. And they don't really know what it is. They just want to have it filled out.

[00:44:34] So I sit down and I go through, and if it's an FMLA form, I go through what FMLA is, right? If it's a short term disability, a long term disability, we go through the language so that we all understand what it is. Now, does that take time? You bet it takes time, but it's important so that you have a reference point that's similar. Okay. Now, directly to answer your question I think I'm like most physicians that I prefer not to take people off work and if I can help it because of the benefits of work. And so I sit down and I explain to the patient that risk capacity tolerance paradigm. And I tell them scientifically as a physician, what I can answer is the risk and the capacity question. I can't answer the tolerance question. Only the patient can answer the tolerance question. I tell them, okay, this is how I'm filling this information out. I'm going to answer the questions based upon the risk and the capacity, right? You may elect not to work because of your perspective on tolerance, but that's not anything that I can judge.

[00:45:43] And you said it so eloquently, if you try to judge that or make some kind of a judgment, you're going to run into lots of problems. Number one, you're going to be wrong most of the time anyway. And number two, to go through some sort of an assessment to try to make sense of all that is an exercise in futility, to be honest.

[00:46:03] Now, having said that, I still have people who get mad at me. And that's just part of the deal. They say that sometimes occupational medicine is a bit of a contact sport. You have to be prepared for people that just don't like your decisions. But I think to be true to the science, you have to be true to yourself with respect to these things. And the minute that you start straying off the science, I think is where we run into a lot of problems.

Kertay: [00:46:28] Yeah. We, I brought up that example of a person's taking an antidepressant and perhaps there's some evidence that makes us wonder if it's getting worse.

[00:46:39] I think that this is an area, I've been really focused heavily in workplace mental health for years and I think that this is one of those areas that we get ourselves into trouble because there's an assumption that if a person is depressed, for example, that they're automatically at greater risk.

Martin: [00:47:02] Sure.

Kertay: [00:47:03] And that may or may not be true, depending on what it is that they need to be doing. And also the, it's really important to understand that feeling functional, feeling like you're contributing is a huge part of psychological health.

Martin: [00:47:24] I was just going to say that in your scenario, what I have found many times is that support structure at the workplace is like the thing that's keeping their head above water. So why would I ever want to take away that? I'd be concerned that if I said you should take time off or you shouldn't go back to work. Now they have lost the only support structure that they might have. That could be tough.

Kertay: [00:47:53] Yeah. I think we have it could take us down an odd path, but I think we have this notion that work is like bad somehow, we just have this thought that everything should be easy and so we have a bias about workplace places being bad for people. It's not generally speaking true. So I think that's probably what we want to do.

Video Information

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Enduring Material activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.


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