Reliably Determining
Occupational Causation
April 21, 2010
Dan Rafael Azar MD MPH QME
Medical Director
Alliance Occupational Medicine
Santa Clara & Milpitas
1
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
2
Evaluation and Treatment
is a Partnership
– Employee-Patients
– Employers
– Carriers (adjusters)
– Utilization Review
– Medical Case Managers
– Attorneys
– WCAB judges
– Legislature
3
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)
4
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
5
First Visit “Basics”
1. Diagnosis
2. Causation
3. Treatment
6
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
7
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
8
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
9
Thoroughness at First Visit Includes
Reviewing 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
10
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
11
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
12
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,
13
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
•
14
(Skip to Slide 23)
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?”
15
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
16
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
17
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)
18
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
19
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)
20
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)
21
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
22
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 treatment23
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”
24
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”
25
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
26
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
27
Treatment Plan for an
Moderate 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
28
Goals of Physical Therapy
• Recover full function
• Establish healthy habits
• Minimize risk of recurrence
29
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
30
Physical Therapy
Late 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
31
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
32
4 Major Causes of
Cumulative Trauma Injury
•
•
•
•
Excessive force
Awkward positions
Static muscular tension
Insufficient conditioning for job
requirement
33
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
34
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
35
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)
36
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
37
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
38
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
39
Case Management
at MD Recheck:
Reinforce:
• To change outcome we need a change in
behavior
• Monitor for passivity, blaming noncompliance, 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
40
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
41
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
42
Low Back Pain
From 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
43
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)
44
Depression
• Pre-existing?
• Identify early because this will impact
coping and recovery.
• Refer to personal MD for treatment
because not occupational causation.
45
Depression “due to injury”
• Chronic Pain
• Disability
• Financial Impact
• Impairment
Reassure –
• “Normal” response to consequences of any
illness or disability
• Depression is situational and will resolve with
physical recovery or emotional adjustment
46
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.
47
Sick Building Syndrome
Chemical 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 48
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)?
49
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
50
Closing Cases as P&S
Depends on outcome:
• Cured?
• Residual symptoms?
• Residual impairment?
• Residual disability?
• Permanent work restrictions?
51
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?
52
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
53
Thank You
Alliance Occupational Medicine
315 South Abbott Ave., Milpitas
2737 Walsh Ave., Santa Clara
Please visit us at
www.AllianceOccMed.com
54