It would be difficult to overstate the number of clients who have come to us over the years frustrated when a doctor or therapist suggested they were depressed. In our society depression is often seen as a character flaw, a weakness, or an excuse. Without doubt, these injured workers are genuinely offended that someone is suggesting that “it’s all in their head.”
On the other hand a prominent psychiatrist who deals with a lot of injured workers testified in a deposition that 80% of people who suffer from chronic pain, (defined as pain lasting for at least six months), will develop clinical depression. Our bodies are just not made to deal with high pain levels for that long of a time. And the fact that former co-workers, adjusters, and rehabilitation nurses are often less than sensitive to an injury that seems to go on indefinitely doesn’t help.
When speaking with doctors about this most of them have readily agreed that it’s very rarely JUST in someone’s head. But they do cite numerous studies, which confirm what the psychiatrist detailed and note that those studies often suggest that if the mental outlook improved then the patient’s capacity to cope with the pain would improve. That doesn’t mean the pain goes away… it doesn’t. It’s just that it’s easier to deal with it and function in spite of it.
We’ve long recommended that our clients develop at least an informal network of people who can provide emotional support as you work through this. That’s all the more true when you don’t get better on schedule, when you cannot return to your old job, or when financial pressures get increasingly difficult. This may be family (although it’s already tough on family), a couple of close friends from church, or a counselor. The important thing is to not try to tough it out. We’re all human and when you have difficult workers compensation case it’s not time to try to be superman.
One medical lexicon defines conservative treatment as “a course of therapeutic action designed to avoid harm, with less possibility of benefit than more risky options.” What’s that mean to you? At the heart of it conservative treatment is an effort to make you better without taking drastic, immediate steps like surgery. Yes, a surgery could possibly make you much better than can physical therapy but PT is a lot less risky than surgery. And if PT fails surgery is still an option. Every doctor is a little different in their view of how much non-invasive treatment needs to be attempted before considering surgery.
Note, however, that the notion of conservative treatment as a potential cure fits like a hand in the glove with an adjuster’s mentality of not paying for anything expensive right away. As a practical matter, what conservative treatment will mean to you is that your doctor and your adjuster will likely go with x-rays well before they do an MRI. Likewise, they will opt for physical therapy and epidural steroid injections before they suggest surgery. Each of these is intended to help you heal and does so while putting you at less risk than with a surgery. And coincidentally they cause the insurance company less money.
X-rays are inexpensive, quick, and usually done right in the doctor’s office. They use a theoretically dangerous ionizing radiation to create images of bones and dense tissue. In the small doses that you receive during a few x-rays there’s probably nothing to worry about. An MRI is expensive (30-40 times as expensive as an x-ray), takes about 30 minutes, and the equipment is often not available in the average doctor’s office although more and more orthopedic surgeon’s offices are equipped with them. An x-ray is far better than an MRI at detecting fractures in a bone, but an MRI is far better at spotting damage to a soft tissue like a ligament, tendon, or disk. As a practical matter, workers’ compensation adjusters like to avoid the expense of an MRI unless other options have been exhausted first.
This doesn’t mean there is no way that the adjuster will promptly authorize an MRI. If there is overwhelming evidence of a disk injury she may well go ahead and do it. But don’t be surprised if there is a delay. This delay can be lessened if you let us push the issue down at the Industrial Commission.
This could be answered on two levels. Mind you our answers, being those of workers’ compensation lawyers, may not be the answers which doctors would give you.
The first level, that of medical journals and the like, evidence based medicine is an attempt to make medicine more of a system using the “current best evidence in making decisions about the care of individual patients.” On the second level, the level of evidence based medicine as it seems to be practiced by doctors who speak at Industrial Commission conferences and treat a lot of injured workers is to put great emphasis on all the scientific aspects of the examination and significantly less emphasis on what a patient is telling them. At least that is what is reported to us by many patients.
What it comes down to is that a lot of injured workers are really lousy at explaining how they got hurt and where precisely they hurt and what makes the pain increase or decrease. Accordingly, their complaints have little value in terms of science. On the other hand physical examinations and tests like x-rays, CT scans, and MRIs are accorded great scientific value.
A doctor may discount what you are telling him if he cannot confirm it scientifically. That sort of stinks if your adjuster won’t authorize the MRI, which would provide that confirmation. In terms of putting evidence based medicine into practice for treatment options a doctor may emphasize the statistical results of other patients around the world and less on the potential benefit in a given patient. The problem with all this is that if your body doesn’t respond to a course of treatment like 95% of the rest of the world does it doesn’t make you a liar. It means you’re an exception. Exceptions are known to exist. It’s unfair to dismiss a patient just because they are an exception.
In a perfect world evidence based medicine sounds like a great idea. In the real world of competing interests and power struggles we’ve seen it misused and sometimes does nothing other than providing a fancy name for an excuse to not pay attention to you.
In it’s simplest form it’s what it sounds like: someone who attends to, or pays attention to, you. When you’ve got the flu it’s good to have someone who will check on you, get you some medicine, and bring you something to drink when you want it. That’s what loved ones do. Now say you had a total knee replacement and cannot walk or stand for any meaningful length of time. And throw into the set of facts that you are single and live alone. You need someone to take care of you. There is no way your are going to heal if you are having to abuse yourself taking care of your every day activities. The adjuster needs to pay for attendant care. It’s part of getting you better just like therapy, medications, and surgery.
Let’s take this scenario a step further. Everything is the same except that you are married. What’s the adjuster going to do? In at least 99% of the thousands of cases we’ve handled the adjuster expects your spouse to take care of you. If that means he or she takes time off of work without pay or uses up vacation or Family Medical Leave Act time the adjuster doesn’t really mind. We think this is wrong. Just because you have family who loves you doesn’t mean the insurance company shouldn’t pay for your medical care.
Largely through the efforts of one insurance company – after losing a case in the Court of Appeals about attendant care – the 2011 laws placed strict regulations on attendant care. We’ve become adept at making sure our clients are in compliance with these new (and in our opinion unnecessary) rules. The key thing is that your doctor needs to document the need specifically, for a limited period of time, in advance of the surgery. If things are done correctly your loved one will be compensated for the services he or she provides. Keep in mind, though, that the compensation rate is what a home health aide would get paid – usually about $10.00 – even if that’s less than what your spouse makes on their job. Every little bit helps though.