Provider Pulse
September 05, 2019

From our medical director: Pointers for difficult cases

By Tom Denberg, M.D., Senior Medical Director

Cases that are complex or involve delayed recovery are uncommon, but they often take up a disproportionate amount of clinician time and can be frustrating for all involved.

Here we list important things to look for in these cases, and some recommendations for preventing and managing them.

  1. Be diligent about understanding pre-injury medical and psychological issues. Take a thorough, careful history and obtain and read pre-injury medical records. If these steps aren’t completed during or shortly after the initial visit, complete them as soon as possible — even if you realize weeks or months post-injury that they never occurred.
  2. Explain to the patient that you will be focusing on the specific work-related injury and are not providing traditional primary care. Tell the patient in the first visit that the goal of care is to restore as much function as possible, and explain what this means. Help the patient understand that complete pain resolution may not be possible during the period that you are focused on dealing with his or her work-related injury, even though you will do what you can to help. In other words, pain alone will not be the primary or most important factor in assessing progress and returning the patient to work.  
  3. Pay close attention to complaints of new symptoms weeks or months after an initial injury, and complaints of multiple symptoms that migrate from one part of the body to another. Note whether patient stories are inconsistent from visit to visit. Being aware of these things requires a thorough understanding of the initial injury as well as of patient statements and exam findings at each clinic visit, including visits with other medical providers.
  4. Pay attention to pain that is out of proportion to physical findings, and pain that fails to resolve within the expected time period for the injury.
  5. If there are any red flags based on items 3 or 4 above, obtain a thorough psychosocial assessment (not counseling) as early as possible, or at least as soon as the issues become evident. Also take a careful history of the use of alcohol and other addictive substances. Consider repeating the history at regular intervals, and consider drug testing to help validate patient statements or your own suspicions, if necessary.
  6. Be extremely reticent about introducing new work-related diagnoses weeks or months after an initial injury, especially when there is no clearly documented supporting evidence for such diagnoses at the time of the original injury. Avoid invoking vague medical hypotheses or suppositions to support additional work-related diagnoses. All diagnoses should be based on definite medical evidence and sound clinical reasoning.
  7. Be careful not to order excessive physical therapy, massage therapy, chiropractic sessions, psychological counseling sessions or similar services. Medical interventions should be provided in limited amounts and continued only when they are associated with quantified, objective improvements in functional status. Assess functional status at regular intervals. Avoid the trap of temporizing and wishful thinking. For example, avoid statements such as “I don’t know what else to do, but I think there’s a good chance the patient will improve after just a few more therapy sessions” or “Six more chiropractic sessions might avert the need for surgery.” The reasonableness and necessity of any medical service needs to be judged in relation to the actual benefit or lack of benefit it has conferred based on a reasonable trial informed by the Division of Workers’ Compensation time-to-effect criteria. If no meaningful benefit has been demonstrated, alternative therapies, including surgery, would need to be evaluated according to their own separate criteria. 
  8. Be willing to carefully consider other clinicians’ findings and determinations, including those of physicians who carry out medical record reviews and independent medical evaluations, or IMEs. Do not take it personally if an expert disagrees with your diagnoses or the care you’ve provided. Do not discount a clinician’s opinions simply because an insurance company, for example, sought the opinion. A fresh expert look at a case can be extremely helpful.
  9. Do not conduct clinic visits if little can be done for the patient. If a case isn’t progressing, you are uncertain about MMI, or it’s otherwise unclear what should be done, consider referring the patient for a second opinion, or speak to a claims adjustor about obtaining an IME.
  10. Delayed recovery cases are more likely to have attorney involvement, but this should not influence your approach to care. When making decisions, always rely on your clinical training and expertise. Do not defer to attorneys (or to the patients themselves. Be professional and objective, and do the right thing for the patient and the employer at all times.
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