By Robert Hall, M.D., Corporate Medical Director, Helios
“She’s not going to be able to go back to work again, right?” I have to admit that hearing this question from an injured worker’s husband before she had even sat down on the exam table threw me for a loop. My first instinct, and initial response, was to clarify whether or not I had actually heard the question correctly. Having neither met the patient before nor being aware of her injury and its potential impact on her ability to return to work, this question left me puzzled. In fact, we had not even discussed her job duties. Although the question of whether or not an injured worker can return work is one of the most important questions to be answered, other questions must be asked (and answered) first. The following questions are the ones I wish patients would ask their doctors more often.
What is my injury and why did it happen?
Attempts to answer questions such as these beg the answer to three other underlying questions:
- Has the diagnosis been established and confirmed?
- Can the doctor explain the diagnosis to the patient?
- Can the patient understand the explanation?
The language doctors often find themselves using during patient visits can leave patients feeling confused and embarrassed to reveal that they still do not understand the explanation. It is not the physician’s intent to confuse patients or to speak in words that seem unintelligible. In some cases, doctors may be trying to use language to effectively communicate with other health care workers in the room, such as a nurse or assistant, or unfortunately, to demonstrate his/her expertise and command of the medical profession.
Two techniques I use when talking with patients about their conditions are analogies and visual aids. For me, informing a patient that they have a median neuropathy at their wrist is not that helpful. I have also found that providing the more commonly known diagnosis term, carpal tunnel syndrome, can generate confusion. However, by using a diagram of the wrist, showing the pathway of the tendons through the wrist and the ligament above them, with a nerve getting pinched in between, provokes that “I get it now” look and response. Additionally, since carpal tunnel symptoms can often radiate beyond the actual site of injury, patients may find the diagnosis daunting or difficult to understand because their entire hand hurts and their fingers are numb. However, by placing my finger on the site of injury, I can further drive home that the precise region of the nerve entrapment is at the patient’s wrist. Further, by communicating, “Right here is where your problem is,” the diagnosis becomes more clear.
What do I need to worry about while using this medication?
Medication side effects are just one part of the equation. Patients also need to understand potential drug-drug and drug-disease interactions. As an example, during a visit, one of my patients who had recently suffered a stroke was developing post-stroke depression and was inquiring about potential medication options. Due to the severity of her symptoms, I recommended an antidepressant. She asked about potential side effects and this led to a discussion about how the antidepressant could interact with the medications she received from the hospital and other medications she was taking. In her case, she had been placed on multiple different blood thinners to reduce her risk of having another stroke. One of the concerns about the more effective class of antidepressants, serotonin reuptake inhibitors, is their potential to cause platelet dysfunction, further increasing the possibility of bleeding. After the discussion, the patient had the information she needed to make an informed decision regarding the risks of taking the antidepressant and knew what symptoms to look for.
Beyond the potential drug-drug interactions that can occur, when a new medication is prescribed, focus must be placed on the potential for worsening of pre-existing illnesses or comorbid conditions. For instance, most healthcare providers are aware that anti-inflammatories can worsen blood pressure control in patients with hypertension. Not as well-known are the other, less common, potential drug-disease interactions that are possible. For instance, the antidepressant duloxetine can worsen glucose control in patients with diabetes and venlafaxine, another commonly prescribed antidepressant, can increase cholesterol levels. Both of these side effects are rare, but may leave patients with diabetes and high cholesterol struggling to determine why their dietary management and exercise are not producing more effective results.
With respect to the potential side effects that individual medications can cause, the question changes from “does this medication have any side effects” to the more important question of “which side effects should I be most concerned about?” For example, dizziness and mild weight gain are well-recognized side effects of anticonvulsants. However, these adverse effects will likely have less long-term consequences than the possible severe skin reactions and liver injury that can rarely occur with anticonvulsant therapy.
How long do I need to be on this medication?
Medications have their place in treatment, but only for a specific need and for the minimally required duration. Too often, pain medications are prescribed at the onset of an injury, but attempts at weaning the medication to determine if the initial symptoms have begun to resolve are delayed. For injuries that should have resolved, how do we know the pain is still present if pain medications continue to be used? The best time to give a patient a weaning schedule is when the medicine is first prescribed. For instance, “here is your medication, here is how long I expect you will need it (based on your injury), and this is how we will get you off of it.”
What other treatment options do I have?
Before any treatment options are recommended, it is important to first identify the cause of the injury and modify any risk factors that could potentially worsen the injury or prevent it from healing on its own. It is critical to remember that the vast majority of workplace injuries should, with all external complicating factors being removed, heal on their own. Muscle strains, ligament sprains, even herniated discs have the potential to heal without substantial medical intervention. The key is eliminating any causative factors and allowing the healing process to proceed. This is where medication and comorbid disease management play pivotal roles. When a patient tells me her low back hurts continuously, but her employer requires her to stand on a hard, concrete floor for ten hours per day with minimal rest breaks, the question is how to modify her job to prevent further spine injury. Her condition is further complicated by her chronically-elevated blood glucose levels that impair her ability to heal, her obesity that places more stress on her lower back, and her chronic tobacco use that limits the amount of oxygen and nutrients being delivered to her lumbar spine tissues. All of these issues need to be addressed for her back pain to resolve.
When looking at treatment options, the use of therapeutic modalities, such as heat and cold have a longstanding place in the management of pain, as heat increases blood flow and cold decreases the inflammatory process. While effective, both of these therapies have precautions and should not be used for prolonged periods due to the risk of burns and further injury. For instance, the prolonged application of heat or cold to an insensate (decreased sensation) part of the body, possibly due to a nerve injury, could result in thermal injury.
Bracing and other compressive treatments are therapeutic options that can help reduce swelling and improve joint stability. A less well-known benefit to bracing is its ability to be a kinesthetic reminder. That is, the device itself provides physical feedback to the user, informing him or her to maintain or adjust toward a more appropriate physiologic posture or position. If the patient’s position or motion is contrary to the purpose of the brace, the patient will be reminded to correct that movement or position, thereby reinforcing the optimal state. Additional physical medicine treatments are also essential to further understanding the injury, strengthening the muscles responsible for safe and physiologic function, and educating patients on further injury prevention.
When can I go back to work?
While not necessarily appropriate before even assessing a patient, the return-to-work discussion should be held at the initial provider visit and every subsequent visit. Returning to work is an outcome. Both the patient and physician should measure, monitor, and track the progress toward this goal, whether psychological or physical. Unfortunately, the concept of out of sight, out of mind often applies to the goal of returning to work. Continuous communication between the employer and the injured worker can be helpful in facilitating return to work. Finally, the physician must be aware of the exact job functions that fall under the injured worker’s responsibility. A video of the injured worker’s job functions would be ideal.
Am I going to be okay?
In the case of the patient mentioned at the start of this piece, after explaining her diagnosis and talking through the various questions, both she and her husband understood that she had a mild case of carpal tunnel syndrome. This was causing some reversible compression (or pinching) of the nerve that travels through her wrist and into her fingers. This brought about a great sense of relief. Her overall comfort level was further improved by hearing that there had been no permanent nerve damage and a road to full recovery was expected, starting with improved ergonomics at work and a carpal tunnel splint to be worn at night. She and her husband left my office smiling and reassured that, yes, she would be able to go back to work and she would be okay.
Workers’ compensation stakeholders should try to ensure all of the above questions are answered, whether by using nurse case management or a pharmacy benefit manager with strong clinical programs that manage utilization and ensure injured workers receive the safest, most efficacious care. By answering these questions, we can work together to eliminate potential complications, leading to a faster return to function and better outcomes for everyone involved. Perhaps more importantly, we can allay concerns and instill confidence that the injured worker is going to be okay.
About Robert Hall, MD
As Corporate Medical Director, Dr. Robert Hall advises our customers and employees on evidence-based clinical and rehabilitation guidelines that optimize our pharmacy, home health, and durable medical equipment programs to promote better outcomes and earlier return-to-work for injured workers. He also offers counsel on our processes and procedures to identify and reduce prescription medication misuse and abuse.
A practicing, board-certified physical medicine and rehabilitation physician, Dr. Hall has treated patients in private practice, private and state-run hospitals, and out-patient clinic settings. His areas of focus include electromyography, pain management, musculoskeletal medicine, and stroke rehabilitation.
After receiving his Bachelor of Science (cum laude) in Electrical Engineering at The Ohio State University, he continued with his medical school training and served as chief resident in physical medicine and rehabilitation at the university’s medical center. Dr. Hall also serves as an adjunct assistant professor of Physical Medicine & Rehabilitation at The Ohio State University Wexner Medical Center. He has been awarded the distinction of “Best Doctors in America®” since 2009.
Helios brings the focus of workers’ compensation and auto no-fault Pharmacy Benefit Management, Ancillary, and Settlement Solutions back to where it belongs – the injured person. This comes with a passion and intensity on delivering value beyond just the transactional savings for which we excel. To learn how our creative and innovative tools, expertise, and industry leadership can help your business shine, visit www.HeliosComp.com.
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