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Garson Caruso
and
Les Kertay

Abstract

Part two of this two-part article on psychological factors in delayed and failed recovery and resultant unnecessary work disability (DFRUD) considers both conceptual and practical interventions, including specific evaluation and treatment methods. The authors propose five categories of intervention for DERUD: 1) advance and operationalize our knowledge base; 2) make conceptual and practical shifts in our approaches; 3) place greater emphasis on prevention; 4) improve recognition of potentially difficult cases, and 5) apply specific management approaches and tools. Further, the authors propose conceptual and practical changes that should be made: Eliminate the dualistic separation of mind and body and the scientific reductionism that follows; change the focus from disability to capability; reduce improper workers’ compensation claims; improve the administrative and medical management of valid claims; enhance collegiality and communication among all stakeholders; and adopt a cost-utility vs absolute cost approach. The overarching goals of managing DFRUD include optimizing administrative and clinical treatment of the worker; protecting all stakeholders from excess; and overcoming barriers to intervention. To these ends, three activities can optimize the process: Intervene early; avoid iatrogenicity (ie, shorten claim durations and reduce costs); and stratify risk and employ stepped care. Barriers to meaningful intervention in DFRUD include questions of jurisdiction and responsibility for management (eg, does management of DFRUD fall to insurers or clinicians); who will pay; what are the maladaptive health cognitions and/or psychiatric comorbidities; and how can clinician behavior be altered to implement evidence-based practice?

in AMA Guides® Newsletter
Garson Caruso
and
Les Kertay

Abstract

The first part of this two-part series discusses psychological influences in delayed and failed recovery and resulting unnecessary work disability; the second part discusses theoretical and practical aspects of the issue, including evaluation and treatment. Delayed and failed recovery and unnecessary disability (DFRUD) refers to a lag in, or lack of, expected recovery from a medical condition and/or unnecessary resultant disability. Causation is complex, and we are not doing well at managing this group of workers using a biomedical model. The traditional biomedical model posits that disease or injury produces symptoms and signs that cause impairment and result in disability. This approach too strictly separates mental phenomena and bodily function (Cartesian dualism) and leads to scientific reductionism when actually six domains are active in worker disability: medical, personal, psychological, sociocultural, systematic (including compensation and insurance), and workplace elements. Medically unexplained physical symptoms (MUPS) should be understood as a disturbance of normal neurological and/or psychological processes underlying symptom production, perception, and experience and cannot be better explained by another physical or psychiatric illness. Within this system of evaluation, administrative and medical iatrogenicity are associated with unnecessary medical care and poor outcomes for individuals. In addition to determining industrial causality and apportionment, if evaluators accept some psychological factors, MUPS, and central sensitization, they must explain to what extent these are compensable. Part two of this article will discuss theoretical and practical approaches, including specific evaluation and treatment methods.

in AMA Guides® Newsletter
Garson M. Caruso
,
Les Kertay
, and
Christopher R. Brigham

Abstract

Persistent symptoms, physical signs, and abnormal test results after acute coronavirus disease 2019 (COVID-19) illness have emerged as a significant problem in the current and ongoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus pandemic. Finding a rational balance between compelling subjective symptoms and limited objective findings in patients with post-COVID-19 conditions is challenging. We advise caution in adopting attributions, explanations, and management strategies, and especially in conferring formal disability status, for these disorders until we understand them more completely. The prevalent uncertainties threaten both overevaluation and overtreatment, with substantial personal and societal consequences, and all stakeholders need to be both intellectually open and cautious going forward. This article highlights several concerns in evaluating and treating patients with enduring COVID-19-related illness.

in AMA Guides® Newsletter