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Les Kertay

Abstract

Disability is a prototypically biopsychosocial phenomenon, and the majority of workplace absences resolve easily and with an expedited return to work. In a minority of worker absences, recovery is delayed less by clinical factors and more by psychosocial variables that can take up an inordinate amount of time from the health care provider (HCP) and also may drive up total costs. Multiple stakeholders participate in this process—the HCP, the patient, the employer, and the insurer—each of whom has overlapping but distinct perspectives and agendas. Often HCPs find themselves in the middle of a complex set of interactions in which competing agendas may be played out. By engaging in effective communications with key stakeholders, the HCP can play a key role in ensuring that the most appropriate clinical outcomes occur. Despite the complexity of the underlying variables, the principles of effective communication are relatively straightforward: Apply a biopsychosocial model rather than a purely biomedical one; bear in mind that key psychosocial variables involved in delayed recovery include variables on the part of the individual, the employer, and the HCP; recognize that psychosocial factors that contribute to delayed return to work are not impairments that require medial or psychological treatment; listen; reach out to employers; and develop nonadversarial relationships with claims adjusters whenever possible.

in AMA Guides® Newsletter
Les Kertay

Abstract

Behavioral health terminology is an area beset by imprecision that results from confusing claim determinations, unnecessary evaluations, and poor outcomes that result from inappropriate treatment. In medical evaluation reports, one notes references to depression, anxiety, and stress, which are not diagnoses but often are treated as such. Behavioral factors can affect claims in four ways: the presence of a formal clinical diagnosis that meets specific criteria, psychological symptoms, difficult life circumstances, and behavioral overlays. Only the first of these can be attributed to a workplace injury or illness, and determining a causal relationship requires, at minimum, a precise diagnosis. For example, by depression does the health provider mean major depressive disorder with specifiers, persistent depressive/dysthymic disorder, adjustment disorder with depressed mood, or some other specific condition? The behavioral layers can affect the outcome of the claims process and may or may not be appropriate targets of an evidence-informed intervention aimed at returning an injured or ill worker to a higher level of function. The point is not to argue whether or not behavioral interventions are appropriate in workers’ compensation, personal injury, and other claims; the point, rather, is that precise language is the first, necessary step in sorting out the myriad ways in which behavior affects claim incidence, duration, and cost.

in AMA Guides® Newsletter
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
Fabien Gagnon
and
Les Kertay

Abstract

Claims of occupational psychiatric disability have increased considerably over the past 20 years. To avoid psychiatric disability overdiagnosis, it is important to improve the clinical assessment of mental health work disability. This article discusses general disability issues and their impact on individual well-being, social participation, and frequently associated poverty. It defines the difference between impairment assessment and disability assessment, explores three common disability models, and raises issues about psychiatric disability and its potential overdiagnosis.

in AMA Guides® Newsletter
Fabien Gagnon
and
Les Kertay

Abstract

Claims of occupational psychiatric disability have significantly increased over the past 20 years. This article is the third in a series on avoiding psychiatric disability overdiagnosis. The first article focused on general disability issues and their effects and defined basic terms and models. The second article focused on improving the diagnosis and assessment of mental health disorders and psychiatric work disability. In this final article, we focus on iatrogenesis in diagnosing mental health work disability and argue for implementing a comprehensive disability assessment approach.

in AMA Guides® Newsletter
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Leon Ensalada
and
Les Kertay

Abstract

Illness behavior refers to the ways in which given symptoms may be perceived, evaluated, and acted on by different persons and can be conscious or unconscious (the latter means unnoticeable and refers to mental processes and content that are significant in determining behavior but of which the person is unaware). Further, consciousness of actions (voluntariness) and consciousness of motives (intentionality) are not necessarily associated. Illness behavior can be learned and reinforced and is a potential confounder in the association between illness or injury and impairment or disability. Illness behavior is not an impairing condition according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), and a table in the article describes the characteristics of the symptom magnification syndrome and other related conditions. Three diagnoses—somatic symptom disorders, illness anxiety disorder, and conversion disorder—possibly are ratable using the AMA Guides. Unsupported and insupportable conclusions regarding symptom exaggeration represent substandard practice because of the importance of such conclusions to the disposition of patients who present for assessment of impairment or disability. Similarly, failure to note and account for illness behavior and symptom exaggeration also represent substandard practice because the goal in impairment ratings is to note and account for all evidence related to the impairment, including the extent of illness behaviors.

in AMA Guides® Newsletter