5Your rehab. mental flow chart Can the employeework at all?increase his/her hours at work?increase the range of duties or tasks they are given?resume normal work/hours at work?
6What are your questions? What is wrong with the employee (diagnosis)?Different or more treatment?Is it the work that is slowing their recovery?Is it the travel to work?Can I change anything about the work?
7The underlying questions Anything about this employee’s complaints that are due to their:Underlying constitutional endogenous degenerative or pre-injury condition(s)?Their personality (including other agendas)?
8The Treating Doctor His mental flow chart My patient is injuredI prescribe treatmentI write WC certificateYOU do whatever is on certificate
9The Next Visit I see my patient again I listen to my patient I give new treatment or same treatmentI write new WC certificateYOU do what is on certificate.
10The ethos of medical practice Do no harmMake people betterIf I can’t make them better, I feel I should try harder and at times, I can hand over the management to my patient because they often are happy to receive what they want, even if not recovered.
11AT SOME STAGE My patient tells me that they are better I write final certificateOR
12My patient keeps telling me they are no better I don’t know what to do, so I do nothing but write another WC certificate and REFER to A SPECIALISTMy role has now become much more passive ….
13TURN IT AROUNDThe best thing for recovery is for the patient to resume as NORMAL a life as possible – including working life.You do not need to be pain free to achieve that.
14THE OBJECTIVE IS NOT FREEDOM FROM PAIN IT IS TO LEAD A NORMAL LIFEPAIN CANNOT BE CENTRE STAGE FOR NORMAL LIFE –
15PAIN cannot be the determining factor in what a person will or will not do ….. The sooner you can shift the emphasis in the employee’s mind and in the treating doctor’s mind from pain intolerance to capability the sooner you will have your employee working effectively
16The ‘One’ Message Keep talking about capability Praise achievement Look for small steps not big goalsShow confidence in the employee’s ability to overcome pain avoidanceWalk this talk with
17The employeeThe supervisorEspecially the doctorThe rehabilitation provider (who should be doing it anyway but can become bogged down in the emotions of a visit to the doctor situation)
18The Doctor’s Perspective Always believes his patientUnderlying fear that he might miss some crucial medical conditionDoes not want to disenfranchise his patientDoctors don’t want conflict
19If you cannot persuade the doctor to increase hours/tasks/reduce restrictions When might it occur?How could it occur?What needs to be done to make it happen?
20The treating doctor and BARRIERS The treating doctor may be the barrierMany do not have up to date knowledge of medical conditions and base their diagnosis, causation and treatment on old fashioned and often failed strategies.The employee may be very faithful/trusting of their treating doctor
21Suggest a ‘second opinion’ – but watch out for the nexus between an old fashioned GP and an old fashioned specialistYou will need to persuade regarding a specialist with the skills you want
22The treating doctor may be oblivious to the underlying agenda The patient/employee who is accustomed to the restricted hours and tasksThe treating doctor may be oblivious to the underlying agendaBRING IT OUT INTO THE OPEN IN FRONT OF THEIR DOCTOR – CHALLENGE THE EMPLOYEE TO REJECT THIS SUPPOSITION
23The employee who likes the day off each week to Sleep inHave their treatmentSee doctorsRECOVER
24It may be the treating doctor’s belief that their patient is so exhausted with working whilst in pain that they need ‘a day off to recover’.THEY’RE MISSING THE POINT!
25WE ALL WOULD LIKE A DAY OFF WORK (at full pay or even less than full pay) TO RECOVER FROM WORKING A COUPLE OF DAYS ….WE ARE ALL TIRED AND WE OFTEN ARE ACHING
26Couple of Steps Reinforce the aim is to return to normal life Propose the idea that if so tired after two days, that is not good in itselfPropose that shorter hours per day should prevent such a level of fatigue/pain
27Come up with a combination of hours for 5 days a week, but the TOTAL hours is the same as employee has been managingDoctors find the logic hard to reject and will usually give it a try
28BUT MOST OF ALL, MAKE THEM FEEL CAPABLE Don’t forgetLOTS OF PRAISEMAKE THEM FEEL IMPORTANTBUT MOST OF ALL, MAKE THEM FEEL CAPABLE
29Questions for the Independent Specialist DiagnosisGot to know what the working diagnosis is for the specialist, because all the opinions and recommendations must be logical in relation to this .....
301. Diagnosis Why is the employee experiencing the symptoms? Is there more than one condition (incl. the underlying etc etc)?What is the relationship between the condition and the employee’s work?Why are the symptoms recurring/not getting better?
312. Ability to workCan the employee do normal work/hours now or in the future – what is the expectation for recovery?What is their current capability if not normal hours/work?Anything about current tasks, equipment that is impeding recovery?Can anything be changed re. tasks, equipment?
323. Psychological IssuesIs there a discrepancy between what the employee complains about and the medical condition/injury they have?Every medical condition and injury has a known set of symptoms and signs. Anything outside this should raise a flag of one colour or another.
34THESE ARE NOT THE SAME AS SAYING THE PERSON IS MALINGERING OR CREATING A FACTITIOUS CONDITION
35They are usually genuine They are often fearful/anxiousThey often believe that pain means damage or injury or generally ‘Don’t do!’They are often not aware that they are acting or thinking in a negative/abnormal/counter-productive wayThey often believe they are doing the right thing to recover – and some do not like to be challenged on this.
36PAIN BEHAVIOUR Apparent that the person is in pain Verbal and nonverbal – serve to communicate the fact that there is painIf you are getting the message that the person is in pain, most likely they are manifesting pain behaviours
37Moaning, grimacing, crying, body postures, facial expressions, shifting posture, limping, not using a limbBut also, history of medication each time in pain, ceasing activity to pursue a pain-related activity, not accepting medical advice – 2nd opinion, & 3rd, more tests
38SYMPTOM MAGNIFICATION Vague, inconsistent historyInappropriate health care utilisationSymptom complex inconsistent with conditionFunctional limitations inconsistent with conditionDisability more than indicated by conditionAbnormal pain inventoriesReported pain level inconsistent with observationsReported functional limitations inconsistent with observationsPain behaviour demonstratedNon-physiologic findings on examinationC Brigham, ACOEM, Advanced Topics, 1996
39ASK Why Is It Present? What Can Be Done When Will It Stop? For any outstanding pain behaviour or complaintASK the DOCTOR -Why Is It Present?What Can Be DoneWhen Will It Stop?