1. Living Enabled or Living Disabled: Beliefs and Choices Chris Brigham, MD Brigham and Associates

2. Goals Identify key questions. Contrast exceptionally abled vs. needlessly disabled. Explore concepts critical to our understanding. Examine how beliefs and incentives drive needless disability. Discuss solutions to combat needless, self-serving disabling and to empower individuals to live full, joyful lives. © 2012 Brigham and Associates, Inc.

3. Questions – Answers? 1.Why do people with the same problem have different experiences with disability? 2.What is disability and how much of this is preventable? 3.How important is work? 4.What is the impact on “needless disability” on the individual and society? What are the human and financial costs? 5.How do beliefs contribute to living abled or living disabled? © 2012 Brigham and Associates, Inc.

4. 6.How do entitlement systems and our own actions contribute to needless disability? 7.Are our workers’ compensation and other entitlement systems fatally flawed? 8.How do we empower individuals to live full lives? 9.What would our world be like if disability was the exception and we all lived full and productive lives? 10.What actions could we take as individuals and organizations to empower and stop needless disabling? Questions – Answers? © 2012 Brigham and Associates, Inc.

5. What We Know Studies and data document that: 1.Disability is increasing, despite improvements in medical care. 2.Costs associated with disability, both human and financial, are increasing. 3.Unemployment is hazardous to physical, mental and social-well being. 4.Workers’ compensation and disability benefit systems are fraught with challenges. © 2012 Brigham and Associates, Inc.

6. Pain ≠ Impairment ≠ Disability Pain Impairment Disability © 2012 Brigham and Associates, Inc.

7. Why Work? Work is of central importance to human existence. Absence from work is detrimental to person’s physical, mental and social well-being. The studies and data supporting these conclusions are irrefutable. © 2012 Brigham and Associates, Inc.

8. Contrasts and Lessons Learned Challenged and Empowered vs. Needlessly disabled Individual Complex web of other participants (systems, organizations and individuals) © 2012 Brigham and Associates, Inc.

9. Challenged and Empowered Live productive, vibrant lives despite challenges Inspirational What can we learn? © 2012 Brigham and Associates, Inc.

10. Nick Vujicic Born with no limbs Motivational speaker “Life Without Limbs” Author Live Without Limits: Inspiration for a Ridiculously Good Life Lessons learned: –Dream big –Improve your own attitude regarding obstacles in life –Use to the best of your ability the gifts you have been given –Proper way of thinking can lead to an abundant life © 2012 Brigham and Associates, Inc.

11. Jessica Cox Born with no arms Pilot Black-belt Lessons learned: –The way we think has a greater impact on our lives than our physical constraints. © 2012 Brigham and Associates, Inc.

12. Bethany Hamilton Survived shark attack, lost her arm Continues to surf Soul Surfer Lessons learned: –Strive to be the best at whatever God calls you to do. © 2012 Brigham and Associates, Inc.

13. Mile Stojkoski Paraplegic post motorcycle accident Completes cross country ultramarathons in a regular wheelchair. Lessons learned: –Persistence –Challenge yourself © 2012 Brigham and Associates, Inc.

14. Stephen Hawking Amyotrophic lateral sclerosis, nearly completed paralyzed British theoretical physicist, cosmologist, and author Lessons learned: –Physical disabilities do not limit your mind © 2012 Brigham and Associates, Inc.

15. Patrick Henry Hughes Born without eyes and unable to straighten his arms and legs (unable to walk) Highly talented multi- instrumental musician Lessons learned: –Persistence –Challenge yourself © 2012 Brigham and Associates, Inc.

16. Michael J. Fox Age 30 diagnosed with Parkinson’s disease Activist for research on finding a cure for Parkinson’s. Lesson learned: –Find the optimistic view, no matter what the situation. © 2012 Brigham and Associates, Inc.

17. Craig McFarlane Blinded at age 2 Accomplished athlete Lesson learned: –Do not consider your limitations as a handicap, they may be your new uniqueness and strength. © 2012 Brigham and Associates, Inc.

18. Grant Korgan Paralyzed in 2010 snowmobiling accident Achieved goal of reaching South Pole via SitSki “Although my body was broken, my spirit never will be. I am unbreakable!” Lesson learned: –Focus on positivity and thriving. –Be a survivor © 2012 Brigham and Associates, Inc.

19. Needlessly Disabled Perceived or labeled as disabled, without significant objective supporting evidence. Lessons learned: –Beliefs define who we are –Root causes of disability are multi-dimensional –“Biopsychosocial” approach is necessary © 2012 Brigham and Associates, Inc.

20. Risk Factors for Delayed Recovery, e.g. “Needlessly Disabled” History of prior claim and delayed return to work Workers’ compensation or personal injury litigation Job dissatisfaction Biopsychosocial issues –Personality disorders –Somatization –Depression –History of childhood abuse –Drug abuse © 2012 Brigham and Associates, Inc.

21. Impairment / Disability Perspective Emphasis Job / Life Satisfaction Problems Locus of Control Reaction Relationship Physical Feelings Affect Symptom Magnification Focus Impairment > Disability Positive (Optimistic) Strength Positive Challenges=Opportunities Self Forgiveness Independent Active Gratitude Joyful No Health (Function) Impairment < Disability Negative (Pessimistic) Weakness Negative Barriers Others (Blame, Entitled) Revenge, Obsession Dependent Inactive Anger Depressed Common Litigation (Adversarial) Contrasts © 2012 Brigham and Associates, Inc. Living AbledNeedlessly Disabled

22. “Peeling the Onion” © 2012 Brigham and Associates, Inc.

23. Beliefs Expectations that we have concerning a situation Define how we see the world Many are formed in childhood Adopt beliefs conveyed by authority figure Profound impact on injury, illness and disability © 2012 Brigham and Associates, Inc.

24. Neuroplasticity Our brains and nervous systems change, structurally and functionally, as a result of input from the environment Positive – athletes (muscle memory) and musicians Negative – addiction and pain © 2012 Brigham and Associates, Inc.

25. Adverse Childhood Experiences Common Long-term, damaging consequences: behavioral, psychological and medical © 2012 Brigham and Associates, Inc.

26. Personality Disorders Enduring patterns of inner experience and behavior that deviate from those expected by the individual's culture. Present in 31% - 64% of individuals with chronic pain Often not recognized or ignored © 2012 Brigham and Associates, Inc.

27. Medicalization Process by which conditions and problems come to be defined in treated as medical conditions and therefore subject to medical study, diagnosis, and treatment. Permits health care providers and drug companies with an income opportunity. © 2012 Brigham and Associates, Inc.

28. Medical – Psychological Silos Medical Perform medical testing to identify pathology Define a diagnosis Provide treatment to achieve MMI Psychological Identify a behavioral or psychological syndrome Courtesy Michael Coupland, Integrated Medical Case Solutions

29. Biopsychosocial Model Identify and manage all aspects that impact health and disability, without “medicalizing” © 2012 Brigham and Associates, Inc.

30. Chronic Pain & Disability Behavior Amplified Pain (Tissue Hyperalgesia) Injury-Illness-Pain CNS Changes Stress Reactivity (neurotransmitters) Cognitive Affective Social Biopsychosocial Model of Health & Disability Lifestyle: Exercise, Smoking, Alcohol and Drugs, Obesity / Diet Work Attachment / Age Depression / Anxiety Personality Disorders Hx of Childhood Abuse Perceived Injustice (retribution owed) Fear Avoidant Behavior (Guarding) Catastrophic Thinking Courtesy Michael Coupland, Integrated Medical Case Solutions

31. What Hurts Us? Pain –Pain Disorder –Chronic Spinal Pain “Naming Stuff” –Cumulative Trauma Disorders –Fibromyalgia “Mind Stuff” –Psychological Labels –Post Traumatic Stress Disorder © 2012 Brigham and Associates, Inc.

32. Our Healers? Iatrogenesis – “First Do No Harm” Inappropriate Diagnostic Evaluation Inappropriate Diagnoses Failure to Educate Patient Inappropriate Treatment –Misuse opioids –Misuse other medications and device, compounded by physician dispensing –Unnecessary therapies and surgeries Faulty Causation and Apportionment Analysis Faulty Work Ability Assessment Faulty Impairment and Disability Assessment © 2012 Brigham and Associates, Inc.

33. What are their beliefs and how can they interfere with recovery? Injured worker Physician Other Providers Family Employer Claims Adjuster Judge Attorneys Others © 2012 Brigham and Associates, Inc.

34. What Are Possible “Solutions”? Society –Recognize the problems and the drivers, and educate all stakeholders –Prevent childhood adverse experiences –Shift focus from disability to ability, disease to function, and the medical model to the biopsychosocial model –Promote concept of personal accountability –Promote concept that “Work is Healthy” –Hold all stakeholders accountable for their actions –Ban advertisements by pharmaceutical and device manufacturers, physicians, and attorneys © 2012 Brigham and Associates, Inc.

35. What Are Possible “Solutions”? System –Provide universal health care coverage? –Avoid litigation and attorney involvement by use of alternative dispute resolution processes –Pay physicians and other participants for outcomes, not for procedures © 2012 Brigham and Associates, Inc.

36. What Are Possible “Solutions”? Employers –Recognize core issues –Provide “healthy” workplace, both in terms of culture and safety –Focus on health productivity, with stay at work and early return to work interventions © 2012 Brigham and Associates, Inc.

37. What Are Possible “Solutions”? Claims Professionals (Insurers and TPAs) –Understand the core issues, with awareness by all participants –Manage claims proactively, efficiently, and with integrity –Involve quality health care providers –Avoid unnecessary adversarial positioning –Identify early risk factors for delayed recovery (e.g. use a screening tool) and intervene Attorneys –Reduce the need for your involvement © 2012 Brigham and Associates, Inc.

38. What Are Possible “Solutions”? Health Care Professionals –Understand the concepts and apply them –Use evidence-based practice guidelines –Educate patients and avoid “medicalization” –Do not provide harmful testing and treatment (especially opioids and certain surgical procedures) –Assess causation and apportionment on basis of facts and science –Assess work ability on consideration of risk, capacity and tolerance –Assess impairment and disability, only if qualified –Work cooperatively © 2012 Brigham and Associates, Inc.

39. What Are Possible “Solutions”? “Patients” –Understand you are responsible for your life and your beliefs drive your experiences –Reframe injury or illness as part of the human experience, an opportunity for growth, and not a barrier –Focus on your abilities, not symptoms, pain and limitations –Be physically active –Choose joy and happiness –Demand quality health care –Focus on staying at work –Avoid involving attorneys or others who may adversely impact your long-term well-being © 2012 Brigham and Associates, Inc.

40. Action Steps Demonstrate integrity. Focus on function and ability. Recognize the power of beliefs. Take personal and organizational steps to reduce the needless human and financial costs associated with disability. Demonstrate in your actions a focus on living a joyful and productive life. © 2012 Brigham and Associates, Inc.

41. cbrigham@cbrigham.com www.cbrigham.com Chris Brigham, MD, Brigham and Associates, Inc. 970 N Kalaheo Avenue, Suite C-312, Kailua, HI 96734 808-254-9400 © 2012 Brigham and Associates, Inc.