Doctors Are Not Trained in Workforce Issues

Few physicians have sufficient training in nuances of occupational medicine yet all of us have the capacity to completely remove a patient from the work force. It has been my observation for many years that when a person is now sitting at home that their pain usually worsens.

• They don’t have the distractions of work so they notice their pain more.
• As there is seldom a specific time plan to return to work their anxiety is increased.
• Being labeled a “chronic pain patient” by everyone including the medical profession begins early.

NBC News Post

NBC News last week reported that with the recent economic downturn tens of Italians are choosing suicide. Here are excerpts from the notes left by the victims:

• “I decided to end it because I am a failure. I can’t live without work.”
• “I can’t live without a job.”

This feeling of failure and loneliness is at the very heart of acts of desperation among the business community in Italy. These messages left is the same mantra repeated by workers and businessmen who either tried to kill themselves and lived to tell the tale or by those who thought about trying, but found other reasons to live.

• “My business is like my family,” “I feel responsible for each of my employees. If my business fails, I fail with it.”

“In debt or jobless, many Italians choose suicide”, by  Claudio Lavanga. NBC News World Blog, May 9^th, 2012

My Historic Attitudes Regarding RTW

I will speak only for myself in mentioning some of my historic perspectives.

• I had the impression that many patients really wanted to come off of work.
  • Some did
  • Most did not
  • I did not understand how devastating it was to a patient and to their family to lose their job.
  • It is time-consuming to go into the details of light duty, etc.
    • It is often easier for me just to take a person off of work.
    • The Workers’ Comp paperwork is difficult and time consuming.
      • It frequently goes to the bottom of the stack.

My Current Approach to the Workforce Issues

• I do understand the implications of losing a job.
• Being out of work has major public health issues.
• Any time off work is of short duration with specific dates to return to work.
• If a patient is already off of work I broach the subject of returning to work very quickly.
• If they have no intention of returning to work, that has to be clearly discussed and an alternate plan implemented.

I did not have one day of training regarding return-to-work issues. It took me at least ten years in practice before I was able to figure some of this out. It is way too long.

People inherently want to be a part of society and contribute. Being active in the workforce is an important part of that need.

“The Journey of 1000 Moons”

“I’m Fine”

Here’s a puzzling situation I often encounter: A patient experiencing severe chronic pain has undergone multiple failed spine surgeries. Yet on my spine intake questionnaire, he or she rates him or herself as a zero on a scale from zero to ten in regards to anxiety, depression, and anger.  Upon further, almost intrusive, questioning by me, they adamantly will stick to their story.  They say that they are really just fine, except for the pain.

Anxiety is a Programming Issue not Psychological

The central nervous system component of chronic pain is a programming problem rather than a psychological issue.

• Anxiety is an emotion that gains strength with time and repetition.
• Anger is a powerful force that covers up the feeling of anxiety
• But it spins these neurological circuits more quickly.
• We deal with anxiety by exerting some form of control.
• If you are successful in controlling the situation or yourself, then your anxiety is alleviated.
• If you lose control, you will become frustrated or angry.

Your Hand Over the Heat

Consider anxiety as a reflex instead of emotion. It is the link that drives much if not most of our behavior and is intended to protect us.  The sensation of pain is one of those protective tools.

If you were to put your hand close to a red-hot burner on a stove, what would happen to your level of anxiety?

• It would quickly escalate.
• You would withdraw your hand.
• You would protect yourself.
• Anxiety would be alleviated.

What would happen to your anxiety if you were forced to leave your hand close to the burner?

• It go through the roof.
• You would feel trapped and extremely angry.

“I Don’t Believe You are OK”

With chronic pain you metaphorically have lost your ability to “withdraw your hand from the red hot burner.” How can you rate yourself as a zero on anxiety and irritability?  If you had no other stress in your life, chronic pain alone would be enough to destroy the quality of your life.

There are several other factors to consider with chronic pain.

• Where is the end?  Where is your hope?
• You truly are a victim of pain.  When you are truly a victim, it is more difficult to let go and not have anger run your life.
• When you suppress anxiety and anger, they become much stronger  White Bears and ANTS.

Maslow’s Miss

Abraham Maslow was a humanistic psychologist who conceptualized a heirarchy of human needs. The basic needs include air, food, and water. You are deeply programmed to be able to “pull your hand away from extreme heat.”  There is not a more basic neurological pattern than not being in pain. When you lose that ability to protect yourself from physical harm the effect on your nervous system is profound.  Regardless of how well you think you are suppressing the pain response your nervous system is fired up.

You are not going to “positively think” your way out of chronic pain.

Video: “Your Hand Over the Stove.”

Our medical and political system has failed.  Employers have abused workers as long as there have been employers and workers.  The intent of worker’s comp’s no-fault system was to both provide excellent medical care as well as improve worker safety.  Although workplace safety has dramatically improved since the early 1900’s, the system is failing to adequately prevent and treat chronic pain.  There is a major report being released this week produced by the Institute of Medicine.  They now estimate the number of people in the US suffering from chronic pain at 116 million.

It is my observation that the whole system of care ignores the most significant factor that contributes to the development of chronic pain—anger.

Anger is universal.  It is part of the human experience.  Some argue for the necessity of anger.  In any case, it is not going away any time soon.  Anger does provide a useful survival mechanism.  When you are threatened and feel anxiety you will take evasive or avoidance action.  When that ability to escape is lost, you will become angry, which increases your body’s physical reaction and mental focus to solve the problem.

The antidote to anxiety is control.

Loss of control = anger.

The current disability system strips the worker of control.  Additionally, at least in Washington State, the injured worker is at the mercy of a medically unsophisticated claims examiner.  That examiner has final say in everything.  As “enlightened” as I am, I cannot discuss a case with an examiner for more than a few minutes before I feel like I am losing my mind.  I cannot imagine having my well being, as well as my livelihood, at the mercy of this system.

It will not matter what systems are designed to “incentivize” workers to return to work, unless this core issue of anger is addressed.  You don’t have to incentivize any living creature to jump out of a cage.

Anger not only traps workers so they cannot fully engage in their care, but it also robs them of the ability or motivation to become engaged.

Although anger can be a useful survival mechanism, it is usually destructive to you and everyone around you.  Your anger imposes its own will on the immediate surroundings, and you have lost all ability to rationally interact with your environment.  The consequences are often disastrous.  The most well designed programs are not going to be effective unless the wall of anger can be penetrated.

I was running an hour late in clinic and was trying to get through my last patient before my already abbreviated lunch.  A Spanish-speaking woman from Puerto Rico was lying on the table moaning.  Her husband, who was sitting motionless across the room, could speak limited English, and there was an interpreter.

She was 32 years old with a thin blanket over her.  All I could tell was that she had been bedbound for several weeks experiencing total body pain. The cause of the symptoms was unknown.  The pain was severe and unrelenting.  Any upright position was intolerable.

They had two children, 8 and 10.  Her husband had just lost his job.  I could not ascertain what type of work she did and I could not picture her being a mother.

As I examined her, she cried out with just a light touch.  I was upset.  My practice is a consultative practice and she had come to see me without a referral.   I didn’t feel that I was the person she needed to see.  Besides, what could I do with her language barrier and seemingly complete inability to be functional or even respond?  I felt overwhelmed as well as rushed.

I prepared to walk out the door and have her referred to a primary care physician. He or she could offer some basic care such as medications and physical therapy.  But I did not know a way to have this quickly done, and she seemed like she was in a crisis.  I turned around and walked back into the room realizing that at least her husband spoke some English.  I spent about 20 minutes explaining the relationship between pain and the central nervous system’s response to it.  I emailed them a copy of the book draft that I am submitting for publication, “Back in Control.”   I asked her husband to read it and explain it to her as best as he could.  I would see them back in a couple of weeks to monitor her progress.

Surprisingly, she and her husband returned.  She could walk and conversed with me through the interpreter.  Her whole body still hurt but she felt a little better.  Her husband had not really engaged in reading the book.  I was encouraged by the little progress, but I felt that if I was going to teach her anything about chronic pain, it was going to have to be done by me in the office through the interpreter.  I spent about a half an hour going through the relationship between pain, anxiety, and anger.  I again asked the husband to assist her in learning and translating the concepts.  I also requested that she begin to write down her negative thoughts and immediately throw them away.  I did not have the time to explain why.

Two weeks later they returned and her pain was markedly improved.  Her husband still had not engaged in the process.  As I talked to her it became crystal clear that she was being tormented by extreme anxiety.  She stood in the opposite corner of the room with her arms wrapped around herself and her whole body was quivering with fear.  They had decided to move their family back to Puerto Rico so she could be with her mother.  I realized that this was the last chance to turn this around.

I explained to her that although she might have a temporary decrease in her anxiety, she was not going to completely outrun it by being around her family.  It was fine to move back home if that was what she wanted to do.  If it was to escape anxiety, I felt that was a bad idea and it would follow her. I became very blunt with her and her husband about the whole situation.  He needed to engage.  She needed to address her anxiety as its own issue and commit to the writing process.  I re-explained some of the central nervous system concepts.  I was fairly sure they were headed back to Puerto Rico.

Two weeks later they returned.  She and her husband were both smiling.  Her pain was gone.  Her anxiety was much better.  They were not moving to Puerto Rico and were very excited about how the situation was turning around.  Her husband was more engaged.  She had pursued her writing negative thoughts with a vengeance.  It had been extremely helpful.  Her husband’s comment was, “I have my wife back.”

I have no illusions that she is yet home free.  Recovery is not a straight-line endeavor.  But she now had tools and more importantly—hope.  Her problem was not chronic pain it was anxiety.

I did not order any tests.  I prescribed some medications for sleep and pain.  I spent about two hours of my time talking to her.  She engaged in the simple but powerful tool of writing down her negative thoughts and throwing them away.  She has a high probability of continued improvement.

What is this worth?  There are two adults and two children in this family who have a higher chance of being contributing members of society.  There is less family stress, which improves the behavior of the children, who are going to school with your children.  The wife has a better chance of being an effective mother and getting back into the workforce.   Minimal medical resources were expended and less will probably be spent in the future.

I did not get paid relative to what I could make if I were to have spent an equivalent amount of time performing surgery.  In fact, this type of interaction usually is a financial loss. The medical system does not reward anyone for taking the time to talk to patients.  It is a uniformly deep frustration amongst physicians that we feel rushed.  We are paid on a production basis, and our overhead is high. It is a significant contributing factor to burnout, which is around 50% of practicing physicians. We also know that the 14 most common diagnoses that are seen by primary care physicians have a direct link to stress.

Four lives affected.  Minimal medical resources expended.  With her severe language barrier, writing down her anxieties was her only choice of tools.I did not anticipate this outcome.

Is this worth anything to anyone?  Our medical care system must evolve.

Anger = loss of control

The need for control is caused by anxiety

Therefore

Anger = “souped-up” anxiety

Video: Caroline Myss-Taking Back Your Spirit

Anger and chronic pain are linked pathways. It is not possible to release yourself from your pain and move foward with your life until you can experience true forgiveness for the people who have wronged you the most. This remarkable video was passed on to me by a friend this weekend. Caroline Myss is a medical intuitive who has a remarkable ability to diagnose and heal disease through her ability to connect with patients. She relates a powerful story about forgiveness. The Navajo indians have a deep connection with the spirit that seems to be lost in our modern world.

I have known Anne for a couple of years. She had been experiencing chronic pain for a couple of years. Her once productive life had fallen apart and she now depended on welfare for her sustenance. She had undergone a lumbar disc surgery a couple years earlier that had gotten infected. She presented to my office with another ruptured disc at the same level. She wasn’t that happy.

I performed a successful disc excision and her leg pain quickly disappeared. I was relieved that she had not developed an infection from my operation. There is a higher risk of developing a post-operative infection if there has been a prior infection. She did well for about 3 months until she bent over to pick up a basket of laundry. Her disc re-ruptured at the same level and side. The size of this herniated disc was larger than the disc I just taken out. There was not much choice except to take her back to surgery and remove it.

During this period of time she was difficult. Her pain was difficult to control. She was understandably angry and demanding. I was in a perpetual battle with her over her needs for pain meds. Engaging in the DOCC project was not of much interest to her. However, she did begin the exercise of writing down her negative thoughts and immediately throwing them away.

Ten days after her second operation she came back to the office with extreme LBP and yelling at everyone at the top of her lungs. When I am dealing with a difficult patient it is tricky to sort out what might be real versus someone trying to get more medications. However my hunch was that there was something really wrong. Her disc operation had gotten infected and she developed a large abscess within the disc space and surgical site.

I had to perform surgery through her abdomen to clean out the infection from the front of her spine. A large bone graft was placed in the disc space to fuse it. A week later I went through her back to finish the fusion. She had now undergone six operations on her back within a span of two years. Her frustration kept climbing.

For weeks after her last operation her anxiety was severe and the pain was uncontrollable. I had her labeled as “not having a chance of really getting better.”  Neither one of us was enjoying our interaction. Finally after about six weeks she began to calm down and I began to talk to her further about the DOCC project. I still did not think she would engage in the tools and she had no access to a computer. But I never give up and she kept writing.

On one of her follow up visits I was about 30 minutes late. I am extremely busy and I did not think it was that much of a problem. I walked into her exam room and she exploded at me.  “I am really upset with you. I feel that when you are late that you are not respecting me.” She was yelling and didn’t stop for a couple of minutes.

My historical response would have been to essentially walk out the room and ask her to come back when she was less upset. I just sat there for a minute and for change I was able to listen. I saw her point. More importantly she had demonstrated a lot of courage to be clear with her surgeon. I looked at her and said, “This is a huge step. As I am the one in charge of getting you through a serious infection speaking up was a courageous move. I am impressed.”

From that day on things changed. She began to write a lot more.  She read “Feeling Good” and started writing in the “three column” technique outlined by David Burns. Her mood began to improve. She re-established a relationship with her daughter and granddaughter. I continued to be impressed with the transformation of her personality and her pain levels kept dropping. I looked forward to seeing her back.

About four months ago she plummeted while having some significant medical and relationship problems.  She clearly saw the relationship between anger and increased pain but could not let things go. I was relentless and would not let her off the hook. She dove into “Forgive for Good”, which is the anchor book for Stage 2 about anger. Every visit was a struggle including figuring out her meds for her increased pain. About six weeks ago she began to pull back out of her anger.

She came in yesterday beaming. She was active and off to see her granddaughter. She was in a new relationship that seemed promising. Her pain was minimal. I asked her, “What happened?”

She replyed that she figured out that whatever was in her past was over. There was absolutely nothing she could do to change it. She had made a decision, “I am not letting yesterday ruin today.”

It is the most concise description I have heard regarding letting go and moving forward. I have enjoyed watching her regain control of her life.

Hi Dr. Hanscom,

I know that you had asked me to send you an email telling you how it made me feel when L&I “stereotyped/categorized/labeled” me.

I know that you had asked for another story but I felt compelled to tell you about the first time I was stereotyped after my injury. It happened in an emergency room in Everett and was about one week after my first back fusion. I had only been home from the hospital for two days when I started getting back spasms. Initially the spasms were very bad but they had progressed to the point where I couldn’t even stand.  I ended up falling to the floor because my legs would not hold me up. It felt as though the muscles in my back where trying to bend me in half backwards. On the third day I couldn’t stand it anymore as the spasms were happening very frequently and I felt almost delirious. My oldest daughter called for an ambulance that transported me to the hospital emergency room. I spoke briefly with a nurse about what was going on and then to the doctor. I overheard them talking and saying that they felt there was NOTHING wrong with me but rather I was there looking for pain medication. Meanwhile I became upset and was telling my oldest daughter about what I had heard. She reached up and put her hand on my forehead and said, “Oh my God Mom you are burning up!” She proceeded to grab a thermometer and stick it in my mouth. After seconds she was freaking out and yelling for a nurse to get in there because I was burning up. The nurse didn’t even believe her so she herself took it again and my temperature was 103 degrees. About this time my younger of the adult daughters arrived.  My two daughters talked about the situation. The younger one grabbed my purse, which had ALL my medications in it, dumped it on the bed, and told the nurse to look at it! She told her that she too had witnessed me falling and that I had NO NEED for any more pain medication. I had more than enough and that they had better do something!

After that they did some blood work, an X-ray, and wrote me a prescription for muscle relaxers. I was basically patted on the head, told me they found nothing, and sent me home. That was on a Wednesday. On Friday morning my phone rang and it was the hospital telling me that I needed to come in and be checked. I had a very serious infection, which was in my spine and my blood and I needed IV antibiotics!

I won’t take up more of your time telling you the rest of the nightmare but I felt like you should know this, BECAUSE they decided what kind of a person I was BEFORE gathering all the facts. It almost cost me my life. If my two adult daughters had not been there to advocate for me I would be dead. I honestly believe they would have not done or checked anything. They probably would have just sent me home saying it was nothing!

I will guess that by now you can understand why when we first met I was so “angry“. Part of my anger stemmed from my nightmare experience that almost cost me my life. There is also about a six-week window during that time that I don’t remember a lot without help from my kids!

I am SO GRATEFUL that I was sent to you and that you decided to help me! I know that I am probably not as far a long with my entire recovery process as you had hoped. But I know that I wouldn’t even be this far if it wasn’t for YOU!

Sincerely,

Mary

My Perspective

Mary is a patient on whom I have performed two low back surgeries. The second was a fusion that went very well. However, the amount of family stress she has been under is beyond description. When I first met her over two years ago, she was one of the most angry patients I had ever met. I did not think she would return. She has made remarkable progress and is now just on minimal pain meds. I thoroughly enjoy my visits with her.

Her stresses continue, but she’s now trying to find a job, which in this economy is no small task. She has been consistently treated poorly by her claims examiner, and we have had to fight for every bit of her treatment. The subject of labeling came up, and I asked her to share part of her story.

BF

I personally went through the whole Mind Body Syndrome treatment paradigm over a span from 1990 to 2004.  I had no idea what was going on and learned the process by taking every possible wrong turn.  I have experienced 16 of the 33 MBS symptoms that Dr. Schubiner describes in chapter 5 of his book, “Unlearn Your Pain.”  Every one of them resolved, including severe burning in my feet, tinnitus, OCD, migraine HA’s, and migratory rashes all over my body.  None of these symptoms were subtle, but they have been gone for a while.  The one I am the most surprised about is the tinnitus—ringing, hissing, or buzzing in the ears in the absence of any such external sound.  It is a very intrusive symptom. Several ENT specialists had explained to me that the brain makes up a high frequency loss with “filler signals,” such as ringing and buzzing, that couldn’t be alleviated.  I was going to just have to deal with it.  And yet, I’m now free of my tinnitus. (Check out Dr. Schubiner’s website to see if some of your pain symptoms are related to Mind Body Syndrome.)

I have mentioned this on the Roundtable a couple of times, but the only resource that pulled me out of my tailspin was David Burn’s book, “Feeling Good.”   The book is remarkable, but in retrospect the most important factor was engaging with the book’s writing exercises.  I wrote with a vengeance.  Within six weeks, my anxiety began to decrease significantly. It is unclear why writing is so powerful, but my opinion is that you are associating thoughts with physical sensations.  This is one way new neurological pathways can be formed.

For me, the key issue by far was anger.  I finally faced my own victim role in 2003.  You can decrease your anxiety with the somatic tools, but anger is the turbocharger that just fires it all back up.  Six months after I realized that I was in the victim role, my life permanently changed.  My OCD broke; I could sleep.  I have never even remotely gone back to those years of severe burnout.

Howard Schubiner, a Mind Body Pain Specialist from Detroit, has also observed what I have seen.  Anger is the key emotion that seems to be closely linked with pain.  A couple of years ago, a patient gave me the book, “Forgive for Good” by Fred Luskin.  He works in Stanford and was involved with four research projects looking at the effects of forgiveness.  It is a very blunt, clear book.  It was when this book hit my practice that I began to observe dozens of patients become pain free.  This whole process continually fascinates me. None of it was anticipated.

I was practicing in Sun Valley, ID for a few years. I did not have a lot of access to pain psychologists. I began to share the “Feeling Good” book with my patients and within a few weeks would see them respond, but only if they engaged in the writing exercises. When they did, their recovery from pain was astounding.  I adjusted meds to get them to sleep, and rehab would gradually be worked into the picture. Even difficult patients would improve.

The process has evolved and I have put together this web site, www.doccproject.com.  It is intended to be a self-directed resource for physicians and patients to use as a template for their own healing.  Over 90% of the effort that goes into my successful patients is their own.  I will pull in mental health resources, biofeedback, etc., as they are open to it.

All this being said, I am not attached to my specific protocol.  Any organized structured program that addresses education about pain, sleep, somatic tools for stress, goal setting, and physical rehab has a high chance of being successful.

The key is getting the tools to assume control of your pain.  Chronic pain patients are suffering. They are labeled by essentially everyone they are in contact with, including the medical profession.  They have no direction or ability to make informed decisions. The DOCC Project approach allows them to regain control of their own care and life. It helps organize their thinking. Once they connect with who they are, you cannot stop them from getting better.  Every human being wants to thrive given the right tools and a chance.

Multiple physicians around Seattle are changing their paradigm of chronic pain to incorporate MBS concepts.  They are beginning to see a lot of success.  One in three Americans experiences chronic pain.  We have medicalized a neurological problem.  The tragedy is that MBS is so treatable. Our profession is rapidly creating disability instead of solving and preventing it.

In this section, I will be sharing some my personal experiences dealing with the Mind Body Syndrome. I hope you will find them helpful.

BF

I have a good friend, Dennis, who related an interesting experience he had regarding Sensitization to Pain.

It occurred when he was working as a hod carrier in his early twenties. A hod carrier is a person who sets up the work area for brick masons. Essentially, the hod carrier enables the brick masons to lay blocks or bricks as efficiently as possible. The work involves mixing cement and carrying it along with the building materials to the next section of wall. This has to be done fast enough to stay ahead of the masons. The materials also often have to be hauled up scaffolding. The masons are not usually very happy if the hod carrier falls behind. It is an extraordinarily intense, physical job.

On one particular job, Denis’s duties also included cutting blocks of basalt with a “wet” saw. This is a saw with an industrial diamond blade. To keep the blade from overheating, water from a small sump pump is continuously pumped over the blade. One day on the site, he felt a very mild tingling sensation as he placed his hand on the saw handle. As he cut blocks early in the morning, the sensation was not particularly uncomfortable. As the morning progressed, the sensation gradually became stronger. By early afternoon, the sensation was so strong that he could no longer comfortably touch the handle. He felt an actual shock. Even the anticipation of the sensation became a problem, and he would not touch the handle.

There were three hod carriers on this crew. They watched him get more and more cautious and finally refuse to touch the handle. Yet when they touched the handle, they could barely feel anything. Needless to say, they gave him a hard time.

The next day, they rotated and the second guy had the same experience. By mid-afternoon he would no longer touch the handle. The third guy now thought they were “toying” with him. Again, when he touched the handle, the sensation was almost imperceptible.

The third day was his turn, and by mid-afternoon he was a believer. The ultimate cause of this phenomenon, a frayed wire, was finally fixed on the fourth day.

What is interesting to me about this story is the degree of difference in sensation over just six to seven hours of repeated exposure. If the initial impulse had been somewhat uncomfortable, the story would have seemed more plausible. However, the sensation went from barely perceptible to an electric shock. Dennis said that even the anticipation of touching the handle produced a physical sensation.

It would be reasonable to assume that if a functional MRI was available to measure the hod carriers’ brain activity throughout the day, there would be an increased number of areas of the brain firing by the end of the day.

Your nervous system is incredibly adaptable. It does not take much repetition for your brain to figure out how to process a known, predictable impulse.

BF