September 26, 2016

Two faulty beliefs about IMEs & impartial physicians

Patients and their advocates tend to be skeptical about independent medical opinions.   There are legitimate reasons to be concerned.  However, I want to point out two common but faulty beliefs that create UNNECESSARY distrust in this aspect of disability benefits and workers’ compensation claim management systems.  First, despite patients’ faith in their own doctors, treating physicians as a group are NOT a reliable source of accurate and unbiased information.  Second, although justice IS even-handed, impartial physicians should not find for both sides equally.

Based on my experience leading teams on three consulting projects that audited the quality of more than 1400 reports of independent medical evaluations and file reviews I definitely share MANY other concerns about the quality of the reports, the process by which they are procured, and the physicians and other healthcare professionals who provide them.  But these two particular issues are not among them. Read on to find out why.

FACT:  As a group, treating physicians are NOT a reliable source of accurate and unbiased information

First is the incorrect belief that the treating physician is the BEST place to turn for an “independent” opinion because they are highly trained professionals who are familiar with the patient’s case.   There are two main reasons why this is incorrect:

(a) There is considerable variability in the appropriateness and effectiveness of the care delivered by practicing physicians, and patients are not in a good position to assess it.  Evaluating appropriateness and effectiveness is admittedly a difficult and imperfect process, but the best way we know to do it is through the eyes of another physician who is equally or more expert in the matter at hand — and has no axe to grind and no financial stake in the outcome:  neither a friendly colleague nor a competitor.

(b) In medical school and residency, physicians are often told they should be “patient advocates” — but that instruction may not include a definition of advocating. (True for me and many others in physician audiences when I have asked about it.)  Patient advocacy sometimes turns into doing or saying exactly what the patient wants, not what is actually in the best interest of the patients’ long term health and well-being.  (I call this being a McDoctor.)  Particularly in today’s world with fierce competition between medical groups for patients and the use of “patient satisfaction scores” in calculating physician bonuses, that is true.  The data is clear:  treating physicians provide unnecessary antibiotics, pain medications, inappropriate treatments and are even willing to even shade the truth on reports in order to keep their patients happy.

The reason why arms-length or “third party” physicians are preferred as the source of opinions is to protect patients from harm from EITHER the “first party” (treating physician) OR the “second party” (the payer — which has an OBVIOUS business interest in controlling cost).  Judges, public policy people, and I get uncomfortable when the WAY the arms length physician is SELECTED is distorted by the interests of either the first party or second party.

FACT:   Impartial physicians’ opinions should not find for both sides equally

Second is the belief that “truly” impartial physicians should come down on the side of the patient vs. insurer half the time.  Or call it 50:50 for plaintiff vs. defense.  This belief is WRONG because cases selected for review or IME have been pre-selected by claims managers and case managers.   These professionals may not be healthcare professionals but because they see thousands of cases and become very familiar with the medical landscape, they ARE often more experienced OBSERVERS of the process of care than many physicians. They learn to recognize patterns of care that fit normal patterns, and care that is unusual.  These days, they are often expected to use evidence-based guidelines to identify outlier cases.  Those who focus on specific geographical areas come to see which doctors get patients better and which ones don’t.

The VAST MAJORITY of the time, there is no need / no reason to refer a case for independent review.  The treating physician IS doing the right thing;  the diagnoses, prescribed treatment, and causation determination (if work-related) DO appear reasonable and appropriate.   If the claims managers/ case managers see no problems or have no questions, they don’t refer the case for outside review.  If it aint busted, why fix it?

So as a rule of thumb, you can assume that some feature or another in ALMOST EVERY case being sent to review has RAISED QUESTIONS in the mind of an experienced observer of the care process.  The reason WHY the case is REFERRED is because that observer has only a very superficial knowledge of medicine.  They need an adviser — an impartial and expert physician who can evaluate the clinical facts and context and then either CONFIRM that the treating physician is doing the right thing or VALIDATE the claims/case manager’s concerns.

When claims/case managers are doing a good job selecting cases for referral, we SHOULD expect that MOST of the decisions will favor the insurer / defense. The more expert the claim/case managers are, the MORE LIKELY the independent physicians will agree — because the claims/case managers are accurately detecting real problems and concerns.

(By the way, a similar ratio seems to apply in the court system.   A judge once told me that MOST defendants ARE guilty – because the prosecutors don’t want to waste their time and public funds bringing cases to trial if they think the defendant is innocent – or if they simply think they will lose.    A perfect example  of this pragmatism is the FBI’s recent decision not to prosecute Hillary Clinton.  The Director made it clear that they didn’t want to waste the taxpayers’ money on a case in which they wouldn’t be able to convince a jury “beyond a reasonable doubt.”)

Consider this:  If you are a treating physician who FREQUENTLY ends up with your care plans rejected by claims managers and utilization review, consider the possibility that YOU stick out.  Your care patterns may be more unusual than you realize.  Your outcomes may be worse than your colleagues’.

Sadly, some physicians discredit input from independent experts in front of patients.  They THINK they are advocating for their patient — on a social justice crusade, but end up harming their patient instead — by teaching them they have been wronged, are a victim of “the system,” and a helpless pawn.  This message:

  • increases distrust, resentment and anger (which in turn worsens symptoms);
  • encourages passivity rather than problem-solving (which in turn increases the likelihood of job loss, permanent withdrawal from the workforce, and a future of poverty on disability benefits).

A former president of the Oregon Medical Association said he counsels patients this way:  “Your two most important treasures are your health and your job. And  I am here to help you protect both of them.”  Healthcare practitioners really ought to do everything they can help their patients find a successful way out of these predicaments, instead of allowing them to believe they are trapped.  The “system” is not designed to solve their life predicament for them — they may have to do it themselves.  The physicians’ care plans should consist of those treatments known to restore function and work ability most rapidly.  Physicians should encourage their patients to tell their employer they want find a way to stay productive and keep their jobs.  And if the employer won’t support them, physicians should counsel their patients to try to find a new job quickly — even if it’s temporary or they have to make a change to the kind of work they do.

Adapting to loss is a key part of recovery.   When I was treating patients, I could tell they were going to be OK when they said with pride “I’ve figured out how to work around it, and life is getting back on track.”

September 9, 2016

Pithy 4-min Video & 1-page Manifesto for you to use

Mathematica just released a 4-minute video of me pointing out why the work disability prevention model is important — in plain language.  The video was made at the request of the US Department of Labor’s Office of Disability Employment Policy (ODEP).  The main messages in the video are:

  1. MILLIONS of Americans lose their jobs every year due to injury and illness;
  2. Worklessness and job loss have been shown to harm physical and mental health as well as personal, family, social, and economic well-being;
  3. Worklessness and job loss should therefore be considered poor healthcare outcomes;
  4. Unexpectedly poor outcomes can often be prevented and there is good research evidence about how to do that;
  5. Changes need to be made so that vulnerable people get what they need at the time when they need it — and as a result are able to have the best possible life outcome, stay in the workforce, and keep earning their own living.

In addition, the video also explains WHY and HOW some people have unexpectedly poor outcomes of conditions that do not normally cause significant work disruption and job loss.  Unless you’re in my line of work, it is hard to understand why things turn out badly in some cases and not in others — especially if they looked exactly the same at the beginning.

The video is loosely based on a one-page Work Disability Prevention Manifesto I wrote.  I put a draft of it on this blog last spring and got many useful comments.  After many revision cycles, it is now as succinct and compelling as I know how to make it.  ODEP had no hand in the Manifesto; it’s my independent work.

I’m glad I can now share these two items with you because the WORLD needs to know more about these issues—and most PEOPLE in the world have a very short attention span and no interest in the topic to begin with.   I hope you will pass this stuff along to the people whose thinking you want to change or whose buy in you need. Then maybe THEY will pass it along to others as well.  Social norms ONLY SHIFT when people share powerful mind-opening ideas with one another.

Lastly, let’s all stop speaking ABOUT these problems.  It is time for us all to start speaking FOR action and FOR changes.

©Jennifer Christian, MD, MPH August 2016

Preventable job loss demands our attention

  • Millions of American workers lose their jobs each year due to injury, illness or a change in a chronic condition.
  • Preserving people’s ability to function and participate fully in everyday human affairs, including work, is a valuable health care outcome, second only to preserving life, limb, and essential bodily functions.
  • A new medical problem that simultaneously threatens one’s ability to earn a living creates a life crisis that must be addressed rapidly and wisely. Most people are unprepared for this double-headed predicament. It can overwhelm their coping abilities.
  • When medical conditions occur or worsen, especially common ones, most people are able to stay at or return to work without difficulty. However, many prolonged work disability cases covered by private- and public-sector benefits programs began as very common health problems (for example, musculoskeletal pain, depression, and anxiety) but had unexpectedly poor outcomes including job loss.
  • Loss of livelihood due to medical problems is a poor health outcome. Worklessness is harmful to people’s health, as well as to their family, social, and economic well-being.

Why do such poor outcomes occur?

  • Medical conditions by themselves rarely require prolonged work absence, but it can look that way. Both treatment and time off work are sometimes considered benefits to be maximized, rather than tools to be used judiciously.
  • Professionals typically involved in these situations (health care providers, employers, and benefits administrators) do not feel responsible for avoiding job loss.
  • Unexpectedly poor outcomes are frequently due to a mix of medical and nonmedical factors. Diagnosed conditions are inappropriately treated; others (especially psychiatric conditions) are unacknowledged and untreated. The employer, medical office, and insurance company (if there is one) operate in isolation, with little incentive to collaborate.
  • Without the support of a team focused on helping them get their lives back on track, people can get lost in the health care and benefits systems. With every passing day away from work, the odds worsen that they will ever return. After a while, they start to redefine themselves as too sick or disabled to work.
  • When people lose their jobs and do not find new ones, they barely get by on disability benefits and are vulnerable to other detrimental effects.

How can we fix this problem?

  • Good scientific evidence exists about how unexpectedly poor outcomes are created, how to avoid them, and how health care and other services can protect jobs.
  • Health-related work disruption should be viewed as a life emergency. Productive activity should be a part of treatment regimens.
  • When work disruption begins, it can be both effective and cost-beneficial to have a coordinator help the individual, treating physician, and employer communicate and focus everyone’s attention on maximizing recovery, restoring function, accommodating irreversible losses, and making plans for how the individual can keep working, return to work, or quickly find a more appropriate job.
  • We must urgently establish accountability for work disability and job loss in our workforce, health care, and disability benefits systems and build nationwide capacity to consistently deliver services—just in time, when needed—that help people stay at work or return to work.

September 7, 2016

Is this disability porn? Lovely duet by disabled dancers

A physician colleague sent me a link to the video entitled “Hand in Hand Dance.”  It features two Chinese dancers, each with a different impairment.  The woman has lost one arm; the man has lost one leg.

As a former dancer myself who has never seen obviously disabled dancers, I was curious.  So I watched the video — and am embarrassed to admit I was surprised at how aesthetically pleasing it is.  Their duet is beautiful and very professional.  The emotional story is clear and compelling:  loss, grief, encounter, relationship, attraction, love, joy.  But for me, the thrilling part was seeing their mastery and pure enjoyment of dance itself.  They use their bodies both gracefully and athletically — exulting in their youth, capabilities, talent, strength, life, and love,

Some people in the disability community are offended by what they call “disability porn”.   You can read about it here  and here.   Is that what this dance video is?  I don’t think so.  These two deserve admiration because they have done the work and have the talent to create an artistically satisfying dance.   But on the other hand, insensitivity is in the eye of the receiver, not the sender.  If I’ve got it wrong, please let me know — and tell me why.

See what you think:

September 4, 2016

“Upstreamist” reduces healthcare utilization by providing a lawyer!

In an effort to reduce demand for healthcare services among high utilizing homeless vets,  Rishi Manchanda, MD did NOT ask to hire more health care professionals.  Instead, he successfully persuaded the West LA Veterans Administration Medical Center to bring in a public interest lawyer once a week.

The purpose was to identify vets with unmet legal needs that were in turn creating / driving demand for health care services.   That bet paid off.  Healthcare utilization decreased by 24% among the 139 homeless vets who participated.   The pilot program cost an average of $525 per person, and the vets gained access to more than a half million dollars in increased disability and other cash benefits.    Helping the vets resolve stressful legal, administrative, or financial barriers to housing, for example, made a big difference.

Manchanda is an advocate for moving “upstream” in order to achieve the so-called “quadruple aim” of healthcare:   better care, lower total medical costs, as well as increased patient and physician satisfaction.   [The Institute for Healthcare Improvement uses the term “triple aim” which ignores the issue of professional satisfaction.]  In Manchanda’s view, the KEY to achieving the quadruple aim is the integration of “social determinants” in health care.

Manchanda asserts that physicians are forced to work  with one hand behind their backs unless social determinants are addressed.  “Unlike all of our peer nations, we have more spending on health care than social services.  That actually creates a scenario where you have DOCTORS talking about moving upstream.”  In fact, he now calls himself an “upstreamist.”    You can read more about his remarks which were made at an AMA conference on radical redesign in health education.

Public health researchers have been intently studying what is called health inequalities or health inequities.  The country of Ireland has a particularly straight-forward definition:  “Health inequalities are preventable and unjust differences in health status experienced by certain population groups. People in lower socio-economic groups are more likely to experience chronic ill-health and die earlier than those who are more advantaged.”  In the U.S., health status varies with race and culture as well as with socio-economic status.

In the US, the phrase “social determinants of health” refers to the EXTERNAL CONTEXT in which a person lives such as safe housing, local food markets, access to educational, economic and job opportunities, access to healthcare services, public safety, cultural and social norms and attitudes, exposure to crime and violence; housing and community design, natural environment, etc.. All of these things have been shown to have an impact on health status.  (See more below).

Social determinants do not include INTERNAL PERSONAL FACTORS like a person’s life philosophy, the things they or don’t know, their past life experiences, preferences, attitudes, motivations, intentions, values, beliefs, emotions, or other psychological dynamics.  Obviously, both internal personal and external factors influence people’s behavior and what happens (outcomes).  Thus, our more comprehensive BPSE model of sickness and disability includes the ENTIRE context:  BOTH external AND internal personal factors.  (BPSE = bio-psycho-socio-economic)

From the U. S. Government’s Healthy People 20/20 website:

Understanding Social Determinants of Health

Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and neighborhood) have been referred to as “place.”5   In addition to the more material attributes of “place,” the patterns of social engagement and sense of security and well-being are also affected by where people live. Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.

Understanding the relationship between how population groups experience “place” and the impact of “place” on health is fundamental to the social determinants of health—including both social and physical determinants.

Examples of social determinants include:
•    Availability of resources to meet daily needs (e.g., safe housing and local food markets)
•    Access to educational, economic, and job opportunities
•    Access to health care services
•    Quality of education and job training
•    Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
•    Transportation options
•    Public safety
•    Social support
•    Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
•    Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community)
•    Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
•    Residential segregation
•    Language/Literacy
•    Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)
•    Culture

Examples of physical determinants include:
•    Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)
•    Built environment, such as buildings, sidewalks, bike lanes, and roads
•    Worksites, schools, and recreational settings
•    Housing and community design
•    Exposure to toxic substances and other physical hazards
•    Physical barriers, especially for people with disabilities
•    Aesthetic elements (e.g., good lighting, trees, and benches)

By working to establish policies that positively influence social and economic conditions and those that support changes in individual behavior, we can improve health for large numbers of people in ways that can be sustained over time. Improving the conditions in which we live, learn, work, and play and the quality of our relationships will create a healthier population, society, and workforce.

August 5, 2016

CMS announces where they will start transforming physician payment plans

If like me you’ve been kinda following Federal physician payment reform (and hoping that what is learned there there will lead to payment reform in the private sector or maybe even workers’ compensation), the Centers for Medicare and Medicaid Services (CMS) made a big announcement this week.

Starting 4 months from now, (January 2017) they will be rolling out / testing a really quite revolutionary change in payments to PRIMARY physicians in 14 regions that include 11 whole states:  Arkansas, Colorado, Hawaii, Michigan, Montana, New Jersey, Oklahoma, Oregon, Rhode Island and Tennessee.    Other areas are the Greater Kansas City, MO area; the North Hudson Valley in New York state, the Greater Philadelphia area, and a region that includes all of Ohio plus northern Kentucky.

If you’re in any of those areas, it would behoove you to learn more about this –- and follow it as it unfolds.    CMS is estimating that 5,000 primary care practices serving an estimated 3.5 million beneficiaries could be touched by this model.   They are currently taking applications for providers in eligible practices in these areas, and don’t expect much trouble recruiting because the care-management fees can be a boon for practices.  Providers may be able to earn an additional $100,000 to $250,000 per year under the model, depending on the number of patients who participate.

The new model CPC+ (Comprehensive Primary Care Plus) has two tracks. Under track one, providers get a monthly fee for specific services in addition to the usual fee-for-service Medicare payments. But in track two, practices get an upfront monthly care-management fee coupled with reduced fee-for-service payments. The purpose of this hybrid model is to let practices provide care outside of the traditional face-to-face encounter.

Learn more here:

August 3, 2016

A smile-filled rebuttal of ageism

I’m sitting here with a smile on my face after watching a 90 year old woman perform on America’s Got Talent — on You Tube.

If you’re worried that maybe you’re getting old and set in your ways, watching this video will be a great tonic.  If you don’t like being ageist but old people seem so, well, OLD and predictable  —  this will sure give you a different perspective on what’s possible.

And what the heck  –  just watch it because it’s a bit outrageous and totally fun:

Yesterday I ordered a book entitled:  Aging or Ageless:  Rising Like a Phoenix from the Myth of Aging by Ron Zeller, a Landmark Forum leader who died recently at age 83.   It’s a book about transcending aging that doesn’t focus on how to stop aging but instead on how to be “ageless” in the face of any circumstance you face.  Ron Zeller got his first diagnosis of terminal cancer at age 60 (which he beat), and his second at nearly 80.  In the 20 years in between, he kept on transforming people’s lives by leading courses for Landmark while taking his health and vitality up to an entirely new level as an endurance athlete. At the age of 64, he ran and won his age division in the 100-mile Wasatch Endurance Race in Utah, one of the most demanding ultra-marathons in the world —  the first of many races he ran in places all over the world.  In 2004 Ron took up power lifting and by the age of 72 had had broken three US national records for his age. As recently as age 77 he completed the 135 mile Bad Water desert endurance race, running solo between the lowest and highest points in the continental United States.

I wonder if that 90 year old woman on America’s Got Talent has read Ron’s book!  Maybe she didn’t have to – because she sensed the secret to vitality on her own.   When I have a minute, I’ll try to find out what happened to her afterwards.   If you do, please let me know.  And if I like Ron’s book, I’ll share it with you.

July 28, 2016

Video on tools & techniques to aid recovery & RTW

You may like watching the video of a group discussion on Tools to Aid Recovery and Return to Work that was presented (and recorded) via Blab yesterday.  It was a stimulating exchange of ideas about both tools AND techniques with my colleagues Les Kertay, PhD and Chris Brigham, MD — as we each sat in our own offices.  Each of us were visible in our own little boxes on the screen.

The session was aimed at professionals in any discipline who want to hone their skills at working with individuals who are having trouble getting back on their feet.  It was sponsored by R3 Continuum and hosted by John Cloonan, their Marketing Director.

The video is now available on You Tube.  There are a few static-y and jumpy spots in the video, but I believe you will find the 60 minute conversation is worth your time.
Here’s the link to the YouTube version:

Afterwards I talked to John Cloonan about Blab.  Apparently it has a built-in link to Twitter, so Twitter users can watch the live Blab video using Twitter’s Periscope capabilities.  Comments from Twitter users are fed to the Blab screen and are visible to presenters, which enables audience participation.  In addition, John was able to simultaneously link the live video to Facebook.   So while we were talking among ourselves, an unknown number of people were watching our discussion via R3 Continuum’s website, Facebook AND Twitter.   If you go any of those places, you can still find it.

Wow, talk about the ability to extend one’s reach and connect with many audiences!   Looks like John Cloonan (as a marketing guy who wants to disseminate messages far and wide) is drawn to Blab because it is possible to attach such a big social media megaphone to it!

As is typical with new technology, there are more challenges than are obvious at first glance.  For example, Blab works much better with a high-speed wired connection.  Some users may find their firewall is blocking it and have to figure out how to unblock it, etc. etc.  I had to restart my silly computer to get the microphone to work.  So having a “tech rehearsal” ahead of time was absolutely essential.

Les, Chris and I are all members of the Praxis Partners Consortium, by the way.

July 21, 2016

Pay attention to burden of treatment – and its impact

Think about it: Becoming a patient can sometimes be like getting three new (and unwanted) part-time jobs:

(1) arranger/consumer of professional healthcare services,
(2) manager of self-care and activity adaptation regimens, and
(3) manager of administrative issues (benefits, purchasing, and billing).

The tasks involved in those additional jobs can sometimes be so time-consuming they interfere with other important responsibilities (like going to work). Some tasks may be beyond the patient’s capability and so don’t get done right – or done at all.

The POINT here is that Burden of Treatment is a significant but under-acknowledged and thus unmanaged issue.  Anyone “in the business”  for a while has had a vague sense that this is a practical concern with major impact.  But to date we’ve just been haphazardly addressing it.

All stakeholders in health-related work disruptions do need to stay alert to how much time and effort patients/claimants/employees are spending on treatment and care regimens of various kinds (and their attendant administrative/financial issues).  We also need to assess how well they are managing that burden.  Once we DO start to pay more attention to this issue and see how the impact varies from one treatment regimen to another, we will see that we have an opportunity to work on REDUCING BoT.

Figuring out how to systematically classify and document BoT is a necessary early step to increase awareness and opportunities for active management. There may well be a vast literature on this topic — but I am unaware of it. The particular study whose abstract appears below reminded me that this issues exists.  It explores whether/how to use the terminology in the ICF to document BoT. (ICF is the International Classification of Function, the lesser known companion to the ICD – International Classification of Disease.)  And I don’t know whether the ICF addresses the burden of administrative issues. Do you?

TAKEAWAY MESSAGE:   Let’s all think more about what a high burden of treatment means for our patients/claimants/employees, and what we can do to reduce it.

GONCALVES AV, Jacome CI, Demain SH, Hunt KJ, et al.
Burden of treatment in the light of the international classification of functioning, disability and health: a “best fit” framework synthesis.
Disabil Rehabil. 2016 Jul 3:1-9. [Epub ahead of print]


PURPOSE: This systematic literature review aimed to (1) summarize and explain the concept of Burden of Treatment (BoT) using the International Classification of Functioning, Disability and Health (ICF) terminology, and (2) inform the development of a future Comprehensive ICF Core Set for BoT.

METHOD: Searches on EMbase, Medline, CINAHL and PsycINFO were conducted. Only qualitative studies were considered for inclusion. The screening and data extraction stages were followed by a “Best-fit” framework synthesis and content analysis, using the established ICF linking rules. Screening, data extraction, quality appraisal and data analysis were performed by two independent researchers.

RESULTS: Seventeen studies were included in this review. The “Best-fit” framework synthesis generated 179 subthemes which identified that BoT impacts negatively on body functions and structures, restricts valued activities and participation and influences contextual factors through life roles, self-identify and relationships. The identified subthemes were linked to 77 ICF categories.

CONCLUSIONS: This study is part of the preparatory phase of a Comprehensive ICF Core Set for BoT and our findings will inform the further needed studies on this phase. The use of ICF terminology to describe BoT provides an accessible route for understanding this complex concept, which is pivotal for rethinking clinical practice. Implications for rehabilitation Health professionals applying the ICF should consider the negative impact of interventions on patient’s life roles and self-identity, body functions and structures and on valued activities and participation. Health professionals who may be concerned about the treatment burden being experienced by their patients can now use the ICF terminology to discuss this with the multidisciplinary team. Poor adherence to rehabilitation programs may be explained by an increased BoT. This phenomenon can now be mapped to the ICF, and coded using a framework well known by multidisciplinary teams.

July 19, 2016

Overcoming fear of sharing our work with others

It’s scary to make a suggestion or share a work sample on a social networking site or a list serv in an effort to help less expert colleagues.  There’s a risk that an even-more-expert colleague will point out the flaws, or even make belittling comments.  If they’re kind, the expert will do it in private.  If not, there is the possibility of gossip behind one’s back, or public humiliation.

A colleague I deeply respect recently took that chance — not because he’s the world’s expert on a particular topic, but because he has a commitment to generously sharing what he does know for the benefit of others.  His goal in sharing his work product was to upgrade the way a particular issue is usually handled across the country.  That’s why I admire my colleague.  He offered a very concrete work product for others to use if they would like.

Fear of humiliation and being incompetent lie one millimeter beneath my skin. That fear, which is pretty common among humans, runs rampant in physicians.  It was intensified by our severe socialization during medical school and internship.  I hesitate every time I put any of my own thoughts or work “out there” for all to see.

I’m not alone in having this fear of being upstaged by someone more expert. For example, a doctor recently unsubscribed from the ACOEM Work Fitness & Disability Section list-serv with this comment:   “I joined the WFD section because I presumptuously (perhaps arrogantly) thought that given my decades of trying to navigate the rocky coastlines of fitness for duty and disability management I might actually have something of value to offer the newbies who might post questions.  So I responded to couple of posts and …… Well, let me tell you, I may be a big fish expert in my insular little pond, but soon recognized that the WFD Section is replete with knowledgeable, articulate, and fluent experts.  I really didn’t have much of anything new to offer. It was kind of like the experience of being at or near the top of your class in a suburban  high school then getting into a competitive college in the big city where everyone is as smart as you or smarter. So you folks don’t need me; you’ve got it covered. And I’m not fishing for compliments or encouragement either (which you couldn’t offer anyway since you don’t know me), just keeping it real.”

Got any ideas for how to solve this cultural problem?  I don’t — other than to point out these three aphorisms which seem relevant:

  • “Don’t let the excellent drive out the good.”
  • “You may need to lower your standards in order to improve your performance.”
  • “In the land of the blind, the one-eyed is king”

Fear of sharing stifles collaboration and innovation — so it inhibits any community’s ability to upgrade its current prevailing level of quality — “what typically happens”.  There’s something wonderful about people contributing what they DO KNOW.  There’s something wrong about being made to feel bad if it turns out someone else is EVEN MORE expert or wise.  So, perhaps we need to ponder, in the “land of the blind”:
— how a kind and respectful person with binocular vision (“the nation’s top expert at seeing”) should behave towards blind and the (rare) one-eyed people?
— how one-eyed people could best respond to input from the (very rare) binocular individuals?
— how blind people should differentiate between the (rare) one-eyed individuals and the (very rare) binocular people?

In the meanwhile, here is what happened with my colleague.   I received feedback that there were some inadequacies in his work product.  I sent that feedback along (anonymously by request) to him.  I ended my email with this:  “On behalf of all of those who are less well organized and systematic than you are, and for whom your tool provides a concrete model of what ‘good looks like’ — thank you for this contribution.   And, please, if you have the time, use the feedback to go take it up a notch!”

His response: “I’m very open to discussions on ways to improve this document.  I look forward to input of all sorts.”   He also plans to teach a session on how to use the “new & improved version” at our professional development conference next year.   THIS is the kind of professional behavior I DEEPLY ADMIRE.

July 14, 2016

Why we need a 1:1 ratio of healers to lawyers when designing reforms for “comp”

While Linda Rudolph was Medical Director of the California workers’ compensation regulatory agency in the mid-1990’s, she defined workers’ compensation as a medically-driven legal system.  I still use that definition when I give my annual lecture on work comp at the Harvard School of Public Health.   Based on my interpretation of what that succinct and elegant summary really means, I believe that any group setting out to improve the workers’ compensation system should have a roughly equal number of people at the table who were originally trained in a healing art and the law — because of the way their minds were indelibly imprinted by that training.

As you may have heard, I was among 38 workers’ compensation experts of various stripes who participated in the Workers’ Compensation Summit co-hosted by blogger Bob Wilson from and blogger Judge David Langham, Deputy Chief Judge of the Florida workers’ compensation system.

I was surprised as we went around the room introducing ourselves.  I was one of only two physicians in the room.  There were no others with healthcare professional training.  There was one person whose original training had been as a vocational counselor.  By far the largest group had had legal training, although many of them were now in other jobs — judges, legal scholars, workers’ compensation system administrators, corporate executives.

Training in both law and in medicine shapes a student’s worldview, teaches a precise vocabulary, builds a foundation of factual knowledge as well as rigorous intellectual discipline, and defines how things work in a certain part of human life.  The training also establishes a finite range of things that seem possible, and offers a particular inventory of potential solutions.  A behavioral acculturation process accompanies it, too.  The point here, though, is that the actual shape and content of those worldviews, vocabularies, knowledge bases, intellectual disciplines, possibilities and solutions — and behavioral cultures — differs in most respects between the two professions.

Earlier in life, I spent 20 years as a physician married to a lawyer.  For many reasons, it was kinda like a nice cat being married to a nice dog.  We had a primordial kind of incompatibility.  But I did get to know what made that particular dog tick pretty well.

Lawyers seem to have a predilection for solutions that involve clarifying rights, justice, entitlements, boundaries, and who is responsible to pay for what.  Lawyers are trained to advocate for their clients’ rights and interests.  Most lawyers seem to spend an awful lot of their time and energy anticipating arguments or actually arguing, fighting, and trying to win  — because the everyday grist of their vocational mill is broken promises and disputes.

As I was pondering the difference between the “head set” of medicine and law, I found a quote from an article in the May 31 Boston Globe about a 35 year old man, a published author and poet, now  graduating from Yale Law School — who at age 16 had hijacked a car at gunpoint and served 8 years in prison.   He said “The law is a way to think and argue, and a way to find solutions….. Law is the language of power, and understanding that language is important to understanding power.”  This quote struck me — not because he’s so amazing (which he obviously is) but because he articulated so precisely what I had predicted a lawyer would say.

Physicians and others in the healing professions have a predilection for solutions that reduce peoples’ suffering and restore the integrity of their bodies/minds.  Medicine has nothing to do with winning.  The first precept of medicine is to do no harm.  Physicians are trained to advocate for their patients’ health, to meet their immediate needs today and maximize their future well-being in the future.  The everyday grist of their vocational mill is providing comfort, relief, and reassurance to a stream of patients coming through the door with symptoms, with bodies or minds that aren’t working right, distressed and worried about the meaning of those things for their health and everyday activities (and often secretly fearing death).

In my view, a good “medically-driven legal system” for people injured at work should concern itself primarily with helping injured workers get back on their feet.  That requires paying roughly equal attention to

  1. Helping them manage any life predicament the injury has caused (reducing worry, suffering, and distress, arranging good care promptly that maximizes healing and restores function as quickly as possible, preserving daily routine, minimizing work disability and job loss or providing assistance to find a new job quickly.  The goal is to get everyday life back to normal as soon and as completely as possible.  Time spent in limbo is destructive.
  2. Minimizing their short-term financial stress as well as long-term financial loss, sorting out their rights, and dealing with disputes.

Everyone’s goal should be to expedite the activities in #1 even if there are difficulties in #2, instead of allowing #2 to delay #1 as is common today.