Delayed Recovery: Identifying Risk Factors in Workers Comp Cases w/ Diana Kraemer of IAIME

Navigating the Complexities of Delayed Recovery in Occupational Health: A Conversation with Dr. Diana Kramer

In this episode of the Fit for Duty podcast, the host Dr. Larry Earl, President of the National Association of Occupational Health Professionals, discusses the concept of delayed recovery in occupational health with guest Dr. Diana Kramer of

Dr. Kramer, an occupational medicine expert, neurosurgeon, and the President of the International Academy of Independent Medical Evaluators, shares her insights on the intricate layers of delayed recovery, addressing risk factors in workers’ comp cases, utilizing the biopsychosocial approach over the limited biomedical model, and talking about medically unexplained physical symptoms.

She also highlights methods to optimize recovery processes, reduce unnecessary disability risk, and the systemic barriers in healthcare and workers’ comp systems. Consideration is given to the importance of education, appropriate care referral, and the significant role of industry engagement for effective approaches.

Key Conversation Points:

00:06 Introduction to Fit for Duty Podcast

00:59 Understanding Delayed Recovery in Occupational Health

01:42 Guest Introduction: Dr. Diana Kramer

02:58 Decoding Delayed Recovery: A Conversation with Dr. Kramer

03:20 Understanding DFRUD: Delayed and Failed Recovery, and Unnecessary Disability

04:57 The Impact of Delayed Recovery on Patient’s Treatment

09:59 The Difference Between Impairment and Disability

13:31 The Biopsychosocial Model of Recovery

18:50 Strategies and Interventions for Biopsychosocial Aspects of Recovery

22:26 Special Offer from the International Academy of Independent Medical Evaluators

22:49 Integrating Biopsychosocial Model Aspects into Clinical Practice

25:39 The Importance of Movement in Injury Recovery

26:43 Addressing Migraines and Headaches in the Workplace

27:25 The Role of Sleep, Diet, and Nutraceuticals in Health

29:33 Understanding Medically Unexplained Physical Symptoms

33:46 The Impact of Imaging Studies on Patient Perception

37:00 Addressing Systemic Barriers in Healthcare

41:32 Raising Awareness and Encouraging Cultural Shifts in Medical Settings

45:43 Closing Remarks and Future Discussions

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Hill Criteria Article: Fedak KM, Bernal A, Capshaw ZA, Gross S. Applying the Bradford Hill criteria in the 21st century: how data integration has changed causal inference in molecular epidemiology. Emerg Themes Epidemiol. 2015 Sep 30;12:14. doi: 10.1186/s12982-015-0037-4. PMID: 26425136; PMCID: PMC4589117.


[00:00:00] HOST: Welcome to Fit for Duty, the podcast elevating occupational health. I'm Dr. Larry Earl, president of the National Association of Occupational Health Professionals. As guardians of workplace health, we stand at the intersection of well being and success. Fit for Duty delves into hot topics, OSHA regulated exams, workers comp, drug testing and so much more.

[00:00:29] HOST: Join us for [00:00:30] practical tips, real stories, and conversations that spark change. Whether you're a seasoned professional or passionate about healthy workplaces, Fit for Duty is your roadmap to a fitter, safer, and more productive workplace. Subscribe now on all major podcast platforms. Let's shape a future where well being fuels workplace excellence.

[00:00:51] HOST: This is Fit for Duty with Dr. Larry Earl.

[00:00:57] HOST: Welcome, colleagues, to Fit for Duty. [00:01:00] Today, we dive into a persistent challenge across occupational health and well being, delayed recovery, identifying risk factors in workers comp cases. I'm your host, Dr. Larry Earl, President of NAOHP, the National Association of Occupational Health Professionals. We all encounter them, cases where recovery stalls, frustration mounts, and traditional diagnoses offer limited answers.

[00:01:27] HOST: Delayed recovery isn't just a clinical riddle, [00:01:30] it's a human story with complex layers. Physical limitations intertwine with psychological anxieties, fueled by workplace pressures and societal expectations. That's why we're thrilled to be joined by Dr. Diana Kramer, a seasoned occupational medicine expert who's navigated the intricacies of delayed recovery countless times.

[00:01:52] HOST: With her guidance, we'll dissect the factors that contribute to this issue, from physical aspects to psychosocial concerns and [00:02:00] workplace realities. Dr. Kramer is proud to announce that she's recently co authored the AMA Guides to the Evaluation of Permanent Impairment, 6th Edition, Chapter 13 on the Nervous System.

[00:02:12] HOST: Dr. Kramer is a board certified neurosurgeon with over 30 years of clinical practice in treating diseases of the brain, spine, and peripheral nerves. She's a certified medical legal evaluator and qualified medical evaluator for the state of California and the president of the International [00:02:30] Academy of Independent Medical Evaluators.

[00:02:33] HOST: Join us as we shed light on the complexities of delayed recovery with the steady flame of knowledge and a shared commitment to patient well being. This is Fit for Duty, and with Dr. Kramer as our guide, we'll unravel the enigma of delayed recovery, one thread at a time.

[00:02:54] HOST: Welcome to Fit for Duty. I'm your host, Dr. Larry Earl. In this episode, we're talking [00:03:00] about decoding delayed recovery, identifying risk factors in workers comp cases, with our special guest, Dr. Diana Kramer, president of IAIME, the International Academy of Independent Medical Evaluators. Welcome, Dr. Kramer.

[00:03:15] HOST: Thanks so much for joining us today.

[00:03:18] GUEST: It's a pleasure to be here.

[00:03:20] HOST: You know, we're talking about delayed recovery in workers comp, and there's this term that I came across, DFRUD, I think is how you like to pronounce it, [00:03:30] Delayed and Failed Recovery, and Unnecessary Disability. Can you explain The general concept surrounding this term.

[00:03:38] GUEST: Yes, this has to do with what we all as physicians understand is the 80 20 rule, where 80 percent of our patients are injured, at work, have resilience, have a recovery and go back to work. And those are not the 20 percent of patients that [00:04:00] don't recover in the trajectory we anticipate. And Return again and again to our offices and a refractory to multiple medical therapies, including physical therapy, and I do physical therapy.

[00:04:17] GUEST: It makes me work. It makes me hurt more. I'm afraid to do it. End up doing multiple imaging studies. And we, adhere to a biomedical model. [00:04:30] We keep trying to treat that purely on biomedical terms instead of looking at other contextual factors that can affect recovery. And that is where the biopsychosocial model works better for delayed and failed recovery.

[00:04:48] HOST: Right. Yeah. We're going to be talking about a lot about the biopsychosocial model. How does delayed recovery though impact the overall outcome of this patient's treatment? And what are some common [00:05:00] factors that contribute to the delays?

[00:05:04] GUEST: So first of all, why is delayed recovery important? We all know that the longer.

[00:05:09] GUEST: The more a person stays out of work, the chance that they will go back to work, decreases. And being out of work is very bad for your health, for your social situation, for your family. People who are out of work have more medical [00:05:30] problems, die earlier, have more poverty, poor quality of life, more alcohol abuse, and more family violence.

[00:05:40] GUEST: So, getting a person back to work is part of the prescription of recovery and health.

[00:05:49] HOST: So, let's talk about some of those key physical and psychological items that you mentioned already and social factors that contribute to delayed recovery in injured workers. [00:06:00]

[00:06:01] GUEST: Sure. So, we have been trained to think in the biomedical model.

[00:06:06] GUEST: Okay. If it's as a surgeon. If it's broke, I want to fix it. but it can be more complicated than that. So for example, in epilepsy patient, if I'm thinking of epilepsy surgery, it has more to do with, the psychosocial context. That person with epilepsy, probably doesn't work. Because if you have a seizure at work, you probably aren't going to [00:06:30] come back to work.

[00:06:31] GUEST: You're not going to be invited. It's unusual. if you have a seizure, if you have two seizures a year, you can't drive. you can't get on a bus because you might end up in the ER. Uh, you are poor. Often on Medicaid or dependent. Um, so I have to factor all of those psychosocial elements into my surgical conversation with that person.

[00:06:57] GUEST: And I'm going to take away their [00:07:00] epilepsy, potentially. Okay, but I'm not going to fix their social situation and that recovery is very difficult. So I see those people for two years after surgery or did when I was operating and I come back in six months, come back in six months and they are depressed. I have taken away their crutch and their life is no better.

[00:07:22] GUEST: Okay, they still can't drive. They are still waiting for that next seizure. come back in a year [00:07:30] and they say, you're right, Dr. Kramer, I feel much better than I did six months ago. You're right. I was going to feel better. Great. Come back at two years. And at two years, they come back and they're like. Oh, I didn't realize how it was in a year.

[00:07:46] GUEST: So that whole context where you take something as physical as brain surgery, okay, in an epilepsy patient and getting that person to recovery is incredibly complex. [00:08:00] It's, it doesn't stop when the sutures come out. and that entire concept of understanding the biopsychosocial model is so important to what we do as physicians trying to get our patients back to work.

[00:08:15] GUEST: So you talk a

[00:08:15] HOST: lot about those psychological factors, fear, anxiety, depression, how do those contribute? I mean, you mentioned some of those things, but can you elaborate on fear in particular?

[00:08:27] GUEST: Yes. So, kinesia, fear of movement, [00:08:30] kinesiophobia is a risk factor for delayed recovery. the concept that pain is harmful is is a concept that is intrinsic to us.

[00:08:43] GUEST: And, you know, I'm, if I put my hand on a hot stove, it's painful. It's protective at some point, pain may not be protective. Pain may just be pain. And limiting a person to pain [00:09:00] relief as opposed to functional recovery can, can impair recovery. So that concept of, fear of movement, kinesiophobia, fear, avoidance, it's stressful for me to go back to this workplace event because I'm afraid.

[00:09:22] GUEST: You know, embarrassment, you know, looking weak in front of my colleagues. I'm afraid of that equipment. I'm afraid I'm going to get injured again [00:09:30] All of those are barriers to return to work. So that's that's my my take by 30, 000 foot view on fear. Very

[00:09:41] HOST: good. Let's, let's talk about a couple of terms. Let's just make sure we have the right definitions because I know some folks are not familiar with the field of impairment and disability.

[00:09:51] HOST: So let's talk about what actually is an impairment versus a disability. So what's an impairment?

[00:09:58] GUEST: An impairment is a loss [00:10:00] of body function or body structure. So, decreased range of motion, amputation for body function. It can be cardiac instability or cardiac, impairment or, you know, loss of function for, it can be psychologically, it can be a loss of mental.

[00:10:23] GUEST: a function, a body system. So loss

[00:10:26] HOST: of, loss of form or function, and how about disability?

[00:10:28] GUEST: disability is [00:10:30] a more nuanced construct. And I'm going to give you an example. Disability actually talk, is, goes to the concept of, of activity and participation. Right. So, And that can be influenced by internal and external factors, things that are intrinsic to me, and then also things that are in my societies we've already talked about.

[00:10:52] GUEST: So, for example, just talk about below the knee amputation, okay, or a trans tibial [00:11:00] amputation. One person with exactly the same impairment, same disease, same impairment, one person may be eager to return to work or return to duty. Even to the combat field, to the combat arena, whereas in the same person, a different person with the same exact injury and impairment may not bounce, may not be able to return to function, may not be able, may be in a wheelchair or in [00:11:30] crutches, may not be able to return to the workplace.

[00:11:34] GUEST: That's the same exact impairment, but an entirely different disability. I'm gonna just give you a second example. Okay. I'm a surgeon, okay? So let's say I lose my thumb. Now I am disabled for my profession as a neurosurgeon. I have an, an activity and participation, [00:12:00] restriction. Okay? However, I could still give this podcast.

[00:12:04] GUEST: I can still teach. I can still see patients that. as my social construct. Let's talk about a jurisdictional or an administrative concept. Okay. Let's say I have insurance, which, insures me for my profession as opposed to insuring me for, so my profession as a surgeon, as opposed to insuring me for the loss of [00:12:30] ability to act as a doctor.

[00:12:32] GUEST: That creates an administrative construct that's going to affect My life and therefore likely my recovery. And then there are jurisdictional issues on Dear DI Disability where disability is, different from state to state in the US and disability may be different in different countries. based on the social construct.

[00:12:55] GUEST: So, impairment, loss of body part or [00:13:00] structure, we think of an impairment, it's something we do biologically and medically. Disability is much more complicated.

[00:13:09] HOST: Yeah, and I think that gets us right into some of those biopsychosocial, models of recovery, right? And, and how the biomedical model that you describe, gives us certain limitations.

[00:13:20] HOST: and you give some very good examples of how, that changes based on some of these, you know, some of these social constructs. So do you want to talk [00:13:30] about how does this traditional biomedical model fall short in addressing delayed recovery? Why is the biopsychosocial approach crucial that we learn more about how to?

[00:13:42] HOST: How to, how to use that

[00:13:43] GUEST: model. Great question. So let's go back to our person with the transtibial below the knee, amputation. none of us lives in a bo in a bubble. I am in my social environment right now, as are you. I have [00:14:00] educational factors, I have financial factors, you know, affecting me as I sit here talking to you right now.

[00:14:07] GUEST: So let's take our two our, our two people who have exactly the same impairment. exactly the same disease. Let's talk about the biological factors. To begin with, our person who can return to duty, return to work, return to duty, has a well healed stump with no pain, [00:14:30] okay, can fit a prosthesis easily. Our impaired individual, our disabled individual, That individual has a painful neuroma, has a non healing ulcer, can't wear a prosthetic.

[00:14:47] GUEST: That creates, that's our bio, biological, model. Let's talk about the psychological model. Let's talk about perceived injustice. [00:15:00] Our, our soldier who wants to return to duty, steps on the landmine, loses his foot, okay. That person has a different injury. They signed up for that job, okay. It's a risk. It's a known risk of being in country, or in a war zone.

[00:15:18] GUEST: So Let's say our disabled person is driving a company car, gets hit by a drunk driver, loses their, their leg, uh, their foot, and that [00:15:30] drunk driver's had three prior DUIs and is driving and has either. is out of jail or is driving without a license. There's a true, there's a justified perceived injustice.

[00:15:48] GUEST: Maybe that was alliterative, but may, that can affect recovery. It's a strong factor for affecting recovery.

[00:15:55] HOST: Right, so, so two of them have same injury. different [00:16:00] social construct, different expectations of even how they got the injury. One is going in realizing that might be a, a real possibility, and the other has no clue that they would be injured in a car accident.

[00:16:12] GUEST: Yes. And, I, in work you see this, I warned them that that piece of equipment was unsafe and they didn't do anything about it. There wasn't, the floor was wet and there was no sign up. So

[00:16:29] HOST: those, those are [00:16:30] workplace social injustices that, will delay recovery.

[00:16:34] GUEST: Yes. Yeah. social, again, different social.

[00:16:39] GUEST: Let's say our purse, our soldier. has great services, that person's highly motivated to return to their brotherhood or sisterhood, wants to get back to Brothers in Arms, needs to be part of that community. It's intrinsic to who they are. they have great medical care, they have rehab [00:17:00] services, maybe they can get a high quality prosthetic, prosthesis, um, think about our Olympic athletes who are, you know, are impaired or have an amputation and are running on those cool blades, right?

[00:17:13] GUEST: Running on those

[00:17:13] HOST: prosthetics faster than any of us, certainly than you and I can

[00:17:17] GUEST: run. Certainly. let's take our disabled, person, isolated. As few, skills was working as a heavy laborer,[00:17:30] didn't do well in school, which is, you know, pretty common, doesn't have an ability to learn, doesn't have technical skills, has poor services, can't get a good prosthetic, can't drive because they can't get, a.

[00:17:47] GUEST: Because they can't get a vehicle that has hand controls. They can't get a modified car. Same impairment, [00:18:00] entirely different outcome based on internal and external factors.

[00:18:06] HOST: Yeah. So have you, have you been able to identify some strategies, interventions that are effective in addressing these biopsychosocial aspects of recovery and how to minimize disability?

[00:18:21] GUEST: Yeah. So, both in my clinical practice and, and as a, In IME doc, seeing people with workers [00:18:30] compensation and often giving treatment recommendations. I think the first thing is to recognize the biopsychosocial model. when we don't consider the psychosocial model and someone comes in with recurrent complaints or escalating complaints and we get another study.

[00:18:53] GUEST: Okay. We may be contributing to, delayed recovery. Okay. When maybe, I [00:19:00] mean, sometimes it's, you need to get another study. Maybe there

[00:19:03] HOST: is a rule out of whatever the red, you know, whatever the, uh, what is the red herring might be?

[00:19:12] GUEST: It's probably, it may be a red herring as opposed to a red flag. And. If we're keeping the psychosocial model in mind, it expands our diagnostic repertoire.

[00:19:24] GUEST: So I'm going, staying with understanding the psychosocial construct and making the correct [00:19:30] diagnosis. Okay, resist framing what may be psychosocial issues in a biomedical model. This does not necessarily take, more time. It takes different time because if we don't get it right, that person's gonna be back in our office multiple times.

[00:19:51] GUEST: And this is part of that administrative construct where there's more time pressure on us as doctors, you know, we don't have 30 minutes anymore. We [00:20:00] may not even have 20. We may not have 15. We may have 10. And how do you do this efficiently? Okay. And I, and because you're going to probably end up doing it anyways in more visits, which is part of that administrative eitrogenicity.

[00:20:20] GUEST: and I think having that biomedical, biomedical model in your mind can slow you down. It makes you more frustrated because you're not, you're not [00:20:30] helping your patient as much as maybe you could, which leads to our sense of. frustration and burnout, as opposed to simply having that biopsychosocial construct in your mind.

[00:20:41] GUEST: For example, you're going to read the chart notes on that person and that's going to take you the same amount of time as you're, if you're looking at the biomedical things, what operations has this person had in the past? What are their, what are their allergies? But what if there's other [00:21:00] information this person's had?

[00:21:03] GUEST: Six surgeries, all for vague complaints. This person has fibromyalgia. This person has a diagnosis of depression. This person is on narcotics. This person is, you know, a high school graduate or has a GED. It's it's all there in the record. Okay, we're looking at exactly the same information But if we process it differently and we're [00:21:30] thinking in the biopsychosocial model, it's not only gonna help our patient It's gonna help us as clinicians

[00:21:37] HOST: I'd like to tell you about a special offer that the International Academy of Independent Medical Evaluators has for NAOHP members.

[00:21:45] HOST: It's called the never a member first year dues for a half price If you're interested in IMEs and medical legal evaluation, check this out. There's a link below, half price for first time members. So let's [00:22:00] talk about some of those, examples of how you integrate some of these biopsychosocial model aspects into the clinical practice for work related injuries.

[00:22:11] GUEST: Sure. So let's talk about two of the most common shoulder pain. shoulder injury, knee injury or shoulder pain and knee pain. So first of all, is it an injury? Okay, is there a mechanism? Is there a causal association? and that actually is important to [00:22:30] diagnosis. Okay, so I hurt my knee at work. Well, what's the mechanism?

[00:22:37] GUEST: Or my, I was at work on Monday and my knee hurt. Well, how is your knee? What'd you do on Sunday? Right. If we're not thinking in causal, front construct, we may miss an important factor. for example, when somebody comes in with knee pain or [00:23:00] shoulder pain, if you do bilateral imaging or bilateral, either x ray or MRI, the degree of degeneration in the affected shoulder is going to be similar to the contralateral shoulder.

[00:23:17] GUEST: And that entire concept of causation science and applies is a biomedical construct that may or may not influenced [00:23:30] diagnosis. It doesn't mean that that shoulder wasn't injured at work, okay. Doesn't mean the repetitive overhead work is causing the problem, but maybe it has to do with my age. Maybe I have that problem because I've lost muscle mass based on my impingement syndrome.

[00:23:53] GUEST: And if I go to physical therapy and I gain muscle, [00:24:00] my impingement syndrome is going to go away, and maybe I don't need that scope. Another one, we have this concept of, after injury, rice. Okay, rest. I

[00:24:09] HOST: was just going to get to, yeah, we talked about that. Good.

[00:24:13] GUEST: Okay, so maybe, and this is very true for low back pain, we used to say, oh, you hurt your back, put you in bed for three days.

[00:24:20] GUEST: Well, there's nothing worse for somebody with a low back pain than to put him in bed, staring at the ceiling. [00:24:30] Their back hurts. They're not moving. and they're going to be more deconditioned by the time you let him out of bed in three days or a week. So let's take that same person and apply the MICE model, okay?

[00:24:44] GUEST: Movement. Okay, ice, exact same construct, but you are reassuring the person within limits. You don't want them walking on a broken leg, you know, [00:25:00] but, it with musculoskeletal injuries, all of us, you know, if we injure ourselves, we're going to hurt more that second day. But then we should be, we should be getting better and moving through that process, getting somebody moving, getting them back to work in a limited capacity, getting them, out walking.

[00:25:23] GUEST: If they can't go to work, whatever it is, that movement is. One [00:25:30] way you can apply the psychosocial model to what is a biological injury. Right.

[00:25:38] HOST: And then you talk about other expectations for sleep, diet, nutraceuticals. Do you want to talk about that a little bit?

[00:25:46] GUEST: I do. So I see a lot of migraine. a lot of post traumatic headache, a lot of, eye stress in the workplace that causes headaches.

[00:25:53] GUEST: so when I'm dealing with that, I'm also, I'm looking for risk [00:26:00] factors. Okay. I'm looking for comorbid conditions. I'm looking for migraine, underlying migraine that's undiagnosed. One in five women in the U. S. have migraine, 50 percent of women are undiagnosed, 1 in 10 to 12 men has migraine. So, and it's a biological condition.

[00:26:18] GUEST: So let's talk about whether or not they have migraine or have made that diagnosis, somebody comes in with headache. Well, how's their sleep? Okay. Improving sleep [00:26:30] improves headache. How's their diet? Are they, do they understand they have triggers? Do they, have they been taught to look for triggers? You know, do they get a headache when they have blood pressure?

[00:26:41] GUEST: I mean when they have low blood sugar. a lot of people do well on magnesium, glycinate or, citrate not magnesium oxalate, and, a lot of people are low, migraineurs in [00:27:00] particular, are low in riboflavin and magnesium. Now this is important because we all have patients who say, I'm either sensitive to medications or I don't like taking medications.

[00:27:13] GUEST: So as part of this shared decision making, which is also important, I can start them with. Okay, well, if you don't want medications, would you be interested in trying some vitamins that might help. And that creates a trust bond, doesn't necessarily take more time, because I don't have to write a [00:27:30] prescription for the vitamins.

[00:27:31] GUEST: I go, go get some, you know, some gummy bears, right? don't take a pill, get some gummies. Some of them taste really good. Okay, you're gonna be motivated to take them because they, You know, other than taking another pill. Oh, I get to take some gummies, right? So that whole construct can help. avoiding overtreatment, avoiding slapping a medication on that person.

[00:27:53] GUEST: Oh, you have a headache because you're depressed. Okay, well that's going to make somebody, you know, you've seen those patients. Well, they wanted to put me on [00:28:00] Cymbalta. Sure. They said I was depressed, right? gentle exercise, stretching, getting out, going for a walk. All of those things work across multiple injuries, multiple illnesses, and don't require more time for the clinician, and maybe faster than writing a prescription.

[00:28:26] HOST: Yeah, and you know, talking about writing more prescriptions [00:28:30] kind of pushes me into the next concept that we talked about, medically unexplained physical symptoms. Do you always, again, you may be reluctant to just need your prescribed more medication. How do we handle, what's the approach to those folks?

[00:28:49] GUEST: This is difficult, because what we are dealing with when we're, somebody comes in with symptoms and we can't find a biological model, what we're afraid of is we're missing something. [00:29:00] Are these medically unexplained physical symptoms medically explainable? But we haven't figured it out yet. One of the tenets of causation, one of the Hill criteria, which is part of the NIOSH criteria, is, the concept of plausibility.

[00:29:17] GUEST: And is what we currently know best science, is it, is it correct, right? There was a time when, germs were not recognized as being part of infection where [00:29:30] cigarette smoking was considered safe. So are Our concept of disease is going to change over time and then I've had some real doozies. I had a woman who had persistent low back pain.

[00:29:44] GUEST: I couldn't figure it out. Her MRI looked pretty good. I have a friend who's a radiologist and I run things by him. And he goes, Oh, she's got, pelvis venous insufficiency. And I'm like, what?[00:30:00]

[00:30:03] GUEST: And I heard, I, I saw another Duke, another diagnosis. It wasn't made. It wasn't, wasn't created until 2014, recently, totally. off the wall and with both of those people. So what's the difference between medically explainable and medically unexplainable? Well, medically explainable symptoms. tend to be consistent over time.

[00:30:28] GUEST: They tend [00:30:30] to follow biological concepts that we're familiar with. They tend to have some ability to potentially fit with the mechanism. of causation, but we just can't figure it out. And we may just not have the right diagnosis, as opposed to medically unexplained physical symptoms, [00:31:00] which escalate over time, change over time.

[00:31:03] GUEST: The fish gets bigger. It was my right arm. Now it's my left arm. It was my right arm. Now it's my left leg.

[00:31:09] HOST: So it's not just a matter of pain tolerance, right? People have different levels of perceived pain. it goes beyond that.

[00:31:19] GUEST: Yes. And some of the things we typically consider to be, more Acceptable as relatively medically unexplained [00:31:30] are fibromyalgia, we really don't have a good reason for that, irritable bowel, whatever that is, chronic fatigue.

[00:31:40] GUEST: It doesn't mean they don't have. potentially underlying conditions, but there are things that we just don't have good biomedical models for.

[00:31:50] HOST: And what are some of the specific physical factors that we should be addressing to optimize the recovery process and reduce the [00:32:00] risk of unnecessary disability?

[00:32:03] GUEST: I think setting expectations is huge, which is not a physical factor.

[00:32:07] GUEST: I think, getting back to that motion concept, Getting people moving, avoiding fear avoidance, um, And that

[00:32:15] HOST: all the pain is not necessarily doing you harm.

[00:32:19] GUEST: Yes, and this whole concept of, well, I can't do this because, and then you show the person in the room, well, you just did that. Okay, so you can do [00:32:30] that.

[00:32:30] GUEST: You're afraid to do it. Um, some of the other physical things are doing the x ray. You do not have a broken arm. it is safe for you to move your arm. You do not, you know, if you have to do the MRI, you have wrist pain. We've done an MRI. You don't have whatever fracture, whatever in your arm, but by the same token, not doing the MRI.

[00:32:55] GUEST: I mean, if, if you MRI somebody's shoulder over the age of about 50, they're going to [00:33:00] have

[00:33:01] HOST: a partial

[00:33:01] GUEST: tear. If you, if you MRI somebody's low back, Okay, with nonspecific low back pain, not radiculopathy, but nonspecific low back pain. Larry, you and I You're going to see a degenerated disc. You're going to see something.

[00:33:15] GUEST: You are. There's a 40 percent chance that you and I have a ruptured disc. Ruptured disc, not degenerated. Disc herniation in our low backs. Completely asymptomatic, assuming you're asymptomatic. If you are 20 or 30, [00:33:30] you still have that same risk of having a ruptured disc, a herniated disc, and it doesn't go up that much over time because the disc has to be hydrated to squirt.

[00:33:41] GUEST: Right. So after dehydrates, your wrist doesn't go up, but at 20 or 30, even 15 people have asymptomatic herniated discs in their lumbar spines. Don't get that imaging study unless you are willing and ready to deal with [00:34:00] what it finds. Yeah. What are

[00:34:01] HOST: you going to, what are you going to treat? and then you're just going to wind up treating something that really isn't causing the, symptoms or pain or.

[00:34:09] HOST: impairment or disability. Uh, yeah,

[00:34:14] GUEST: I'm sorry. One more thing. Then you take that person. You talk about biomedical model. You take that person. You've done a physical exam. So what can we do physically? We can do a good physical examination. It's an art that's being lost. Okay. Good physical examination. Make the [00:34:30] diagnosis.

[00:34:31] GUEST: Okay. They have nonspecific low back pain or they have a radiculopathy. Okay. If somebody has a radiculopathy, I'm gonna, and they've been through. the appropriate steps, you know, they've had the physical therapy hasn't gone away. I'm going to get an MRI and if there's a disc sitting on that nerve, okay, it correlates with that radiculopathy.

[00:34:52] GUEST: I've got a different treatment paradigm that's going to lead to more rapid return to recovery and therefore to work [00:35:00] as opposed to somebody with non specific low back pain where I put them through physical therapy. Physical therapy makes them. hurt more. So I, they want an MRI. I do that MRI. If I don't do that MRI, they're going to go to another doctor or I'm going to get a bad satisfaction score.

[00:35:18] GUEST: Right? So,do the MRI. Now this person with potentially perceived and justice, you know, unresolving pain now gets to [00:35:30] say, I have two ruptured discs in my back. Right? That person is well on the road to delayed recovery. Okay. Okay. Yeah. Or failed

[00:35:41] HOST: recovery. Right. So, so why aren't we addressing these issues effectively?

[00:35:46] HOST: What are these systemic barriers in healthcare and in the comp systems that contribute to delayed recovery? You touched on some of them, right? Patient expectations. You talked about satisfaction scores. Sometimes we think we're, [00:36:00] you know, we, we want to, we want to go this way, but. if we don't, we're going to get dinged in our satisfaction scores or in, as you said, seeking care elsewhere.

[00:36:12] HOST: How do we set those

[00:36:13] GUEST: expectations? Or we're going to disappoint, sorry, we're going to disappoint our patient. They're going to be looking at us going, why aren't you getting that MRI? I hurt. How are you going to fix me and that speaks to our inherent desire to do what we do, which is treat and [00:36:30] make people better.

[00:36:32] GUEST: So it's not necessarily negative. It can be a positive expectation of our own. You know, we have personal factors as opposed to our patients. So then let's talk about the workplace. is there a model, there's no model for addressing job satisfaction, but if there's, it's very difficult to deal in our clinic with a sense of perceived injustice.

[00:36:56] GUEST: Those tend to be administrative issues.[00:37:00] one of the most diagnostic questions regarding return to work is, do you think? You can return to work. we can be caught between the systems, the bureaucracy. I just mentioned that to some extent. when we're dealing somebody with delayed recovery who may have, non psyche, psychological factors, this perceived [00:37:30] injustice, this fear avoidance, there can be, A fear of referring that person for behavioral treatment, even CBT or counseling, or we don't have time to do, uh, health education.

[00:37:45] GUEST: We don't have time and we're not particularly educated to change health beliefs, deal with health illiteracy. and educate. I mean, we don't have a system. You have to have a person in your office that can do that. [00:38:00] Um, we, administratively, if we send someone for psychological evaluation for depression after an injury, there's a fear, administratively and medically, that the employer is going to buy that disease.

[00:38:18] GUEST: And that is a huge barrier. to referral to diagnosis and referral. And it may, it can be legitimate because people [00:38:30] can have independent underlying personal factors. Depression, anxiety, personality disorder, that affect their recovery. So, it's not simple. Yeah, and generally

[00:38:42] HOST: you're not always covered by the workers comp, uh, system, right?

[00:38:45] HOST: And shouldn't be. You make a referral for all these things and expect, oh, well, it's going to be paid for and they're going to have access. Not always.

[00:38:53] GUEST: Right. But what we can do is if we're in that treating workers comp bubble [00:39:00] is we can communicate better with the, if the person has a true, a treating physician, a primary physician, we can, we can separate these things clearly.

[00:39:12] GUEST: In my opinion is not related and therefore should be treated in a different system, not necessarily telling the primary to do it, but saying this is not related. And it may be that that helps get the person the care they need outside the [00:39:30] system. And that is a time constraint for us. It's a social constraint.

[00:39:35] GUEST: We don't want to step on the other doctor's toes. Um, we're taught to think within our box. Don't answer that question if it's not asked. All those things contribute. there's huge administrative barriers. they may not have a doctor. They may not have psychiatric services or psychological services within 50 miles.

[00:39:57] GUEST: They may not have PT within 50 miles.

[00:39:59] HOST: Yeah. [00:40:00] Access can be huge. Yeah. We've got a few more minutes. How can we, raise awareness then? Encourage some of these, let's say, cultural shifts within the medical and occupational settings to better address these complexities.

[00:40:14] GUEST: Yes, I think we'll have to come back another time.

[00:40:16] GUEST: If you don't mind, I'm inviting myself. So, um, so I think the first thing is there's this boat is recognition. So there is this, within ourselves, within [00:40:30] our clinics, within our personal interactions, we can affect that on a one to one basis in our tiny little clinic. Okay. But this is a massive issue. So how do we educate industry?

[00:40:44] GUEST: How do we educate? administrations, how do we educate and engage the workplace? And these are systems issues. So I think what we need, what we need is education. I can tell you that, having, been at [00:41:00] workers comp, the workers comp, uh, meeting last November, that this, this concept of delayed recovery, failed recovery, high cost, high risk, longstanding claims, pensions, is On the minds of insurers and with AI and big data, there's more, there's more ability to look at this.

[00:41:28] GUEST: So part of this is [00:41:30] personal, how we approach our patients and how we interact with our doctors. What I aim does I-A-I-M-E does is we educate on the causation science, we educate on the ac, I would say, accurate and ethical evaluation based on causation. Because fear is in the mind of the beholder, right?

[00:41:48] GUEST: So, our eye of the beholder. but then engaging industry, engaging workers compensation systems, medical directors, teaching at the state [00:42:00] level. all of those are ways that we as physicians can affect. our media locale, and then there's this bigger social construct, which, is a massive effort. but I think we need to recognize that there, there are people in industry that are motivated in helping workers recover faster and better, because it, You know, it's financially valuable.

[00:42:25] GUEST: Not only is it good for workers, and that's a big factor why, uh, some, [00:42:30] you know, why claims administrators want to be involved with patient, you know, directing these, injured workers care or patient care, but there's a lot of treatment delay. You know, so those are all answers. One other model I'll tell you, sorry, quickly is both the official disability guidelines and the, medical treatment guidelines, which is part of the California medical treatment utilization, schedule, all of those have.

[00:42:58] GUEST: biopsychosocial,[00:43:00] considerations within them. And they've also gone to a risk stratification model, particularly in the online versions of. those companies and I'm not endorsing any one of them. I have no commercial interest, but they now will add the risk factors and they will, some of they, you know, we look at the median recovery time for chiro, median recovery time for a number of visits for chiropractic care.

[00:43:27] GUEST: But there are outliers and there is a bell shape. [00:43:30] Maybe we can use that bell shaped curve to say my patient. is not recovering, this is the outlier for this group of people, they need another set of physical therapy. We can't stop at six. And it may be that adding those comorbidities can help us get better patient care.

[00:43:55] HOST: Yeah, absolutely. Great, great points. I think we're going to have to End it there. We have [00:44:00] much more to talk about. And I think, you know, a part two is definitely, it's definitely going to be in the, in the offerings. We have to talk about interventions, some preventive strategies, risk assessments, a whole bunch of other things.

[00:44:14] HOST: So, let's plan a part two to continue the discussion of very enlightened. Thank you very much, Dr. Diana Kramer for joining us today on fit for duty.

[00:44:25] GUEST: Dr. Earl, thank you for inviting me and coming up with this great concept [00:44:30] and part of what we need to do in the biopsychosocial model is podcasts like this.

[00:44:36] GUEST: So thank you very much for putting this together. Okay.

[00:44:39] HOST: Stay tuned for part two. And thanks again, Dr. Diana Kramer. Take care. Bye bye. And that wraps up this episode of Fit for Duty. Thanks for joining me today, everyone. I hope you found this conversation as engaging and informative as I did. As always, building healthier, happier workplaces starts with knowledge and collaboration.

[00:44:59] HOST: [00:45:00] So if you enjoyed this episode, please consider subscribing to Fit for Duty, wherever you listen to podcasts. That way you'll never miss a beat when it comes to the latest trends, best practices, and inspiring stories in occupational health. Until next time, stay safe, stay well, and keep elevating workplace excellence.


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