In 2003, a neurosurgeon performed a laminectomy of his neck. That’s an operation where the lamina or the bone over the back of the spinal cord is removed to relieve pressure. He seemed to improve for a little while. In 2005, his symptoms worsened, and in 2009, he underwent a fusion through the front of his neck between his 5^th and 6^th vertebrae. Again there was a slight improvement but two years later he was in my office with crippling pain throughout his whole body.

Normal studies

As I talked to him, I could see how desperate he was for relief. He also wasn’t sleeping and his anxiety and frustration were a 10/10 on my spine intake questionnaire. I couldn’t find any neurological problems on my physical exam. When I looked at his neck MRI, I could see where the two prior surgeries had been performed, but there were no pinched nerves. The alignment and stability of the vertebrae were also fine. He also had undergone several workups of his brain and the rest of his nervous system. Everything was normal.

When I explained to him that I did not see a structural problem that was amenable to surgery he became understandably upset.  He was stuck on the idea that the prior surgeries had helped and that I was missing something. It didn’t matter what I said or how I explained the situation to him. He wasn’t buying it.

What I didn’t tell him was that I had also looked at his scans he had prior to undergoing each surgery. Telling a patient that they did not really need a prior surgery is a very unproductive, unpleasant interaction; I didn’t see why this patient’s prior surgeries were performed. On the first MRI of his neck, there were no bone spurs and the spinal cord was completely free. There wasn’t a structural problem that could have been corrected by surgery. On the scan before the second operation, there also wasn’t a hint of anything that could be causing any symptoms of any type.

The power of placebo

What’s difficult for patients (and physicians) to realize is that the placebo rate for any medical or surgical treatment is between 25-30% or even higher. The response and improvement is not only real but is powerful. It is the result of your body’s own healing capacity. It is a desired response, and you feel less pain.

The pain-killing effects of a placebo are reversed with Narcan, which is the drug used to reverse the effect of narcotics. There is a part of the frontal lobe of your brain that shuts off pain pathways for short periods of time. Another example is the placebo effect of cardiac medications causes the heart rhythms to actually change. Just because a prior surgery or procedure on normal age-appropriate anatomy might have been temporarily effective is irrelevant. It should have nothing to do with current decision-making. I tell my patients “If I can see it, I can fix it” and  “If I can’t see it, I can’t surgically correct it.” It’s critical to have a specific structural problem with matching symptoms before surgery becomes an option. Surgery: The Ultimate Placebo

I suggested that he take a look at the DOC website and I would be happy to explain the whole program to him in as much detail as needed. He was so angry that I didn’t think I’d hear from him again.

Early engagement

Over the next couple of months, I received a couple of emails and had a telephone conversation that seemed to go pretty well.  He was willing to engage in the DOC protocol and began some of the writing exercises. I had a second phone conversation with him a couple of weeks later that seemed to go even better. He was able to recognize that his thought of me “missing something that needed to be fixed” was an obsessive thinking pattern. I was encouraged and thought that maybe I had been able to break through his “story.”

Time went by and our third and final conversation was dismal. He couldn’t let go of the thought that “something was being missed” and that his seventh cervical vertebra was “out of alignment.” I assured him it was OK. As a surgeon, I am also quite obsessive about not missing problems that I can fix. At this point, it didn’t matter. He’d found a surgeon who was going to fuse his neck.

Injury conviction

Physicians use the term “injury conviction” to describe this phenomenon. It is the relentless pursuit of a cause for your symptoms that is well beyond reason. My concept has changed in that I feel this pattern of thinking becomes its own irrational set of neurological circuits. It is similar to phantom limb pain and my term is “phantom brain pain.” Regardless of whether the original source of pain is there, the symptoms are the same. Rational arguments have absolutely no effect.

Hell

I wrote a post Anxiety and Anger: The Highway to Hell. Unfortunately, if you’re in this pattern, you’re in Hell, and the only way out is through you. The deep tragedy is that if you don’t realize you’re in Hell, you’ll remain there. I never give up, but I have learned to let go when I can’t penetrate that firewall of obsessive thinking. For those of you that have let yourself out this hole, I am open to suggestions as to what gave you the insight to move forward. Awareness is the basis of the entire DOC process and is always the first step.

I don’t know how many more tests and surgeries he’ll undergo over the next 30 years. The personal cost to him and society will be enormous.

What’s puzzling is that if any of the surgeons who’d chosen to operate on this man’s essentially normal anatomy were examined by a board examiner about their indications for his surgeries, they’d be failed immediately for giving a “dangerous answer.” It’s our medical responsibility to you to not offer risky procedures that have been documented to be ineffective.

Video: “Get it Right the First Time”

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Crystal could not walk for more than half of a block without having to sit down. As she had been this way for several years, she was becoming increasingly weaker. She was very unhappy at the prospect of losing her independence, in addition to experiencing a lot of discomfort. Understandably, her anxiety was through the roof.

The Surgery

I performed a three-level laminectomy on her at L2-3, L3-4, and L4-5. This procedure removes the narrowing around the nerves, and about 70% of the time, patients are able to walk without pain. It takes a while for the strength and endurance to return. Unfortunately, most patients don’t engage in the rehab enough to experience the full benefit of their surgery. As she was so frail, my optimism for Crystal was tempered. I knew her leg pain would improve, but probably not her strength.  She also just did not seem like the person who would engage in a full rehab program.  I never give up though, so I talked to her about the DOC project and told her about my website.

Post-Op

The surgery went well and Crystal’s legs felt better. During our first phone appointment, she began to ask a lot of questions about the website and had begun the writing exercises.  She was slightly encouraged, and I was pleasantly surprised. The talk evolved into a somewhat extended conversation about the central nervous system and conditioning. It is difficult to make the effort to exercise when a person has a lot of anxiety.  To see a full recovery, I ask all of my patients to workout with weights three to five hours per week.  She was interested in getting completely involved in the process.

One month after the surgery, she was sleeping better, and felt her anxiety dissipating. She would go out for small walks every now and then. I encouraged her to join a gym. I really did not expect her to go.

Her Outcome

When I talked to her a few months ago, she was a different person. Her voice was energized. She had joined a gym and was working out four or five times a week. She felt a dramatic increase in her strength and endurance. Her anxiety was down by 80-90%.  She was going out with her friends and socializing. She was ecstatic.

I asked her to write a follow up letter about her experience, which is about a year from her surgery.

Crystal’s Letter

Dear Dr. Hanscom,

How nice it is to feel better!

It’s great to be able to do some of the things again that I used to do. I am doing everything that I have been asked to do. I am working out in the gym every week. I am also working through all of the stages of the web site. All of the books have been interesting and helpful.

My friends tell me how good I look. They say that they no longer see the look of pain in my face.

I feel like I have my life back.

Sincerely,

Crystal

Move Forward

I have kept in touch with Crystal and we talk every three months. Seven years later, she is still working out in the gym, and her strength and endurance have continued to improve. She is active in the community with a nice circle of friends. This in sharp contrast to when I first met her and she was lying around her house, at the mercy of her pain.

The tools on this website are self-directed. My observation is that there is no question of “if” you’ll better, but only a question of “when.” The decisive factor is a patient’s willingness to engage. It is stories like Crystal’s that keep me moving forward with this project.

“Better Not Look Down”

The post A New Life at 72 first appeared on Back in Control.

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Normally aging discs

As you age, the discs between your vertebrae lose water content and become stiffer. That is a normal part aging.  You lose flexibility. Over age 50 most people have degeneration of at least one disc. There is no evidence that supports the idea that a degenerated disc causes pain. (1)

At age 32, I underwent a disc excision for a ruptured disc followed by a second operation two weeks later for a deep wound infection. My three lowest discs are completely degenerated and collapsed. Other than an occasional muscle strain from my terrible golf swing, I do not experience back pain. I saw patients weekly with “terrible looking spines” and sciatica from pinched nerves. However, most of them had no back pain. The upshot is that most spine fusions for LBP are performed on normal spines for a given person’s age.  The results are poor. There is less than a 30% chance of long-term success. (2)

If there is an identifiable structural problem with a matching pattern of pain, the success rate of surgery is much higher. These are the only situations that I will perform surgery. An example would be a bone spur pinching the 5^th lumbar nerve root while there is pain down the side of the patient’s leg. In this case, there is a strong correlation between the structural description and the pain. This pattern of pain usually disappears after surgically removing the spur.

Mouth pain vs. a cavity

I frequently compare spine surgery with dentistry. Generally a dentist can specifically identify the structural problem causing your pain.  It might be a cavity that has gone down to the root.  The chance that your dentist can solve this problem with a filling, root canal, crown, etc. is essentially 100%.

What if you went to your dentist with “mouth pain,” but the source of the pain could not be identified?  This is also a common occurrence. The pain may emanate from the sinuses, be caused by TMJ, or can even be a “neurophysiological” symptom. What would be the chance of success if your dentist started doing procedures without seeing which tooth was the source of the pain? It would be almost zero.

Fusions for back pain

Currently there are hundreds of thousands of spine fusions being performed annually for “back pain.” Often, they are based on injections into the discs called discograms that have been shown to be unreliable. Or they are based on MRI’s showing “degenerative changes.” We know bone spurs, arthritis, and degenerated discs do not correlate well with back pain. Yet major structural bony interventions are being performed with the surgical world not being able to accurately diagnose the source of the pain. Many surgeons feel somewhat compelled to perform the surgery because it is the “last resort.”

Fusions not only are ineffective in relieving back pain, but the downside risk of complications and breakdown of the spine often creates serious problems. There is even a medical term called “Failed Back Syndrome”. What is not well-known is the extent of the destruction caused on these patients’ lives. I discuss this outcome in the appendix of my books, Back in Control and in Do You Really Need Spine Surgery? Take Control with a Spine Surgeon’s Advice. Many of these situations were catastrophic.

Surgery is not the “definitive” answer for lower back pain. It is usually the wrong answer!!!

1. Boden, SD et al. “Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: A prospective investigation.” Journal of Bone and Joint Surgery(1990); 72: 403 – 8.
2. Carragee, EJ et al. “A Gold Standard Evaluation of the ‘Discogenic Pain’ Diag­nosis as Determined by Provocative Discography.”Spine(2006) 31: 2115 – 2123.

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I am on a much-needed vacation this week in Italy.  From 1980 until 1990, my wife lived in Florence.  We have many friends in Italy we like to visit as much as we can.  It is a unique opportunity for me in that she is fluent in Italian and we are able to spend time in our friends’ homes in the heart of Tuscany.  There is nothing quite like sitting down to a home-cooked Italian meal overlooking a beautiful valley.

Last night was one of those evenings.  Our friends not only put us up in their apartment, they had us over to dinner with several other friends.  The conversation drifted towards medical care.  One of the guests had experienced some medical problems of a moderate nature that required several physician visits and a couple of procedures.  He said that the aspect of his care that most struck him was that at no point during his care did anyone from the receptionist to the doctor ask him how he was doing.  Additionally, when he was asked some detailed questions about his condition, he was asked if he was a doctor.  When he replied that he was not, he was told that he had been informed enough and that he should not ask so many questions.  You might imagine his frustration.

I have witnessed a lot of success with the DOCC protocol, but it has become increasingly clear that the protocol is just a framework. It helps organize both the physician’s and patient’s thinking about chronic pain and therefore makes it much easier to create a treatment plan.  It is the patient who organizes and implements the plan. The physician is more in the role of a “coach” as well as being continually aware that there might be a potential structural problem.

About a year ago, I was talking to the pain psychologist I work with about what we were doing that seemed to be more helpful to our patients than either of us had historically observed.  She kept insisting that I was the factor that made the difference.  I was sure it was the DOCC protocol and the work she does.  After more and more positive results, I finally agreed that I played a major role in their recovery.  To clarify, I don’t believe that I have a special gift or am the world’s best doctor.  I simply stay committed to my work with the patient.  With increased attention over the last couple of years, I have seen more patients who had been in pain for decades become pain free.

Through my numerous difficult experiences, I have had many layers of my own personal labels stripped off.  Physicians, especially surgeons, are perfectionists.  It gives us an early competitive edge in high school and college.  It is somehow held up as a virtue by our medical culture and demanded by society.  Unfortunately, it is a complete disaster with regards to our ability to connect with our patients.  By definition a perfectionist is continually judging himself or herself by an unattainable standard.  As I have labeled myself, I have labeled others around me.  As it has been my reality for over 50 years I had no clue that this process was taking place.  I recently wrote an article, “The Cry of Chronic Pain—No One is Listening.”  The essence of the article is that once you have a label of a “chronic pain patient” placed on you, the world, including you, feels that it is just “something you have to live with” and your care becomes essentially palliative care.

I recognize that labeling is universal but it is not constructive.  I am aware that I label people constantly. As I work to become aware of the label I am placing, I am able to eventually see who you truly are.  You are a whole person.  Neither you nor I are the labels we place on each other.

The energy for your healing journey comes from you, not me.  What I contribute is that I am able to see you as a whole person and you are somehow able to remember that part of you that is really you.  When that part of you “wakes up,” there is no stopping you.  You are your own oasis in the middle of the desert.  I cannot ever tell who will engage or when.  The DOCC project is just a rough framework and every journey is completely different.  I am continually energized and inspired by the incredible obstacles you overcome to return to a rich, pain free life.

I recognize that essentially all physicians are compassionate.  Many physicians have figured out this journey and most have not had to experience burnout to learn it.  I am continually humbled by numerous examples of deep compassion by my colleagues.

I always thought I was compassionate. I was very well intentioned and always gave every patient my best shot.  However, the physician burnout rate is around 50% and we truly have a life full of more stress than you can imagine.  If you are just trying to survive, there is only so much you can give.  Additionally we have no resources or tools to help us out.  The safety net is a concrete floor.  It has been shown in several studies that it is during the third year of medical school that compassion takes a dive.

I am not writing this post for you to begin looking for a physician who is compassionate.  It is not a bad idea, but it is not necessary for you to heal.  Remember this process is about you taking full responsibility for every aspect of your care and your life.  You don’t need me.  You don’t need the DOCC project.  You just need to connect with that part of yourself that is whole and wants to thrive. The person who you need to experience compassion from is you. Use whatever means you have at your disposal to figure this out.  It will probably take some outside help but there are multiple resources. Quit trying to “figure all of this out” and just go.

NH, BF

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“Happy”

We all want to become better, happier people, and we work pretty hard at it. The marketing world keeps reminding us that we are not even close to our potential and holds up endless images of perfection that reinforce that idea. The solution advertising offers is a better appearance, more friends, accomplishments, public recognition, power, etc. We are programmed into being defined by external factors.

Additionally, self-help resources are everywhere. There are seminars, healers, books, lectures, and retreats, much of which can be helpful. The message is “if I had more of  ‘___________’ I would be a happier person.”  This includes wisdom, the tools on this web site, less pain, etc.

What we really mean when we say that we want to be happy is that we would like to experience less anxiety.

The “Abyss”

Many, if not most, of my patients would test out just fine on a psychological test. But chronic pain will still take you down anyway. It creates extreme anxiety and frustration. I define “The Abyss” as:

Anxiety x Anger x Time

The Abyss represents an unspeakably dark area of your brain. My patients can’t express it with words. I spent over seven years in a severe burnout. My experience also included chronic pain in several areas of my body. I experienced an intense burning sensation in both of my feet, tinnitus, multiple areas of tendonitis, migraine headaches and crushing right-sided chest pain.I didn’t know why I was having all of these symptoms and all the testing was normal. I eventually lost all hope. I “pre-tested” every millimeter of the pathway outlined on this website, mostly by trying multiple approaches that didn’t work. Suffering from chronic pain is far removed from happiness.

 Paradoxes

• The DOC process is paradoxical. The harder you try to get enough of the tools to “fix” yourself the less likely you are to be successful in becoming pain free (or happy). It is critical to understand that you have to enjoy your day with the idea that your pain or your life circumstances may never improve. In other words you must learn to enjoy life with what you have—NOW!
• If you are waiting for more wisdom, more re-programming tools, more money, a nicer spouse, better-behaved kids, or less pain before you can fully engage in your life, it’s never going to happen. It is life’s ultimate paradox. The harder you try to “fix” your life and yourself, the less likely you are to enjoy it.
• We also forget how illogical it is to think that all of the variables in our lives are going to align so well that we are going to finally be fulfilled. And if it could happen, how long do you think it would last?  Think how much energy we spend trying to control so much. Yet, we don’t give up trying.

The Reverse Paradox

Then there is the other side of the paradox. The more you can enjoy your day in light of your current life circumstances; you will then possess more energy and creativity to create a life that you desire. The Eye of the Storm

An Exercise

I often do an exercise with my patients. I look at my watch and point out that the time is X and you have Y number of hours left in the day. I ask them to make a decision to enjoy the next number of hours regardless of their circumstances, including the pain. A major key to solving your pain is to step fully into the life you want, with or without the pain.

When I was in the middle of my own intense burnout about 10 years ago, I had to make ongoing decisions to just enjoy the next 15 minutes. I’m serious. I had to make a conscious effort every 15 to 30 minutes.

My ongoing challenge to myself and to my patients is, “Enjoy your day—today.”

Listen to the Back in Control Radio podcast Enjoy Your Day – Today

The post Enjoy Your Day-Today first appeared on Back in Control.

The post Enjoy Your Day-Today appeared first on Back in Control.

Gabriel Garcia Marquez

“It is not true that people stop pursuing dreams because they grow old. They stop pursing dreams when they are crushed by relentless anxiety…

Gabriel Garcia Marquez modified by David Hanscom

Life just beats us up—pain or no pain. Eventually many if not most of us gravitate towards a survival mode. Instead of living life with creativity and vigor, we’re just trying to get to Friday and recover over the weekend.

Chronic pain greatly magnifies this process. Instead of aiming for Friday, you are trying to just get through the day. As you become more anxious and frustrated, it becomes more difficult to engage in positive experiences with your family and friends. Good food, wine, and hobbies gradually disappear. In almost all cases, people suffering from chronic pain become increasingly isolated.

The major problem with this sequence is that an inordinate percent of your nervous system is focused on your pain, so you will feel it more. The reason that goal setting becomes such an important part of the DOC project is that it causes your thoughts to be somewhere else besides your pain. Goal setting is not positive thinking. Positive thinking is just another way of suppressing negative thinking and particularly in the context of chronic pain it is a disaster.

I was reminded about a poem I wrote in 2003 while attending a surgical training session sponsored by one of our instrumentation companies.  It was a remarkable weekend that altered my surgical approach to spinal deformity. Most of the three-day course was spent working on cadavers. I wrote this poem:

Whoever you were
You were generous
Giving yourself
To be my teacher
On your last day of
School

Remember the time of your life where your dreams were running free. Spend some time with it and re-connect with that energy. Reminisce with your partner. You have only one shot at this life. Give it your best shot!!

The post The First and Last Day of School first appeared on Back in Control.

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People of the Lie

I read a book during my late teens that shed some light on my mother’s behavior. It is a brilliant book by Scott Peck called People of the Lie. The book begins with the story of a 12 year-old boy who has a near-psychotic break after being given a 22-caliber rifle for Christmas. His parents were confused because they felt that they were making a positive statement to him. Their son was entering his teen years and they wanted to send him the message that they trusted him enough to give him as big a responsibility as owning a gun. The problem was that it was the same gun his 15 year-old brother used to commit suicide the prior Christmas.

The Essence of Abuse

The essence of abuse is being unaware of another person’s needs. If you are consumed by anxiety and just trying to keep your head above water, there is a high chance you are unable to view a given situation through another person’s eyes.

This is taken a step further with regards to anger. When you are angry, you cannot see anything clearly. It is truly all about you. Anger is temporary insanity, and it is dangerous to interact with people or make decisions in that state of mind. When you are experiencing chronic pain, you are frustrated and angry much of the time. You have a legitimate gripe in that your basic need to be pain-free is not being met. Maslow’s miss You feel the world, including your family, owes you something. You feel justified when you vent your anger whether it is directed at someone or just expressed.

Your Family’s Perspective

It is becoming increasingly clear that chronic pain is a major family issue. Its effect on a family is usually devastating and I frequently bring the topic up in clinic. Rarely, do I have people disagree with my statement, “Chronic pain is disruptive and is rough on your family. Family members in the room invariably begin to nod their heads. It is like a dark cloud over the household. I ask them if they love their family and the answer is always, “Of course.” Then I ask them if they snap at their family when they are upset. You can guess the answer. I point out to them that everyone has a choice of creating a safe haven for themselves at home. If you are upset, why would your family be a target. They are the least logical choice.

How do you think your children or partner perceives your mood and actions?  You are frustrated because you have lost control of the pain and your life. How much control do you think a five-year old has when you are angry or in a rage after yet again being disappointed by the medical world or beat up by the worker’s comp system? Pain Rules the Roost

You may not perceive your actions as abusive. I guarantee you, it is abuse.

Rules of Engagement

I ask my patients as part of their healing process to ask their family what it is like to be around them when they are upset?  I ask them to visualize scenarios from the receiving parties eyes. The answers are not pretty.

I also ask my patients to never talk to their family when they are upset. They have to go to another room or leave the house. They cannot re-engage until they have calmed down. You cannot suppress or control anger. But you don’t have to become a living weapon. Anger must be dealt with using one of the strategies that have been presented in other parts of this web site. Protect Your Family from Your Pain

One homework assignment I ask a family to do on their way home from my visit is to recall a time in their relationship that was full of happiness and joy. Their eyes widen when they realize that they have not connected with that energy for a long time. They are to recall as much detail as they can about that era and then I ask them to work immediately on creating that environment. Their pain is not the family’s problem.

Then I point out one of the basic rules of healing from pain to never share their pain with anyone – ever. The moment they walk out the door they will never complain about pain. You can just feel the relief in the partner, spouse or child within seconds. Your family member cannot help you and they will become frustrated. Besides, your pain is not that interesting of a subject. Do you really enjoy discussing your pain compared to discussing an interesting topic or learning new ideas? How interesting are you to your friends and family when you not only continue to talk about your pain but do it over and over again. Just stop it – now. You are only reinforcing the pain pathways. The chronic pain marriage-go-round

Many people, including me, are addicted to the power of pain and simply do not want to give it up. You are probably not the one reading this post but it is important to understand how powerful pain is. No one, at the end of the day, really wants to give it up. It is only solved by remaining aware of its effect on you and how if affects others. The clearest delineation of this tendency is outlined by Anthony DeMello in his book, The Way to Love. He defines love as awareness and anger blocks it – completely. My victim/ anger pathways run deep and I read a few pages of this book every week. It has taken me a while to accept that these are permanent pathways and the only logical answer is to commit to remaining aware of when they are triggered. I have learned to come out of the Abyss more quickly.

Wake up! There are 116 million of you in the US suffering from chronic pain. That is one in three. If you consider the effect your pain is having on your family, the numbers of people affected have to be well over half of the population.

The post Pain = Anger = Abuse first appeared on Back in Control.

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Our medical culture is geared toward concrete solutions.  This is particularly true when you, the patient, have finally made up your mind to even see a surgeon and waited for some time to get an appointment.  I realize that most of the time you are there to discuss the “definitive” solution of surgery.  It is a major step.  As soon as I mention that surgery is not a viable alternative, many patients become very upset. Then, when I begin to explain the various aspects of the pain experience, it is almost impossible for them to really hear me.  You have been in pain for a long time and you just want your life back—now.

As reported by the Institute of Medicine, the elephant in the room is this: 116 million people living in United States suffer from chronic pain.  Whatever is being done to treat chronic pain, it’s not working.

Lisa was able to work past her initial frustration with me over a couple of weeks.  It became quickly apparent to me that she was an extremely organized, competent businesswoman who was able to grasp many of the smaller details of the DOCC process very quickly.  She asked me many pointed questions.  She also realized that her frustration with the many aspects of her situation was a major block to engaging in her journey back to health.  Accepting things she could not control was going to be one of her first steps.  In the course of the conversation, she came up with a notable quote she gave me permission to share with you.

“Every problem is a solution waiting to happen.”

-Lisa

BF

The post Problems are Opportunities first appeared on Back in Control.

The post Problems are Opportunities appeared first on Back in Control.

• You can only engage in the tools that enable your brain to heal itself.
  • The basic starting point is regularly practicing active mediation.
• In fact, the more focused you are on getting rid of your pain, the lower the odds are that the pain will abate.
•  Pain will still be running the show.
  • It is important move forward with or without your pain
• The new neurological pathways do not have to embody pain.

I have a metaphor that I share it with many of my patients. Trying to “fix” chronic pain is like putting your hand into the middle of a hornet’s nest. You cannot be successful in controlling these powerful survival responses. The process is that of connecting with your true nature and letting go – like a bunch of balloons.

A Bunch of Balloons

Imagine climbing a large mountain the size of Mount Rainier. At the peak, there is a “better you.”  The climb represents our endless quest for self-improvement. This journey takes endless forms: self-help books, healers, psychologists, medications, etc. There is a significant problem with this situation: “What does that ‘better you’ look like?” You may have a vague idea, but generally it is a concept that is idealized and humanly unattainable. Additionally, you are expending a tremendous amount of your life energy on this endless quest.

Instead, imagine a bunch of balloons tied to a railing. The strings represent your neurological patterns that are holding you down. What the various reprogramming tools accomplish is to cut the strings. Eventually, you will take off. There is no longer a goal to achieve a “better you.” You are able to enjoy the life you have with what you have. You are also not expending any effort and the potential is limitless.

You are fine just the way you are this minute. There are many interferences connecting with your true value system. Once you re-connect with who you really are, your life will change. Remember: the consistent result of many patients going through this process is a rich pain-free life.  The main variable is the degree of commitment – and letting go.

The post A Bunch of Balloons first appeared on Back in Control.

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I have argued for 25 years that a claims examiner should not be in charge of a given case.  The caseload for a given examiner used to be 400-600 workers.  Even if you had an occupational medicine physician in each claims examiner’s chair, she could not manage the claim.  I would hope the ratios were better, but even if it were 200-300 claims per examiner, the responsiveness would not be even close to the workers’ needs.  Each worker’s ENTIRE LIFE depends on an overloaded examiner.

Many claims examiners seem to have the mandate to “be tough” and move the claim through as quickly as possible.  I assume that the vast majority of examiners are initially motivated to provide the best service possible to the patient.  However, after dealing with angry workers on a regular basis, it is difficult not to develop a “thick skin.”  What that attitude does is make the claimant angry, and everything grinds to a halt.  I have to spend a lot of time just calming down my patient (and myself).  In the end, the “labeling” of workers as anything less than a “human being caught in the quagmire of a huge system” is counter-productive.  There has always been an obvious dividing line between workers with a benevolent claims examiner and those with a hard-liner.

I understand from the claims examiner’s perspective that it is important to move a claim through quickly.  However, claims tend to be dealt with more quickly when the relationship of the examiner to the worker is one of an ally helping navigate the worker through the maze of worker’s comp.

Additionally, there is a high turnover rate amongst claims examiners.   It takes several weeks for the new examiner just to get through his or her stack of claims, during which time patient anxiety goes through the roof.  How would any of us feel to have our middle school teacher changed halfway through the year and then find that her replacement has no idea who any of us are or what are needs are?

The level of medical training a claims examiner has is minimal. The claims examiners do not have enough medical training to make thoughtful medical decisions.  Currently, even if your surgical approval company approves a given surgery, I often have to still argue with the examiner about getting the surgery performed.  An insane phrase I here all too often: “The final word rests with the claims examiner.”

Many examiners do develop a valuable perspective in recognizing outliers and dangerous medical care.  However, that perspective is not uniform, and I cannot quantify what percent have that kind of experience.  I do know that many examiners are new and do not have that perspective.  There is too much variability to put so much responsibility into this position. Even if I could clone myself and sit in every claims examiner’s chair, I could not competently make the best medical decisions for that given patient.  Medical care cannot be delivered at that distance.  The examiners are in a “no win” situation.

I am also well aware of the “rumor mill” amongst the claims examiners.  Certain physicians are labeled and care is delayed.  Different treatment philosophies get picked up within the system.  Their own concepts of the human body and medical care enter the medical decisions.  When confronted, they will ask for an IME, which delays all care for at least 4-6 weeks.  They then use the IME recommendations as a template for the care of the patient.  The IME physician spends just a few minutes with the patient and their attitude is not one of providing the optimum care for the patient.  I understand that there is a need for IME’s, but that need is not to influence ongoing medical care.  With that “authority,” the claims examiner often makes everything even more difficult for the physician and the patient.

Meanwhile, I try to help “calm down” the patient, as the circumstances are extremely adverse from our perspective, and the patient’s pain and tolerance to the pain is completely out of whack.  As the final nail in the coffin, I usually cannot persuade worker’s comp, which has wreaked havoc on my patient’s life, to approve any mental health services.

I disagree with comments about the ideal system not being able to respond to the needs of a given patient.  Payments of modest financial incentives can and will change physician behavior.  But no system can respond to the complexity of an injured worker’s life and specific needs.  Each one of us becomes incredibly frustrated just dealing with airlines trying to make changes to a travel itinerary. Imagine having you’re medical treatment plan being altered against your wishes. These claims examiners are dealing with these workers entire life, including their ability to put food on the table.  My point is that any system cannot respond to the specific complexity of a given claim.  The better solution is to give the workers the tools to navigate their own way through the morass.

I am suggesting the following regarding the role of the claims examiners:

• Respect the injured worker and treat them accordingly.
  • It should be a major part of their orientation and ongoing in-service training.
• They should not be involved in medical decision making.
  • They should be able to approve reasonable care quickly and then ask for RN or physician input if they have questions.
  • This process should be expedited as quickly as possible.
  • How does delaying the ordering of tests save any money?  It would be different if there were no time loss.  The delay costs much more than the test.
• Their main role should be to make sure that the claim is run as seamlessly as possible.  Improving communication between all parties should be emphasized.
• They need to understand how trapped their claimants feel and not react when the worker is upset.  What would they do in a similar circumstance?  I don’t think any of us on the roundtable would react much differently.

There are many physicians who will not see worker’s comp patients due to the hassle factor.  Often, if a surgeon deals with worker’s comp, it is just to do a consultation and perform surgery.  By isolating out the worker’s comp variables, the decision making process regarding major surgery can become flawed.

I spend most of my time talking patients out of any type of spine surgery.  I specifically work just on discrete structural problems with matching clinical symptoms. I am diligent in trying to deal with all of the variables affecting the outcome of surgery, especially with a worker’s comp situation.  I will meet with nurse case managers as well as talk and meet with vocational counselors.  I will not close a claim until all parties have a plan in place.  I have one patient who had eight people involved in getting him back to work.  It took me ten months and at least five hours of phone calls and meetings.  After four years of chronic pain and disability, he is now working full time again.

I am one of the most interactive surgeons I know in getting a claim resolved.  I have learned how broken this system is.  I am not blaming the claims examiners.  It is a system that sets them up to fail.  Although I think the ultimate answer is to give the patients the tools to navigate their own way back to full health, there are many system changes that must be made.

I realize that there are several claims examiners on the roundtable.  I will be looking for their input with interest.  Right now, life in the trenches with my injured workers is intolerable.

BF

The post Examiners from the Worker’s Perspective first appeared on Back in Control.

The post Examiners from the Worker’s Perspective appeared first on Back in Control.