What I Learned at AADEP

Saturday, January 17, 2009 | 0

by David J. DePaolo

I attended the American Academy of Disability Evaluating Physicians' 22nd annual conference in Indian Wells, Calif., Jan. 9-10. The weather in the Palm Springs area was sunny and warm, the Renaissance Esmeralda Resort and Spa was beautiful, and the presentations frank and candid.

This group of physicians genuinely seems dedicated to the well-being of their patients, and its members espouse a philosophy I believe would go a long way towards “fixing” what is wrong with workers’ compensation. They are also refreshingly honest with their colleagues, deriding unnecessary treatment and preaching a strong return-to-work ethic.

The conference started off with Dr. Stanley Bigos, who argued that while “guidelines” (be they AMA Guides for impairment, American College of Occupational and Environmental Medicine [ACOEM] or Office Disability Guidelines for treatment, etc.) are ultimately good for medicine, and workers’ compensation specifically, there is still a tendency for “convention” to creep in. “Convention” as used by Bigos is a euphemism for what everybody traditionally thinks but which is not supported by scientific evidence, basically conventional wisdom.

“When the focus is on science,” Bigos said, “then you want to make everything sound scientific.”

Bigos is an internationally recognized expert in spine and is professor emeritus at the University of Washington, School of Medicine.  He was the principle investigator in the Boeing Study of Occupational Injury Problems and has consulted for national health departments and programs around the world.

The lack of scientific evidence for back issues and treatment is appalling according to the presentation statistics provided by Bigos. Of 1,321 citations reviewed, only 185 were potentially relevant. Of those, only 21 met rigid scientific protocol as being valid and having repeatable and verifiable outcomes.

The result of those studies that met highly stringent scientific protocol: 1) Do not perform surgery. 2) Reassure the injured worker that it’s okay to go back to work. 3) Exercise, exercise, exercise.

“We are taking significant risks with our patients by taking them off work,” Bigos concluded.

Dr. Richard Deyo, said the trend of increasing back complaints correlated with a huge increase in back imaging which correlates with a huge increase in back surgery, and yet … absolutely no improvement in outcomes.

Deyo is the Kaiser Permanent Professor of evidence-based family medicine at Oregon Health and Science University and deputy editor of the journal Spine as well as the author or co-author of more than 250 peer-reviewed scientific articles, mostly concerning back pain.

In addition to noting a lack of correlation between radiology, surgery and outcomes, Deyo also noted that, since the introduction of opioid medications (Oxycotin, etc) there have been more deaths from such medications than heroin and cocaine combined, along with poor evidence regarding the use of such medications for treatment. Deyo did, however, say  there is no data accounting for legitimately prescribed use of the opioids versus illegal “recreational” use in the death statistics.

However, an increase in invasive treatment of back issues has not resulted in a decrease of complaints. In fact, there is an increase in complaints, with a huge increase in costs. The data suggests, according to Deyo, that exercise-related physical therapy is actually the most efficacious treatment (which further suggests that California’s arbitrary limitation on the number of physical therapy visits is not well designed).

Likewise, the number of injections to treat intractable back pain has increased dramatically, with no corresponding decrease in the rate of complaints, according to the studies presented by Deyo.

The No. 1 treatment recommend by Deyo (this became a repetitive theme) is … return to work, agreeing with Bigos that the greatest risk to injured workers is a disabled status.

Dr. Gordon Waddell, a professor at Cardiff University and a consultant to the UK Department for Work and Pensions, cited British studies reflecting the greatly increased risk of early mortality as a consequence of unemployment (indeed, a 50% increase in coronary artery disease).

Les Kertay,  a licensed clinical psychologist, concluded that providing compensation for an injury was not determinative of return to work, but rather job protection was key. He noted that most systems (and this is particularly applicable to current workers’ compensation models) reward people who present in the worst possible light, but punish those who help themselves. Obviously, as has been pointed out in my editorials in the past, the motivations under current systems are entirely backward.

Other highly respected experts at the AADEP conference, while presenting their various specialty topics, all basically rallied around a few common themes: 1) Life hurts, get used to it. 2) The worst thing that could be done to an injured worker is to keep him or her off work. 3) Disability is more psychological than physical, and that if someone wants to get better they will. 4) Work is good – it gives people purpose, a sense of accomplishment, validity. 5) Surgery generally is uncalled for and makes people worse (at least back and carpal tunnel surgery).

Certainly many in the medical and legal communities are going to have issues with these conclusions and they should, because under the current workers’ compensation systems their very livelihoods are taken to task.

And what of that certain worker population who simply are unable to work? I don’t mean those who are physically incapable of work, but those who, for one reason or another, simply have an aversion to work? There are many such people in society, and this is an issue that must be dealt with. Presently, those folks are motivated to stay off work because that is how the reward system that is set up, along with rewards in place for professionals to help those folks stay off work.

I don’t pretend to have the answers. These are complex psychosocial issues that require minds much greater than mine to tackle. The issues, the reasons, the factors are all entirely too complex for a simple fix.

But at least there is one professional group that looks to science, not folklore or anecdotal evidence, to identify the issues. I’m impressed that these folks are willing to stick their necks out and challenge the status quo. We need more of that.

David J. DePaolo is president, CEO and Editor in Chief of WorkCompCentral.0