Chronic Pain and Anxiety Disorders

Chronic pain by itself is often debilitating, and the struggle to obtain a correct diagnosis, effective pain management, and ongoing treatment can be stressful and overwhelming.  As we discussed in a previous post, depression often co-occurs with chronic pain, and can further complicate treatment.  The same is true of anxiety disorders.

Chronic Pain Disorders Associated with the Co-Occurrence of Anxiety

Like depression, anxiety is more likely to co-occur with certain conditions, such as:

It is no secret that physicians and dentists have stressful and demanding careers.  One Cardiff University study showed that of 2,000 British doctors, at various stages of their careers, 60% had experienced mental illness.[1]  Often practitioners ignore or fight through both chronic pain and anxiety and show up to work, to the point of endangering themselves or others before acknowledging their disability or seeking adequate treatment.

While anxiety alone can result in an inability to practice, either indefinitely or in the short-term, it is also quite common in those suffering from chronic pain to experience an anxiety disorder.  Anxiety disorders are also the most common type of psychiatric disorders in the United States, with 19 million adults affected.[2]

Chronic Pain and Anxiety—Worse Together

Facing a long-term or permanent disability can be anxiety provoking for a physician, who must (1) face giving up a career he or she invested so much time and financial resources to establish; (2) seek a correct diagnosis, course of treatment, and adequate pain management; and (3) often struggle with adapting to the loss of a previously enjoyed quality of life.  Conversely, chronic pain is also common in people with anxiety disorders,[3]  with up to 70% of people with certain medical conditions (including hypertension, diabetes, and arthritis) had an anxiety disorder first.[4]

Regardless of whether anxiety or chronic pain came first, individuals suffering from anxiety can experience pain that is particularly intense and hard to treat.[5]  In a 2013 study, 45% of 250 patients who had moderate to severe chronic joint or back pain screened positive for at least one of the common anxiety disorders (generalized anxiety, social anxiety, PTSD, OCD).  Further, those that had an anxiety disorder reported significantly worse pain and health-related quality of life than their counterparts without anxiety.[6]

Symptoms of Anxiety[7]

There are several anxiety disorders and, while the below list is by no means exhaustive, sufferers of anxiety often exhibit the following symptoms:

Generalized Anxiety Disorder

  • Difficulty controlling worry
  • Restlessness, feeling wound-up or on edge, irritability, muscle tension
  • Being easily fatigued and problems with sleep
  • Difficulty concentrating or having their minds go blank

Panic Disorder

  • Sudden and repeated attacks of intense fear
  • Feelings of being out of control during a panic attack
  • Intense worries about when the next attack will happen
  • Avoidance of places where panic attacks have occurred in the past

Social Anxiety Disorder

  • Feeling highly anxious about being around other people (including having a hard time talking to them, blushing, sweating, trembling, or feeling sick to your stomach)
  • Feeling self-conscious in front of others and worried about feeling humiliated, embarrassed or rejected, or fearful of offending others
  • Worrying before an event and/or avoiding places where there are other people
  • Having a hard time making and keeping friends

Post-Traumatic Stress Disorder

  • Flashbacks, bad dreams, difficulty sleeping, frightening thoughts, angry outbursts
  • Avoiding places, events, objects, thoughts, or feelings that are reminders of the traumatic experience and trouble remembering key features of the traumatic event
  • Being easily startled and feeling tense or “on edge”
  • Negative feelings about oneself or the world, and distorted feelings like guilt or blame
  • Loss of interest in enjoyable activities

Obsessive Compulsive Disorder

  • Fear of germs or contamination
  • Unwanted or forbidden thoughts, including aggressive thoughts towards others or self
  • Having things symmetrical or in perfect order; excessive clearing and/or hand washing; ordering and arranging things in a precise way; repeatedly checking on things; compulsive counting

Treatments for Anxiety

Some of the treatments that have been successful in addressing anxiety in those with chronic pain include:

  • Cognitive-behavioral therapy (CBT)
  • Psychodynamic therapy (talk therapy)
  • Support groups
  • Relaxation or meditation training
  • Alternative treatments, such as acupuncture and hypnosis
  • Exercise
  • Medication

Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.

[1] Michael Brooks, Why doctors’ mental health should be a concern for us all, NewStatesmen, April 11, 2016, http://www.newstatesman.com/politics/health/2016/04/why-doctors-mental-health-should-be-concern-us-all

[2] What are Anxiety Disorders?, Global Medical Education, https://www.gmeded.com/gme-info-graphics/what-are-anxiety-disorders

[3] Chronic Pain, Anxiety and Depression Association of America, April, 2016, https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain

[4] Global Medical Education, Supra.

[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection

[6] Health Behavior News Service, part of the Center for Advancing Health, Chronic pain sufferers likely to have anxiety, ScienceDaily, May 8, 2013, https://www.sciencedaily.com/releases/2013/05/130508213112.htm

[7] Definitions according to National Institute of Mental Health: https://www.nimh.nih.gov/index.shtml

Chronic Pain and Depression

Chronic pain is often difficult to diagnose and treat.  Consequently, those who suffer from chronic pain typically must also deal with a significant amount of stress, due to repeated failed treatments, numerous medical appointments, interruption of work and enjoyable activities, and the inability of their friends or family to understand their physical limitations.  This can, in turn, cause or worsen depression.  When depression occurs alongside chronic pain, it can make dealing with and treating the pain even harder.

Chronic Pain Disorders Associated with the Co-Occurrence of Depression

While mental health conditions, including depression, can often be disabling in and of themselves, they are unfortunately also quite common in those suffering from chronic pain.  Depression is more likely to co-occur with certain conditions, such as:

  • Back Pain
  • Neck Pain
  • Joint Pain
  • Arthritis
  • Migraines
  • Fibromyalgia

Studies show that rates of depression are high in residents and medical students (15%-30%) than rates in the general population, and the risk of depression continues throughout a physician’s career.[1]  According to a British study, 60% of dentists reported being anxious, tense, or depressed.

Dentists, doctors, and other medical professionals place extreme amounts of pressure on themselves because the stakes of their professions are so high.  In addition to perfectionism and self-criticism, other predictors of depression in doctors include:  lack of sleep, stressful interactions with patients and staff, dealing with death, constant responsibility, loneliness, and making mistakes.[2]

Often practitioners work through both chronic pain and psychiatric disorders for some time before acknowledging their disability or seeking adequate treatment.  In the case of depression, this can be due in part to the social stigma that surrounds it.  For all of these reasons, depression may go undiagnosed or seem less of an immediate concern to those suffering from chronic pain.  However, if you are experiencing symptoms of depression and chronic pain, studies show that it is important to treat both, because chronic pain can become much more difficulty to treat if the depression is allowed to progress unchecked.

Chronic Pain and Depression—Worse Together

Facing a long-term or permanent disability can trigger depression—this is especially understandable for doctors or dentists who have put years into medical school and establishing their careers, only to become disabled and have to step away from a profession that has become a significant part of their identity. Depression can also precede chronic pain.  For example, several studies have examined the link between depression before the onset of back-pain.[3]

Regardless of which came first, together they are formidable to treat.  Major depression is thought to be four times greater in people with chronic back pain than those in the general population, and studies show that individuals suffering from both chronic back pain and depression experienced a greater degree of impairment than those with either depression or back pain alone.[4]

Treatments for Depression

Focusing solely on pain management can prevent both the patient’s and treating physician’s ability to recognize that a psychiatric disorder is also present.  Yet, even with correct diagnoses, both issues can be difficult to treat together.[5]  For instance, those who suffer from both chronic pain and mental illnesses can have a lower pain threshold as well as increased sensitivity to medication side-effects.[6]  Some treatments that have proved successful in addressing depression in those with chronic pain include:

  • Cognitive-behavioral therapy (CBT)
  • Psychodynamic therapy (talk therapy)
  • Relaxation or meditation training
  • Acupuncture
  • Hypnosis
  • Exercise
  • Medication

Symptoms of Depression

  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Trouble falling asleep or sleeping too much
  • Feeling tired or having little energy
  • Poor appetite or overeating
  • Trouble concentrating
  • Feeling bad about yourself, or that you are a failure or have let yourself or others down
  • Thoughts that you would be better off dead, or hurting yourself in some way

Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.

_________________________________________________________________________

[1] Robert P. Bright, MD, Depression and suicide among physicians, Current Psychiatry, April 10, 2011.

[2] Id.

[3] William W. Deardorff, PHD, ABPP, Depression Can Lead to Chronic Back Pain, Spine-health.com, Oct. 15, 2004, http://www.spine-health.com/conditions/depression/depression-can-lead-chronic-back-pain.

[4] William W. Deardorff, PhD, ABPP, Depression and Chronic Back Pain, Spine-health.com, Oct. 15, 2004, http://www.spine-health.com/conditions/depression/depression-and-chronic-back-pain.

[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection.

[6] Anxiety and Depression Association of America, Chronic Pain,  https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain.

Can Your Disability Insurance Company Dictate The Medical Treatment You Must Receive To Collect Benefits? Part 4

Care Dictation Provisions

Throughout this series of posts we’ve addressed the increasingly restrictive medical care provisions in disability insurance policies.  In Part 1, we discussed the evolution of the care standard and its effect on an insured’s ability to collect benefits and control their own medical treatment.  In Part 2 we looked at the “regular care” standard, which places no obligation on the insured to undergo any unwanted medical treatment.  In Part 3 we looked at the “appropriate care” and “most appropriate care” standards, which require much more vigilance on the part of policyholders, because they must be prepared at any time to establish that the treatment they are receiving is justified under the circumstances.  In this final post, we are going to look at the most aggressive and intrusive language that has been adopted by insurance companies in an effort to dictate the care of their policyholders.

Here is an example of a very strict care provision, taken from a Great West policy:

Regular Care of a Physician means personal care and treatment by a qualified Physician, which under prevailing medical standards is appropriate to the condition causing Total Disability or Residual Disability.  This care and treatment must be at such intervals as will tend to lead to a cure, alleviation, or minimization of the condition(s) causing Total Disability or Residual Disability and which will lead to the Member’s return to the substantial and material duties of his own profession or occupation or maximum medical improvement with appropriate maintenance care.

Clearly, this provision was designed with one goal in mind:  to give the insurer nearly unlimited power to scrutinize a policyholder’s course of treatment, including the ability to insist that any given procedure is necessary to cure or minimize the disability and maximize medical improvement.  It is easy to see how an insurer might invoke this provision to assert its control over the medical decision making of their policyholder and use the leverage of benefit termination and claims denial to dictate their treatment.

Imagine that you are a surgeon with a herniated disc in your cervical spine, and that your policy contains the provision cited above.  Your insurer insists that a fusion of the surrounding vertebra is the procedure most likely to alleviate your disability. Your doctor disagrees, recommending a more conservative course of treatment, such as physical therapy, modified activity and medication, such as muscle relaxants.  Your doctor also warns you that if you have the surgery, you will experience reduced mobility and risk adjacent segment degeneration.  However, your disability benefits are your only source of income.  Fearing a claim denial, you agree to the procedure despite your doctor’s concerns.  This results in a no-lose scenario for the insurer.

The best case scenario, from your insurer’s perspective, is that the surgery (for which you bore all the risk both physically and financially) is successful and you are no longer disabled.  At worst, the procedure fails and the insurer merely has to pay the benefits it was obligated to pay to you in the first place.  For you, however, an unsuccessful procedure can mean exacerbation of your condition, increased pain, and prolonged suffering.  It is therefore vital that you understand your rights under your policy.

Insurers are risk-averse by nature, and disability insurance is no different.  Modern disability insurance policies, and particularly the medical care provisions, are designed to minimize the financial risk to the insurer. Insurers place an enormous burden on claimants to prove that their course of treatment meets the rigorous standards in their policy. Though stringent policy language can make it significantly more difficult to obtain the benefits you are entitled to, it does not strip you of your right to make your own medical decisions.

In order to preserve your medical autonomy in the disability claims process, you must become familiar with the details of your policy before filing a claim.  Understanding the terms of your policy—including the care provision in your policy—is critical to successfully navigating a disability claim.  You need to be familiar with your policy’s care requirements from the outset, so that you can communicate effectively with your physician to develop a plan of treatment that you are comfortable with and that comports with the terms of your policy.

Even if you have a basic understanding of your rights under you policy, it can be daunting to deal with an insurer that is aggressively seeking to dictate your medical care.  In some cases, you may be forced to go to court to assert your right to make your own medical decisions—particularly if your policy contains one of the more recent, hyper-restrictive care provisions like the Great West provision above.  Insurers know this, and they also know that most claimants are in no position to engage in a protracted court battle over whether they are receiving appropriate care.  However, simply submitting to the medical mandates of your insurer to avoid the stresses and costs associated with litigation can have drastic consequences, depending on the nature of the medical care you are being asked to submit to.  If you should find yourself in this difficult position, you should contact an experienced disability insurance attorney.  He or she will be able to inform you of your rights under your policy and help you make an informed decision.

 

Can Your Disability Insurance Company Dictate The Medical Treatment You Must Receive To Collect Benefits? Part 3

“Appropriate Care” and “Most Appropriate Care”

In this series, we are looking at the different types of care provisions disability insurers insert into their policies so that they can later argue that they have a right to dictate the terms of your medical care.  In Part 1, we discussed how many policyholders do not even realize that their policy contains a care provision until the insurance company threatens to deny their claim for failure to obtain what the insurer perceives as sufficient medical care.  We also discussed how care provisions have evolved over time to become more and more onerous to policyholders.  In Part 2, we looked at one of the earliest and least stringent care provisions—the “regular care” provision—in detail.

In this post, we will be looking at a stricter care provision—the “appropriate care” provision.  Here is an example of a typical “appropriate care” provision:

Appropriate Care means you are receiving care by a Physician which is appropriate for the condition causing the disability.”

Disability insurance carriers implemented this policy language to allow their claims handlers and in-house doctors to weigh in on the type and quality of care their policyholders receive.  As you’ll remember from Part 2 of this series, “regular care” provisions only required policyholders to be monitored regularly by a physician.  Thus, under a “regular care” provision, as long as the policyholder was seeing a doctor, the insurer could not scrutinize or direct his or her treatment.  Only by changing the policy language could they hope to have greater influence over the medical decisions of their policyholders.

This prompted insurers to add the additional requirement that the care must be “appropriate.”  But what is “appropriate?” If you are suffering from cervical spinal stenosis, you likely have several reasonable treatment options available to you. For example, your physician might recommend physical therapy, but also indicate that you would be a candidate for more invasive treatment, such as steroid injections.  If you have an “appropriate care” provision, does that mean that your insurer gets to decide which treatment you receive?

When presented with this question, most courts determined that “appropriate care” limits the insurer’s review of its policyholder’s care to whether it was necessary and causally related to the condition causing the disability.[1]  Courts also held that “appropriate” care does not mean perfect care or the best possible care—it simply means care that is suitable under the circumstances.[2]  Thus, if physical therapy, steroid injections, and surgery are all suitable treatments for cervical stenosis, most courts agree that your insurer cannot deny your claim or terminate your benefits based upon your decision to undergo a course of treatment they view as less effective than another.

In response to these cases, disability insurers again modified their policy language and created the “most appropriate” care provision.  Here is an example of what a “most appropriate” care provision looks like:

“[You must receive] appropriate treatment and care, which conforms with generally accepted medical standards, by a doctor whose specialty or experience is the most appropriate for the disabling condition.”

This change places significant restrictions on a claimant’s autonomy not only because it limits the type of physician the claimant may choose, but because it restricts the claimant’s medical care to a singular “appropriate” course of treatment.

These types of provisions can make collecting disability benefits extremely difficult.  For example, take the experience of Laura Neeb, a hospital administrator whose chemical sensitivity allergies became so severe that they rendered her totally disabled.  After one of her doctors—Dr. Grodofsky—concluded that she had no identifiable allergies, Ms. Need sought another opinion from Dr. William Rea, founder of the Environmental Health Center in Dallas, Texas.  Dr. Rea concluded that Ms. Neeb’s hypersensitivity to chemicals was so severe that she was “unable to engage in any type of work,” and required extensive treatment to manage the condition.  Ms. Neeb’s insurer, Unum, nonetheless denied the claim.  The court ultimately held that Ms. Neeb failed to obtain the “most appropriate care” by treating with Dr. Rea, agreeing with Unum that Dr. Grodofsky’s conclusions were correct.[3]

Ms. Neeb’s case illustrates just how restrictive the “most appropriate care” provision can be. It places the burden squarely on the policyholder to show that their chosen course of treatment and treatment provider are most appropriate for their condition.  If your policy contains a “most appropriate care” provision, it is essential that you find a qualified, supportive treatment provider who is willing to carefully document your treatment and the reasoning behind it.  You do not want to place yourself in a position where you cannot justify the treatment you are receiving and must choose between an unwanted medical procedure and losing your benefits.

In the final post of this series, we will discuss the hyper-restrictive care provisions appearing in disability insurance policies being issued today and the serious threats they pose to patient autonomy.

[1] 617 N.W.2d 777 (Mich. Ct. App. 2000)

[2] Sebastian v. Provident Life and Accident Insurance Co., 73 F.Supp.2d 521 (D. Md. 1999)

[3] Neeb v. Unum Life Ins. Co. of America, 2005 WL 839666 (2005).

Orthopedic Issues Series: Degenerative Disc Disease – Part 2

In Part 1 of this post, we discussed the anatomy of the spine and some of the causes of Degenerative Disc Disease (DDD).   In Part 2 of this post, we will be discussing some of the symptoms of DDD, and some of the methods used to treat DDD.

Symptoms

Not all people with intervertebral disc degeneration experience pain or other symptoms.  This is due to the fact that the degeneration of the discs, by itself, does not bring on the symptoms described in the first paragraph above.  However, as disc degeneration becomes more severe, it can lead to other conditions that bring on the symptoms people normally associate with DDD (e.g., pain, numbness and tingling, weakness, etc.).  Some of the conditions commonly associated with DDD are:

  • Spinal osteoarthritis: Sometimes referred to as spondylosis, this condition occurs when the breakdown of the cartilage and intervertebral discs leads to increased contact and irritation of the vertebrae.  It may also lead to the formation of osteophytes (abnormal bone growths) on the vertebrae that can also put pressure on nerves and contribute to the pain and nerve-related issues described above.
  • Spinal stenosis:  This condition can occur when an individual develops spondylosis. The inflammation associated with spinal osteoarthritis may cause a narrowing of the spinal canal (the hollow space in the middle of the vertebrae through which the spinal cord travels) and put pressure on the spinal cord.  This pressure on the spinal cord can cause numbness, weakness, cramping, or general pain in the arms and legs.  In some cases it can also cause bowel and bladder dysfunction.
  • Foraminal stenosis:  This condition is the result of reduced space between the vertebrae, often brought on by the degeneration of the intervertebral discs.  The reduced space may lead to increased pressure on nerve roots emerging from the spinal cord, resulting in localized pain as well as numbness, tingling, and weakness in the extremities.

Treatment:

Because DDD can cause such a broad range of symptoms and subsequent conditions, the treatment options vary widely.  Depending on the circumstances, treatment can range from conservative options, such as physical therapy and anti-inflammatory medications, to surgical intervention, in the form of a discectomy, laminectomy, laminoplasty, or spinal fusion.

If you are experiencing any of these symptoms, the best course of action is to consult a physician.

For more information on how disability insurers evaluate claims based on Degenerative Disc Disease, see:

A Stiff Upper Lip Can Lead to Getting Stiffed by Your Insurer

Disability Insurance: Who Gets Denied?

Myelopathy: Part 1

Myelopathy: Part 2

Orthopedic Issues Series: Degenerative Disc Disease – Part 1

This post is the first in a series we will be doing on common orthopedic issues.  In Part 1 of this post, we will discuss the anatomy of the spine and some of the causes of Degenerative Disc Disease (DDD), a common yet misunderstood spinal condition that affects a large portion of the population.   In Part 2 of this post, we will go over some of the symptoms of DDD and some of the methods for treating DDD.

Anatomy

There are thirty-three vertebrae in the vertebral column of the human spine, twenty-four of which articulate and move.  Between each of the vertebrae in the three articulating sections of the spine – the cervical, thoracic, and lumbar spine – there is an intervertebral disc.  Each disc, composed of soft jelly-like center (nucleus pulposus) surrounded by a capsule of connective tissue (annulus fibrosis), provides shock absorption and flexibility within the spine.  There is very little blood flow to this region of the body, and if discs are damaged or deteriorate they cannot regrow or heal themselves.

Causes

Degenerative Disc Disease (DDD) is the breakdown in the size and cushioning of the intervertebral discs, which can lead to chronic pain, weakness, numbness and tingling in extremities, and reduced flexibility in the spine. The name of the condition is actually somewhat of a misnomer – it is not actually a “disease”, but rather a condition that is characterized by the degeneration of the intervertebral discs over time. Because of this, the condition can be confusing to understand.

Reduction in the size and cushioning of your discs is part of the normal process of aging, and magnetic resonance imaging (MRI) studies have shown that almost everyone over the age of 60 has degeneration of their intervertebral discs to some degree.[1]  Not all people with disc degeneration have back pain or other symptoms – in fact, individuals with relatively mild disc degeneration may experience no symptoms whatsoever.

However, age is not the only factor in DDD.  Deterioration of the intervertebral discs can be accelerated and exacerbated by other factors.  The culprit in many severe cases of DDD is stress-related damage in the form of repetitive use, trauma, injury, poor posture, poor movement, and obesity.  Among these, one of the most common factors is repetitive use.

Medical professionals are particularly susceptible to developing DDD due to the static postures that some specialties require in clinical practice, most notably dentists.  For example, the repetitive, static posture of a dentist performing clinical procedures creates compressive forces on the cervical discs due to neck flexion and compressive forces on the lumbar discs due to axial loading (the weight of the body compressing the spine vertically).  When these compressive forces are applied for year after year on a daily basis, the result can be an accelerated deterioration of the intervertebral discs.

For more information on how disability insurers evaluate claims based on Degenerative Disc Disease, see:

A Stiff Upper Lip Can Lead to Getting Stiffed by Your Insurer

Disability Insurance: Who Gets Denied?

Myelopathy: Part 1

Myelopathy: Part 2

[1] http://www.arthritis.org/about-arthritis/types/degenerative-disc-disease/

Alzheimer’s: Is there a Helpful Drug on the Horizon?

Alzheimer’s disease is a serious disability that can dramatically impact a physician or dentist’s ability to practice.  In this post, we will be looking at some of the risk factors associated with Alzheimer’s, some of the signs that may indicate the onset of Alzheimer’s, and some of the proposed methods of treating Alzheimer’s.

Risk Factors

Alzheimer’s is a form of dementia that affects memory, thinking, and behavior.  There are three primary risk factors for Alzheimer’s:

  1. Age: Most people that have Alzheimer’s are 65 or older, and the likelihood of developing Alzheimer’s doubles every five years after age 65.
  1. Heredity: Scientists have identified certain “risk” genes that can contribute to the risk of developing Alzheimer’s. Amyloid precursor protein (APP), presenilin-1 (PS-1), and presenilin-2 (PS-2) are proteins that directly cause Alzheimer’s, although “deterministic” Alzheimer’s occurs in only 5% of cases.  APOE-e4 is another gene that scientists believe may be a factor in 20 to 25% of cases, although they are not sure precisely how it increases the risk.
  1. Family History: People who have parents, siblings, or even children with the disease are more likely to have Alzheimer’s. The risk also increases as more family members develop the disease.

Warning Signs

The Alzheimer’s Association lists 10 warning signs that may indicate the onset of Alzheimer’s: Continue reading “Alzheimer’s: Is there a Helpful Drug on the Horizon?”

The Reality of Addiction: Physicians Are Susceptible Too

We’ve discussed the prevalence of depression and stress in physicians, but what about addiction?  While physicians are just as likely as the general public to become dependent upon alcohol and illegal drugs, they are more likely to abuse prescription drugs.  A survey of 55 physicians that were being monitored by their state physician health programs for problems relating to drug and alcohol abuse showed that 38 (69%) abused prescription drugs.  While certainly concerning, this is not necessarily surprising, as physicians have far greater access to prescription drugs than the average person.

Compounding this issue is the stigma associated with substance abuse.  Oftentimes, those who do not suffer from substance addiction believe that drugs and alcohol are something that people can quit easily, and that substance abuse can be solved by a quick trip to a rehab facility.  But in many cases, substance abuse is more than mere recreational use of medications.  In some cases, those who abuse prescription drugs may be trying to relieve stress or self-medicate chronic physical and/or emotional pain.  In other cases, substance abuse may be a result of the phenomenon called “presenteeism”—doctors may be taking the medication simply because they believe it is the only way to continue working in spite of an illness, impairment, or disability.

How can medical professionals with substance addiction get help? One way is to seek confidential treatment to avoid the scrutiny of a medical board or coworkers.  Confidential programs can be both outpatient and inpatient, with inpatient programs usually lasting around one to three months.  After treatment, patients are able to continue recovering by completing 12–step programs, like Alcoholics Anonymous.  However, this treatment option has similar relapse rates to the general public: nearly half of patients relapse in the first year.

A second road to recovery is physician health programs.  These programs actively monitor patients after treatment for a period of five years by conducting drug testing, surveillance and behavioral assessments.  This path may be difficult for physicians to come to term with after keeping their addiction hidden.  However, going through the physician health programs boasts a much higher success rate of 78% (only 22% tested positive during the 5-year monitoring period), and roughly 70% of medical professionals who pursue this method of treatment are still working and retain their licenses.

If you, or a physician you know, struggles with substance dependency, we encourage you to seek out appropriate help.  If you are a physician with a painful disability, you should not put your patients at risk by attempting to work through the pain or by seeking to dull the pain with self-medication.  If you have disability insurance, you should contact an experienced disability insurance attorney.  He or she will be able to guide you through the claims process and help you secure the benefits that you need without putting yourself or your patients at risk.

REFERENCES:

http://www.medscape.com/viewarticle/819223_3.

Unique Conditions

In past posts, we have looked at some conditions that are common in doctors and dentists—such as carpal tunnel syndrome and essential tremors—and discussed ways that these conditions can affect both your practice and your disability insurance claim.   In this post, we will be discussing a few unique conditions that—while they may not be severe enough to cause you to file for disability benefits—can be particularly inconvenient for doctors and dentists.

Left–Right Confusion

Roughly 15% of people suffer from a condition that makes it difficult for them to differentiate between their left and their right.  While this may be a mere annoyance for most people, it can be a significant problem for a doctor or a dentist.

One doctor tells the story of how he mistakenly ordered an x-ray for the wrong foot of a patient, and the radiologist insisted on performing the x-ray on the foot that the doctor had indicated even though it was very obvious which foot was injured.[1]  Due to the confusion, the patient ended up leaving the doctor’s care.  In other, more extreme cases, “wrong-side surgery” has occurred due to left-right confusion.

Face–Blindness

Face-blindness, or prosopagnosia, is a cognitive disorder that affects people’s ability to identify faces and places.  It is much less common than right-left confusion, occurring in only about 2.5% of people.  Face-blindness also exists on a spectrum, with some people having mild prosopagnosia, while others are unable to pick out the faces of their spouses or children in a crowd.

While face-blindness doesn’t necessarily have a large effect on operations, it can negatively impact your relationships with patients.  For instance, if patients are unaware that you suffer from face-blindness, they may be offended if you fail to recognize them outside the office setting.  Fortunately, in most instances, prosopagnosics can use other characteristics, such as posture or voice, and contextual clues, such as location, to identify an unfamiliar face.[2]

Dyslexia

Like left-right confusion, dyslexia also affects approximately 15% of Americans.  This condition affects the way that the brain processes language, both written and spoken.  It is often referred to as a “reading disability,” but it can also affect writing, spelling, and speaking.  Although there are various therapies designed to minimize the effects of dyslexia, in most cases dyslexia is a lifelong condition.

Many doctors with dyslexia do not reveal their condition for fear of stunting their professional growth or causing patients to lose trust.  However, as one dyslexic doctor has observed, first-hand awareness of personal deficiencies can actually enhance patient trust, because it can make a physician more compassionate and understanding.[3]  Another dyslexic doctor considers her dyslexia to be a gift because it has made her a more creative problem solver and enhanced her ability to recognize patterns, which has proved very useful in her chosen field of radiology.[4]

Conclusion

While these conditions may not be severe enough to support a disability insurance claim, they can change the way that you approach your practice and patients.  It’s important to be aware of these conditions because even if you don’t have any of these conditions, a colleague or patient might.  We encourage you to be cognizant and understanding of others’ disabilities, and to foster a culture of acceptance and accommodation in the medical field.

[1] See http://well.blogs.nytimes.com/2015/08/10/you-will-see-the-doctors-fallibility-now/?smid=tw-nytimeswell&seid=auto.

[2] For more info on face-blindness, see http://www.newyorker.com/magazine/2010/08/30/face-blind.

[3] See http://www.reuters.com/article/2015/02/26/us-dyslexic-physicians-idUSKBN0LU2E520150226.

[4] Id.

Fibromyalgia: Part 2

In Part 1 of this post, we listed some of the symptoms and potential causes of fibromyalgia.  In Part 2, we will discuss some proposed treatments for fibromyalgia.

Treatment

Unfortunately, while there are a variety of ways to treat fibromyalgia, there is currently no cure for fibromyalgia.  Some of the most prominent courses of treatment include:

  • Exercise: Many fibromyalgia patients may be afraid to exercise because they think it will increase their pain.  However, being active may help to alleviate pain because physical activity can increase endorphin levels that patients may be lacking.  Exercise can also alleviate stress, anxiety and depression—common symptoms of fibromyalgia.
  • Physical Therapy: Some physical therapists utilize exercises that help fibromyalgia patients relax tense muscles and move in ways that will not exacerbate pain levels. Physical therapy is often used as a precursor to exercise.
  • Medication: Antidepressants are often prescribed to help with the depression, fatigue, and sleep issues associated with fibromyalgia. Medications that facilitate restful sleep may also help with the pain, by allowing patients the rest needed to recover.  Other drugs, such as Lyrica, have been approved by the FDA to directly treat fibromyalgia pain.  Remember, you should always consult with your doctor before taking any medication.

Conclusion

Fibromyalgia is a condition that varies from person to person, with people having both good and bad days.  If you suffer from fibromyalgia, note what makes your pain worse or better, and try to avoid or continue those practices.  As always, it is important to consult with your doctor to ensure that you are receiving appropriate treatment for the chronic pain caused by fibromyalgia.

If your fibromyalgia has progressed to the point where you can no longer practice, we encourage you to contact an experienced disability attorney before filing a disability claim.  Disability claims involving fibromyalgia can be particularly difficult, due to the subjective nature of the condition, so it is important to have an experienced advocate at your side to help you navigate the claims process.

Fibromyalgia: Part 1

In this post, we are going to take a look at some of the symptoms and causes of a debilitating condition known as fibromyalgia.

Symptoms

Fibromyalgia is a syndrome that is characterized by chronic, widespread muscle pain. Other symptoms include:

  • Fatigue;
  • Trouble sleeping;
  • Morning stiffness;
  • Muscle knots, cramping, or weakness;
  • Painful trigger points;
  • Dry eyes;
  • Concentration and memory problems, called “fibro fog”;
  • Irritable bowel syndrome;
  • Anxiety or depression; and
  • Headaches.

Fibromyalgia is difficult to diagnose, because most of the symptoms are relative or subjective.  Notably, certain forms of arthritis may cause similar symptoms.  However, persons with arthritis suffer from pain that is localized in joints.  In contrast, persons with fibromyalgia suffer pain that is primarily felt in muscles, tendons, and ligaments.

Potential Causes

Because fibromyalgia is difficult to diagnose (due to the subjective nature of its symptoms), there is no clear consensus as to the causes of fibromyalgia.  Here are some of the theories that researchers have suggested:

Lower Levels of Serotonin and Endorphins

Serotonin is a neurotransmitter that is associated with calming and feelings of well-being and happiness.  Endorphins are also associated with happiness and serve as painkillers.  If someone has lower levels of serotonin and endorphins, they may be more susceptible to feeling pain, or may feel pain more intensely than someone with normal serotonin and endorphin levels.

Stress

Some researchers theorize that stress causes muscle “microtraumas,” which in turn leads to a cycle of pain and fatigue caused by an inability to rest due to the pain.

Gender and Biological Changes

Statistically speaking, women seem to be at greater risk for fibromyalgia.   For this reason, some scientists have proposed that fibromyalgia pain may be connected to hormonal changes such as menopause.

Heredity/Genes

Fibromyalgia could be due to a genetic tendency that is passed down and regulates the way one’s body processes pain.  Although, as of yet, no particular “fibromyalgia gene” has been identified, several genes have been found to occur more often in people with fibromyalgia.

Trauma

Accidents, injury, and illness involving the brain or spinal cord may contribute to fibromyalgia pain.  Such trauma may alter the way neurotransmitters, such as serotonin, are produced, or it may lower an individual’s emotional threshold for pain.

Essential Tremors (ET): Part 2

In Part 1 of this post, we looked at the risk factors, symptoms, and treatment options associated with ET.  In Part 2, we will discuss how having an essential tremor could potentially affect your total disability claim.

How do I file for total disability when I have ET?

For those with an “Own Occupation” policy, which means you are considered totally disabled if you can no longer work in your own profession, having ET would certainly qualify you for benefits if you are a medical professional.

Many physicians think that they can simply decrease the types of procedures they perform or amount of time spent at working as their ET becomes more disabling, but this is the wrong move to make.  Changing your work responsibilities can alter your “occupation” under the terms of your disability policy.  For example, if you forego performing medical procedures and merely manage your practice, the insurance company may claim that your occupation has changed from a physician to an office manager, and attempt to decrease or deny your benefits.  Similarly, if you start to work part-time instead of full-time, and then file for disability, an insurance company will likely classify you as a part-time worker, and thus only give you part-time benefits.

Other physicians may decide to continue working in spite of their ET.  This is also a mistake.  Trying to work when you have ET places your patients at risk.  If a patient did get injured and filed suit, his or her attorney would almost certainly assert that you should not have been working with patients and that you knew your ET could harm the patient.

The correct way to deal with insurance companies and your condition is to stop working as soon as it impinges on your ability to perform your occupation and file for disability insurance.  Since, in many cases, the onset of ET is gradual, it is important to discuss you symptoms with your doctor so he or she can determine when your condition will progress to the point that it affects your work.

Conclusion

ET is a condition that can have an effect on actions as small as carrying a water glass or tying your shoes.  It can also affect your occupation and the financial security that comes from having total disability insurance.  We encourage you to speak with your doctor if you think you may be at risk for or have ET, and to contact a disability insurance attorney to help with the claims process if you are planning on filing for disability benefits.

Essential Tremors (ET): Part 1

We’ve done a profile on how Parkinson’s disease can affect physicians and dentists, but did you know that essential tremors are eight times more common than Parkinson’s disease?  A hand tremor is one of the last things a physician or dentist wants.  Not only can it affect daily life, but working with patients safely becomes increasingly difficult.

In this post, we will list some of the risk factors and common symptoms associated with essential tremors and take a look at what can be done to perhaps alleviate symptoms.

What is an essential tremor and what are the symptoms?

An essential tremor (ET) is a neurological disorder that causes rhythmic shaking of part of the body—most often the hands, head, or voice.

The primary symptoms of ET are involuntary shaking, voice fluctuations, nodding head, balance problems, and tremors that get worse during periods of emotional stress, fatigue, caffeine use, and/or purposeful movement.  ET is a progressive disorder than can become worse over time.

What is the difference between Parkinson’s and ET?

Many people believe that Parkinson’s and ET are the same thing.  However, there are some subtle differences between the two conditions, including:

  1. Timing: ET usually occurs when you are in motion, while Parkinson’s is most noticeable when you are at rest.
  1. Related Conditions: ET generally does not cause other health problems, but Parkinson’s has been connected to poor posture, a shuffling gait, and slow movement.
  1. Parts of Body Affected: ET is most common in the hands, head, and voice. Parkinson’s most often starts in your hands and may also affect the legs and chin.

What are the causes and how do you know if you are at risk?

ET appears to be a genetic disorder, because approximately 50% of people with ET have a particular genetic mutation.  However, scientists are not sure what causes ET in people who do not have the genetic mutation.  Researchers have found that changes in specific areas of the brain may contribute to development of the condition, but such studies are inconclusive.

Because the other causes of ET are unknown, the primary way to determine whether you have a high risk of developing essential tremors is to check your family history.  Due to the fact that the mutation is an autosomal dominant disorder, if one of your parents has ET, you have a 50% chance of developing the disorder.  Another risk factor is age—people over 40 are more likely to have an ET.

Is there a cure for ET or a way to prevent it?

Unfortunately, is currently not a cure for ET.  However, now that scientists have found a genetic link, further research could potentially discover ways to prevent ET.

How can I alleviate my symptoms?

Since emotional stress is one of the things that can aggravate ET, look for ways to relieve your stress. Other methods of alleviating ET include decreasing your coffee and caffeine intake and making sure that you get an adequate amount of sleep each night.  Certain medications may also can help with ET, although it is important to speak with your doctor before starting any sort of treatment.  Finally, surgery may be an option in some cases, although surgery certainly is not without its risks.  Surgery for ET generally involves the implantation of a DBS, or a Deep Brain Stimulator.  The DBS is a small device that delivers targeted electrical stimulation to the brain in an effort to reduce the frequency of tremors.

In addition to the foregoing methods of alleviating ET symptoms, there are other things that you can do to make living with ET easier, such as using a travel mug or straw for drinks, using heavier utensils for eating, wearing clothes that don’t have difficult buttons or laces, and saving your most difficult tasks for days when your tremor is least pronounced.

Protecting the Protectors: Depression, Medical Professionals, and the Conflicts Involved with Under-reporting

Today we’re taking a closer look at how depression can affect doctors and dentists, their practices, and the way they file for disability insurance. We examine how the medical community’s approach toward mental health is perhaps preventing some doctors from reporting illness, and how this changes a doctor’s ability to obtain adequate treatment and secure disability insurance benefits.

Depression and anxiety are undeniably prevalent among physicians and dentists.  For instance, a study in Australia showed that the rates of depression in doctors is four times higher than the general population and in a British study, 60% of dentists surveyed reported being anxious, tense, or depressed.

Simply looking at the daily life of doctors, and comparing that to the risk factors for depression shows some striking connections between the two. Some of the risk factors associated with depression (as outlined by the Mayo Clinic) include being overly self-critical, having serious or chronic illness and dealing with traumatic or stressful events. Interestingly, these are many things that doctors and dentists struggle with; indeed, probably more often than the average person. Doctors and dentists have to be self-critical because if they aren’t, lives could be at stake. In addition, doctors and dentists often suffer from chronic illness and pain due to the physically and emotionally taxing nature of their work. Worrying about patients, running a practice, and working long hours are all part of the job description for the average doctor.

While physicians and dentists commonly have symptoms of depression, they often don’t report their issues due to the stigma of mental health issues within the medical community. Lay people look to doctors and dentists as the paragon of health, and physicians take the same approach: while their patients are characterized by their illness, physicians are supposed to be the ones who cure them. While the general populace’s approach to mental illness has improved greatly over time (we no longer lock people in tiny jail cells simply because they are mentally ill), the negative stigma attached to depression and anxiety in the medical and dental community is still present. In the Australian study noted above, half of the respondents reported thinking that they were less likely to be appointed to a new position if they had a history of mental illness, and 40% admitted thinking less of doctors that have a history of depression or anxiety.

Nevertheless, it is important for doctors to recognize whether they exhibit signs of mental illness. Aside from needing to be mindful of their own health and well-being, doctors are responsible for the health and well-being of their patients, too.  Physicians and dentists both are in the unique position that a mistake that they make at work could endanger a life. Attempting to work through depression and anxiety symptoms that impair the doctor’s ability to provide responsible patient care could lead to a malpractice suit. Perhaps the solution to this issue is a re-evaluation of the medical community’s approach to mental illness. While that seems like a large task to take on, it starts with each individual doctor either seeking treatment for mental health, or supporting those that do.

For physicians, states have programs in place called Physician Health Programs (PHPs) that are supposed to support the health, including mental health, of medical licensees. A PHP is advertised as a way to get the help one needs, while avoiding disciplinary action such as a loss of license. Physicians should be aware, however, that PHPs are often connected to the licensing boards, and non-compliance with the PHP can lead to disciplinary action. For example, in Arizona, while the PHP is operated by an independent agency, it does have a formal contractual relationship with the state licensing board.

Continue reading “Protecting the Protectors: Depression, Medical Professionals, and the Conflicts Involved with Under-reporting”

Arthritis and Its Many Forms: How It Affects Dental Professionals

The number one cause of disability in America is arthritis, which afflicts over 50 million people. With a U.S. population of 320 million this means that 1 person in every 6 has arthritis. These large numbers could be due to the fact that there are over 100 different types of arthritis ranging from lupus to gout. In this post, we will look to focus on the three most prevalent types of arthritis: osteoarthritis, rheumatoid arthritis and psoriatic arthritis. We will also discuss how they can affect your practice as a dentist, and how to approach a disability insurance claim for arthritis.

The Basics: Symptoms, Causes & Treatment

Osteoarthritis (OA) is the arthritis that arises simply from the overuse of joints, and for this reason it is known as “wear and tear” arthritis. Symptoms include pain, swelling and stiffness in the joints after either overuse or long periods of inactivity. It is most commonly developed as people naturally age and their bodies reflect that age, but can also be found in professions with repetitive movements, such as dentistry.

Since OA is due to aging or the effects of repetitive motion, OA is often progressive. It is the most common form of arthritis, and treatment can range from added exercise and weight loss (where the main cause of the OA is obesity), to taking various pain relievers, and even surgery.


((See Osteoarthritis of the Hand in http://www.webmd.com/osteoarthritis/osteoarthritis-of-the-hand)) h9991469_001

Rheumatoid arthritis (RA), on the other hand, is an autoimmune disease, and is three times more common in women than it is in men. The body’s immune system mistakenly attacks joints, which leads to inflammation that causes further damage. While the symptoms are similar to OA in that there is joint pain and swelling, rheumatoid arthritis also can bring about fevers, fatigue, and weight loss. The joint pain you may be experiencing is often symmetrical, meaning both sides of the body are affected, in RA.

Unfortunately, the causes of RA aren’t fully understood. Symptoms can start and stop, occasionally going into remission, but RA is usually progressive. Risk factors for RA include family history of the disease, smoking, periodontal disease, and microbes in the bowels. There is no cure for RA, and it is treated somewhat similarly to OA in that pain medication, increased exercise, and surgery can be used to try to alleviate symptoms.

((See Rheumatoid Arthritis in http://www.ezhealthmd.com/medical-conditions/rheumatoid-arthritis/))rheumatoid-arthritis-hand Continue reading “Arthritis and Its Many Forms: How It Affects Dental Professionals”