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Memphis Orthopedic Group presents:

Memphis Orthopedic Group presents:. 17 th Annual Worker Compensation Seminar. Working with employers to help the Injured Worker since 1942. We’ve been doing this a LONG time. Disclaimers. Please report any concerns or offenses taken to the COMPLIANCE OFFICER Dan Hein 901 756-0068

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Memphis Orthopedic Group presents:

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  1. Memphis Orthopedic Group presents: 17th Annual Worker Compensation Seminar

  2. Working with employers to help the Injured Worker since 1942

  3. We’ve been doing this a LONG time

  4. Disclaimers Please report any concerns or offenses taken to the COMPLIANCE OFFICER Dan Hein 901 756-0068 Email address: Dhein@mskgroup.org

  5. I was TRAVOLTIFIED

  6. LOCHEMES was originally ROCKEFELLER

  7. Jeff Francis, Assistant Administrator, Division of Workers’ Compensation Tennessee Workers’ Compensation Reform

  8. Jeff Francis • Assistant Administrator • Workers’ Compensation Division, • Tennessee Department of Labor and Workforce Development • A native of middle-Tennessee, Jeff received his B.B.A. degree in Marketing from Austin Peay State University in 1983 and his Master’s Degree in Labor Studies from the University of Massachusetts in 2000. • As a Program Coordinator for the Tennessee Department of Labor and Workforce Development from 2004 until April 2008he developed and managed the Medical Impairment Rating Registry. • He is now the Assistant Administrator of the Workers’ Compensation Division of the Tennessee Department of Labor and Workforce Development. His responsibilities include the budgeting, Human Resources, Information Systems, and Claims and Coverage aspects for the Division. He has been married to his college sweetheart for over 27 years. They have a married daughter teaching the third grade and a son who recently graduated from MTSU, who recently came off his dad’s payroll.

  9. Dan Hein the Wise Guy

  10. Dr Chris Pokabla, MD Proximal Humerus Fractures: Evaluation and Management

  11. LETS ALL TAKE A BREAK!!!

  12. Music Written and Produced by ADAM LOCHEMES

  13. Check Captain Munch out!

  14. BEALE STREET FLIPPERS

  15. Sometimes its all in the way you word something!!

  16. Dr. Ken Grinspun, MD Malingering

  17. Symptom Magnification & Malingering Kenneth A. Grinspun, MD MOG Work Comp Seminar April 16, 2014

  18. Objectives • Definition • Prevalence • Detection/Appreciation • Treatment Strategies

  19. Rationale • Bane of work comp! • We all know it’s there, but what can we do about it? • Why do patients malinger/magnify? • How do we spot them earlier? • How can we decrease the aggravation? • How can we decrease costs?

  20. Malingering:“No syndrome is as easy to define, and yet, as difficult to diagnose.”

  21. Difficulties • Proving malingering • Confronting malingering • The moment a malingerer is confronted, the traditional doctor patient relationship breaks down • Treating malingering • Staying on the same team • IME’s, 2nd opinions...

  22. Confronting Malingering • “Clinicians may be reluctant to address this behavior directly, even if there is strong evidence, because they are afraid of the consequences (e.g., mislabeling someone, being threatened, or being sued) [Binder & Iverson, 2000] • Social media pushback

  23. What does the 6th edition say about malingering? • Not much, just half a page! • Use the term with caution • Under normal circumstances the clinician rarely gets sufficient evidence for such definitive labeling • Suggests using the term symptom magnification because its more clinically accurate and less likely to create disputes

  24. How does DSM - IV define malingering? • “The essential feature of malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtain financial compensation, evading criminal prosecution or obtaining drugs.”

  25. Malingering vs. Symptom Magnification

  26. Malingering is a medical term that implies intent

  27. Symptom Magnification refers to the conscious or sub-conscious tendency of an individual to under-rate his or her abilities and/or overstate his or her limitations. Symptom magnification does not imply intent.

  28. Symptom Magnification • Unconscious Motivation • Somatoform Conditions • Schemas • Factitious Disorders • Other Physical Diagnoses • Aging • Missed Diagnosis • Doctor Bias

  29. Unconscious Motivation • Malingering is defined as conscious motivation • Unconscious motivation means patient is not entirely faking, but problems are not simply physical • A lot like teenagers • Capacity to cope with adversity

  30. Somatoform Disorder • Physical symptoms are not intentional • Example: paralysis of limb

  31. Schema • High order abstraction of a person’s understanding • Frequently wrong • One study showed it’s the best predictor of RTW • 94% RTW if good understanding • 33% RTW if poor understanding

  32. Schema • Examples • degenerative disc disease progression • “I want to be 100% before I return to work” • friends/family/attorney experiences with work comp and/or disability

  33. Schema • It reminds me of dealing with a teenager • Strong conviction • Questionable foundation

  34. Factitious Disorders • Psychological (as opposed) to intentional motivation in order to assume the sick role • Munchausen

  35. Aging • Pain associated with aging isn’t always gradual • Arthritis does make people more susceptible to injury • People may not be as “tough” as the used to be • 1990’s TKA dissatisfaction - 10% • 2010’2 TKA dissatisfaction - > 20% • Job descriptions that are clearly not in line with a person’s age

  36. Aging • Getting old isn’t painless • Difficult to distinguish pain from aging and work injury

  37. Missed Diagnosis • Fortunately, not very common • Psychiatric patients can have medical problems • MRI’s, nerve studies can be very helpful

  38. Doctor Bias • Work comp doctors vs. Attorney doctors • Reluctance to be the “bad” guy

  39. Prevalence • Hoover Commission - 1993 California • 20-30% of work comp claims are fraudulent • cites financial incentives to fake injury/stress • no objective measurements/testing

  40. Prevalence • 2009 Study - Prevalence of malingering for chronic pain in the context of a medico-legal setting with financial incentive • 20-50% • clinical diagnostic systems used

  41. Prevalence • AFL-CIO 2012 • 2% • used malingering as the measurement

  42. Prevalence • “The reality of course is that no one knows what the real numbers are.”

  43. Detecting Malingering & Symptom Magnification • Surveillance • Psychological Tests • History • Physical Examination • Isokinetic Testing

  44. Video Surveillance • Possibly the only way to “prove” malingering • Disadvantages • expensive • time consuming • hard to catch someone “in the act”

  45. Psychological Testing • Many tests have been developed • MMPI - Minnesota Multiphasic Personality Inventory • TOMM - Test of Memory Malingering • Opinions vary • None are conclusive • Based on probabilistic evidence

  46. History/Red Flags • Rare or bizarre symptoms • Symptoms worsen or don’t improve with time/rest • Symptoms begin after a latency period • Multiple symptoms • Hostility - “Why am I not getting better?” • Drama - tears, family members present

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