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The Rise and Fall of the Visual Pathology Era of Medicine

For 120 years, Medicine and Disability Management—such as it was—was handled by The Standard Medical Model that did arguably work since about 1880. 

In that long-ago-bygone era of “Visual Pathology,” patients saw their own Family Physician, who had often known them for years—with fractures, heart disease, back pain, pneumonia, etc. Questions were asked and with a physical exam, tests, X-rays, and nowadays scans, the pathology could be seen, and the objective diagnosis made. Physicians had lots of experience dealing with these visible pathology diseases, they knew their patients and their often-physical jobs well and treatment was prompt, efficient, effective & engaged. 

With years accumulated of disease data, validated guidelines allowed for predictable courses for healing and return to work, which simplified disability management and allowed for relatively predictable absenteeism frequency and duration. 

The Mental-health Disability Tsunami

As we are all aware, the last few years have seen a virtual tidal wave of mental-health disability claims, to the tune of $51 billion per year in Canada. 

Nowadays, patients with often ill-defined and vague mental-health symptoms see whatever physician is on shift at their local ER or walk-in clinic. The pathology is invisible. 

While it was easy to say if a patient with, say, a broken arm, could return to work as a production-line worker or clerk, it is harder to say if a depressed Accounts Manager is able to return to work.

Physicians, already overwhelmed with high demand for their services, have limited time and are not really trained in this sort of “Functional Assessment” and more often than not, defer to all demands for time off work, creating “Absenteeism/Disability on Demand.”

The Prevalence of Mental Illness in Society

The usual prevalence in the population at large is said to be 5–10% for depressive symptoms and 4–6 % for “anxiety disorders,” which tend to be lifelong. These figures overstate what is seen in the working population for several reasons: 

1. Many occur in the elderly who have left the workforce.
2. Many in the general population with more severe cases of “depression” or “anxiety disorders” are either on “chronic disability” or unemployed and not in the workforce.

Mental Health: is it a priority for your organization?

Why the Standard Medical Model Is Failing To Keep Up With Mental Health Disability

The failure of current and legacy solutions to manage mental health disability efficiently & effectively for rapid return to work rests on the “invisible pathology” nature of mental health amplified by external factors or “Absence Amplifiers”: 

• Continuity of Care: Workers see whatever physician is on call in their local walk-in or ER, often a different physician each time, with no Continuity of Care.

1. Invisible & Subjective Pathology: A mental health diagnosis is opinion based, lacking the objective visible pathology diagnosis by biopsy, X-rays, blood tests, etc., upon which everyone could agree. 
2. Diagnosis: While validated mental illness diagnostic tools (see below) do exist for many mental health diagnoses, they are time consuming, and they are often not done by overwhelmed physicians.
3. Functional Assessment: Physicians are not well trained and have insufficient time to assess if a worker with a mental illness can do their job.
4. Time off Work: Overwhelmed & time challenged physicians are generally compliant to all requests for time off work.
5. Treatment: Medications and other therapies used to treat mental illness can take months to have a therapeutic effect.
6. Knowledge Base: The explosion of knowledge in the past 30 years has admittedly made it harder for the average health-care practitioner to remain “current” with Best Practice Guidelines.
7. Wait Lists: Access to mental health specialists can take months.
8. Transactional Care: While 10-minute appointments often suffice for visible pathology, the diagnosis and treatment of mental illness require longer appointments and often for a longer period. 
9. External Factors: As opposed to visual pathology, marital, financial, family or workplace stresses and job dissatisfaction often play a much greater role in perpetuating the disability.

Mental Health Disability or True Mental Health Disease 

Although the prevalence of mental-health disability claims in industry is known, the actual prevalence and accuracy of diagnosis of true mental health diseases in the workforce are less clear. 

After having reviewed thousands of mental health disability cases, MedExtra is of the opinion that the most common cause of workforce mental-health prolonged claims is—regardless as to what appears on “Attending Physician Statements”—what is colloquially called “BURNOUT.” 

What Is “Burnout”?

Burnout is a colloquial term and not a medical term but is generally diagnosed when:

1. A Varying Constellation of Mental Health Symptoms: Anxiety, depression, insomnia, mental exhaustion, cynicism, helplessness, etc., of relatively recent onset.
2. Worker Claiming Workplace as Cause: The worker ascribes, often in very emphatic terms, often loudly blaming a certain individual supervisor, as the cause of their symptoms, while at the same time denying any stress elsewhere in his or her life!
3. Worker Demanding Time Off Work: The worker again, often emphatically, states that they are not going into work and demands “time off.” Period. 
4. An Undercurrent of Rage: While this can be subtle, it is part of Burnout, which often complicates treatment and return to work as overwhelmed physicians often do not see this. 

While not in the official list of psychiatric diagnoses, the official DSM V diagnosis that most corresponds to “Burnout” would be one of the following: 

• Adjustment Disorder with Mixed Symptoms
• Work Stress
• Unspecified Trauma- and Stressor-related Disorder

Treatment of Burnout

As the causes of Burnout are multifactorial, treatment targeting both the principal symptoms and underlying causes or stressors: 

• Medical Approach: Treatment should judiciously and appropriately target the principal symptoms as there are few, if any, treatment guidelines for Burnout. These would include the treatment of anxiety or insomnia with benzodiazepines or that of a depressed mood with SSRI antidepressants.
• Workplace Approach: While transfer of the employee to another department or to a lesser workload can help, this is not within the purvey of physicians. 
• Pharmacogenetics: Uses genetic testing to determine which medications will work best in a given patient. While showing some promise in research studies, this is not yet “mainline.” MedExtra is closely following developments here
• Psychotherapy: While therapy with a trained psychologist is arguably effective, it is often expensive and difficult to “access” for most patients.

The often unnoticed and unaddressed undercurrent of rage in Burnout patients, often directed against a particular manager or supervisor, complicates treatment. With patients/workers who often seem unwilling to compromise, few of these cases have a proverbial “happy ending,” with many proceeding to long-term disability. 

The Role of a Virtual Medical Director (Vmd) in Mental-health Disability 

Our years of experience as practising physicians and corporate medical directors has taught us that the best way to a timely resolution of any absence, but most importantly for “Burnout,” is early access to Best-Practice-Guidelines based targeted care, within a holistic comprehensive solution, along the entire continuum of care, systematically applied to all absenteeism and not just limited to Burnout:  

1. Protocol-Driven: All absence claims (excluding incidental days off) managed as per Virtual Medical Director protocols and in line with corporate absenteeism policy.
2. Metrics & Data-Guided: Absent workers are followed, using validated metrics applied to the specific data in their medical record, to track prognosis for return to work and quality of their care.
3. Best-Practice-Guidelines Based Targeted Care: Validated by years of data and proven to provide optimal outcomes and faster return to health & work.
4. In-House MedExtra Metrics: With years of experience, we have developed our own, in-house metrics to review worker medical records to: 
   1. Triage: Proactive separation of absenteeism into groups: 
      1. Complex & on the severe end of disability scale, warranting targeted care
      2. Resolved cases with workers taking extra time off work 
      3. That small percentage of workers actively “gaming” the system
   2. Validation of Care: Assessment of Key Performance Indicators for care & cost control
5. Assessment of Ability to Work: Often overlooked by overwhelmed physicians in case of mental-health disability, done systematically & on a scientifically valid basis, this speeds up return to work.
6. Cooperative & Professional with Treating Physicians: Assisting overwhelmed treating physicians in these often complex cases, they see us as their allies, which always enables optimal care and outcomes and faster return to work.
   
   For more information, please refer to MedExtra or contact us to learn more about it.