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Information Is Power:
Practitioners Present Evidence Based Results to Promote Use of Psychological Assessments With WC Patients
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While workers compensation systems ("WC") vary widely from state to state, most systems have tended to dismiss the value of psychological testing in evaluating patients injured on the job. This article highlights practitioners who are educating decision makers in the WC arena on the benefits of evaluating underlying psychological and social factors that may affect the patient’s response to treatment.
For the past several years, Patrick Waring, MD, has been speaking with case managers, adjustor trade groups, independent insurance companies, and large national insurance companies who carry workers compensation insurance in the state of Louisiana to explain the benefits of psychological evaluation in diagnosing injured workers. Waring specializes
in interventional pain management at The Pain Intervention Center in greater New Orleans. The clinic, which specializes in interventional pain management techniques, serves all segments of the population, including WC patients.
“My experience is that adjustors and payors often don’t want to delve into issues other
than the specific work injury reported by the patient,” says Waring. “They feel that doing
so might prolong the claim beyond the physical injury reported. They’re concerned about increased costs, and they tend to believe that the whole area of psychological evaluation is
a very subjective one. Yet in denying such evaluations, they often are denying the course of care that would actually help the patient return to work sooner—and that would in fact be the most cost-effective approach.”
“A person with severe depression, for example, is not likely to respond well to major back surgery,” says Waring. “If you haven’t take the time to identify this psychological factor up front, you might be embarking on an expensive surgery or course of treatment that won’t help the patient and that may lead to the added expense of treatment for a failed back surgery.”
BBHI 2 test addresses relevant issues
In his practice, Waring administers the BBHI™ 2 (Brief Battery of Health Improvement 2) test to all WC patients. This brief psychological assessment, which is normed on a population of pain patients, is designed for use with medical patients to help identify bio/psycho/social factors that may be contributing to the patient’s pain experience.
When speaking with decision-makers, Waring discusses some of the primary benefits the test offers. “The BBHI 2 test helps provide objective information on a number of issues that are particularly relevant in the diagnosis and treatment of WC patients, such as perceived disability, pain fixation, satisfaction with the treating physician, and compensation focus,” says Waring. “All of these factors tend to come into play more with WC patients than the average indemnity or HMO patient, and may stand in the way of a positive therapeutic response.” In addition to the test’s usefulness as a screening tool prior to interventional treatment, Waring points out its value as an outcomes measure to assess the patient’s progress.
A shift in perspective
Since he began talking with key players in the Louisiana WC system, Waring has seen some change in attitude. “They are beginning to understand that you can’t separate mind and body issues; that psychological factors such as the patient’s motivation play a role in treatment effectiveness,” says Waring. “They are recognizing that these issues need to be taken into account, especially when you are considering a highly invasive therapeutic procedure such as spine surgery.” After meeting with Waring, some adjustors have become strong advocates for psychological testing as a necessary aspect of evaluation. He also notes that some adjustors and case managers are now asking for the results of the BBHI 2 test because of the objective information it provides.
“Often, physicians feel they shouldn’t need to explain themselves,” Waring comments, “but clearly there are benefits in doing so, as a means of educating others so that we can work together more effectively to care for patients.”
Focusing on the facts
In Florida, Albert Ray, MD, is taking steps to influence change in the WC system as well. Ray serves as medical director at Pain Medicine Solutions in Miami. About 80% of the clinic’s patients are WC cases.
Ray presents seminars on pain medicine to case managers, adjustors, and nurses who deal with WC patients through managed care companies that contract with the clinic. He has increased the incentive for participation by arranging for the course to carry one hour of state-approved continuing education credit.
Ray suggests an irony in the WC system: While guidelines and regulations place an emphasis on making fact-based case recommendations, many decision-makers are operating on false premises about injured workers in general.
“One of the misconceptions I address in the class is the belief that many WC patients don’t want to improve,” says Ray. “Decision-makers often feel that the worker’s complaint may not be legitimate, that the patient may be exaggerating symptoms for secondary gains. While this is true in some cases, statistics show that the majority of injured workers do want to get better. If the patient hasn’t responded to treatment, it may be because non-structural factors haven’t been addressed.”
Treating the whole patient
Ray also points out to attendees that making fact-based decisions about patients depends on gathering all of the relevant data by conducting a comprehensive pain evaluation. Such an assessment looks not only at structural issues but also at psychological, emotional, and cognitive issues, including the role of cellular memory of pain. He explains the benefit of identifying underlying factors that may present obstacles to the patient’s progress before reaching a diagnostic conclusion.
Ray provides three criteria for determining when a comprehensive pain evaluation is recommended: 1. if the patient is not responding to treatment in the expected time frame; 2. if the patient is declared a non-surgical candidate; and 3. if pain is the patient’s major complaint.
In addition, Ray emphasizes the value of using an interdisciplinary treatment program such as the one employed at his clinic. “The facts show that this approach is frequently more effective than having the patient see various practitioners, each of whom is focused only on one area of specialty. When practitioners are operating independently of one another, communication among them may be limited—or it may fall on the case manager to review all of the practitioner’s notes and try to reach a conclusion about the best course of action for the patient.”
“In an interdisciplinary treatment program such as ours, the physician, physiatrist, psychologist, and other practitioners work together as a team to treat the patient,” Ray says. “Because we
all are officed in the same building, we can communicate readily about the patient, including meeting weekly to discuss the case.”
Gathering objective information
Ray’s presentation also includes a discussion of the psychometric tools used at the clinic with all patients. The battery includes the TOMM (Test of Memory Malingering), a brief visual recognition test designed to help discriminate between individuals with true memory impairment and malingerers; the MMPI-2™ (Minnesota Multiphasic Personality Inventory-2™) test, which helps identify underlying psychopathology that may predate the injury; and the BBHI 2 test.
“The focus on objective evidence that governs the WC system has traditionally meant that if the problem doesn’t show up on a medical test such as an MRI or an X-ray, it doesn’t exist,” says Ray. “But pain perception is a very complex issue. The difficulties facing most chronic pain patients don’t show up on such tests. The value of the BBHI 2 test is that it provides a useful tool for gathering objective information on underlying pain-related issues.”
Ray points out that the BBHI 2 assessment is particularly useful
because it is normed on pain patients. Another benefit he emphasizes is that the test helps pinpoint specific information such as pain level in different areas of the body, which is likely to prove far more valuable to the clinician than a general daily pain measurement. In addition, the use of the BBHI 2 instrument, along with the TOMM and the MMPI-2 tests, allows comparison of results to determine if there is any indication of malingering or magnification.
Changing attitudes
Ray has found that attendees of the training gain a better appreciation of how powerful underlying influences can be. “Once people learn that patients are much more likely to improve when the correct factors are identified, they tend to have a different attitude about patients in general, to refer them to appropriate treatment earlier, and consequently to help the patient return to work sooner,” says Ray.
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A Two-Way Street
In addition to providing education for decision-makers within the WC system, Waring also points out the value of educating patients. “Patients often have the misconception that until they are ‘100% fixed’ they
will not be ready to go back to work,” says Waring. “The concept of a ‘fix’ is a dangerous one. Most patients will not experience a complete return to
their previous state of health. The focus should be on improvement. We need to help patients take charge of their physical and psychological problems and move in a positive direction.”
Waring notes that the BBHI 2 test can be useful in this regard. “The test provides objective information that
can help physicians and other providers as well as case workers open the conversation with the patient about
their choices. Through dialogue, we may help the patient overcome their resistance to change, which is often a significant issue. We may also identify that with job modification or retraining, the patient can continue working during the course of treatment.”
“There are issues on both sides of the equation,” says Waring, “with patients as well as with those of us who play various roles in the WC system. Both sides need
to come together or we won’t succeed in improving
the situation.”
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Albert Ray, MD, is board-certified in both pain medicine and psychiatry. In addition to operating an interdisciplinary private practice, he serves as medical director at Pain Medicine Solutions in Miami, Florida. Ray also is a clinical associate professor at the University of Miami School of Medicine.
Patrick Waring, MD, is board-certified in both pain management and anesthesiology. Waring has served as medical director of Pain Management Services at Memorial Medical Center-Baptist Campus and Doctor’s Hospital of Jefferson in New Orleans. He presently practices interventional pain management at The Pain Intervention Center, which is located in the greater New Orleans area.
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| Nurses Report Psychological Testing Helps Them Provide Better Patient Care
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Increasingly, health care professionals are realizing the utility of identifying psychological factors that may influence a patient’s response to treatment. Because nurses may spend more “face time” with patients than do other members of the care team, they are often the first to sense the presence of a psychological issue through that age-old tool, “gut feeling.” Based on their front-line experiences with patients, some nurses also recognize the fallibility of such gut feelings and advocate for the use of objective psychological assessments to validate subjective impressions. This article focuses on three nurses who discuss how the use of psychometrically sound psychological assessments has helped them understand their patients, tailor care to individual needs, and improve outcomes.
Validating “gut feelings” with objective data
Rosalee Bachman, RN, has worked with chronic pain patients long enough to witness the benefits of administering psychological assessments to patients. “In the past, we did not have a formal process for gathering psychological data on patients,” says Bachman. “Sometimes we might receive a note from the family doctor of a past psychiatric history, but most of the time there was nothing. We just had to try to pick things up from talking with the patients.”
Bachman supports Dr. John Brendel, an Interventional Pain Medicine Physician with Interventional Pain Specialists of Wisconsin. Brendel began incorporating psychological assessments into his practice in 2001, starting with the P-3® (Pain Patient Profile) test, which measures depression, anxiety and somatization. He has since added to his protocol the BBHI™ 2 (Brief Battery for Health Improvement 2) test, which they use to benchmark patient health status.
Bachman explains how psychological assessments have benefited the clinic staff and the patients: “The P-3 test works as an indicator to help point out when we should refer people on for psychological counseling before we do any further procedures. Now we can back up our ‘gut feeling’ with the test results.”
The majority of Brendel’s patients are treated with cervical or lumbar epidural injections, but some patients require further treatment. Brendel has the BBHI 2 test administered to those patients three times: prior to receiving the advanced procedure; two weeks post-procedure; and three to four months post-procedure. Bachman says comparing the functional rating on the three BBHI 2 profiles has been very helpful to the medical team by quantifying improvement in the patients’ daily functioning. When the BBHI 2 scores show improvements, Bachman can point out to patients that not only has their
pain level improved, but also that their depression is decreasing, and their outlook on life is better. She notes that patient outcomes have been enhanced since the care team has incorporated psychological testing into their protocol.
Expanding bariatric surgery program to include psychological testing
Teri Barker-Connor, RN, who works in a very different medical setting from Bachman, also appreciates that her “gut feelings” are validated with the objective data gained through psychological assessments. Barker-Connor is the Bariatric Surgery Program Manager at Park Nicollet Medical Clinic,
a large multi-specialty clinic with several offices throughout the Twin Cities area of Minnesota. Until recently, Barker-Connor had recommended
a psychological evaluation only when she sensed the need from her nursing assessment.
Feeling that she had been missing some important information, Barker-Connor was dissatisfied with having to rely only on her “gut feelings.” She could see that there were weaknesses in the program due to the quantity of phone calls she and the other nurses would receive from patients who were struggling following bariatric surgery. While the program already addressed support, education and nutrition for their patients, Barker-Connor felt something was missing. After several conversations with local psychologist Lana Boutacoff, PhD†, who provides psychological evaluations for another surgeon in the area, Barker-Connor invited Boutacoff to a meeting with the Park Nicollet surgeons. Boutacoff was helpful in convincing the surgeons that psychological evaluations, when conducted and written properly to meet the specific needs of bariatrics, can be very valuable for the medical team and patients. As a result of her efforts, the program added psychologists to the staff, and they now include testing with the MMPI-2™ (Minnesota Multiphasic Personality Inventory-2™) and MBMD™ (Millon™ Behavioral Medicine Diagnostic) and QOLI® (Quality of Life Inventory) tests in their evaluation protocol.
Framing patient expectations and preparing medical staff
In evaluating candidates for bariatric surgery, Barker-Connor finds the psychological profiles particularly valuable because they provide information about personality characteristics that may influence how a patient is likely to react following surgery.
“The assessments help the psychologists alert the staff to issues we need to prepare for,” says Barker-Connor. “The tests also help us frame expectations for the patients based upon their psychological profile.”
Barker-Connor also finds that the information in the psychological profile helps increase her confidence when dealing with patients. To illustrate, she recalls a recent patient who was medically a good candidate for the surgery, but whose psychological profile indicated that the patient would likely face difficulties following the surgery. Barker-Connor explained these issues to the patient and recommended that she see a psychologist within the first year following surgery. “I felt much more confident making the recommendation because I was armed with the objective data in the patient’s psychological profile,” says Barker-Connor. “I was not just relying on my ‘gut feelings.’”
Customizing care to patient needs
Maureen Moran, LPN, lead nurse for Advanced Pain Management in Milwaukee, Wisconsin, has seen firsthand how psychological testing has helped the staff at her clinic tailor patient care to individual needs. The P-3 test has been a part of their evaluation protocol for more than five years. “Patients may look fine on the outside, but once we administer the P-3 test we may find that issues may be present that are impeding their recovery,” says Moran. “I believe that because of the test, we learn how to focus our services to be of most benefit to the patient. For example, we learn when we need to spend additional time with patients to help them build up their self-worth, and help them learn how to manage their daily activities.”
Countering resistance through education raises patient awareness
Moran notes that some patients resist when they are requested to take a psychological test. She counters this resistance by
talking with these patients and acknowledging their pain, then explaining that there may be reasons for the pain that are not readily apparent, or that the patient may be depressed because of the pain. She explains that the P-3 test is a tool that helps the medical team identify these kinds of factors and ultimately helps the team provide better treatment. Moran finds this approach does ease the resistance.
Like Moran, Bachman also finds a discussion with the patient helps counter resistance to psychological testing. “I point out to the patient that the psychological test can identify issues that could affect their healing, so that we can address those issues,” says Bachman. “I tell them that we understand that irritability is a normal part of the pain process and can be a manifestation of depression or anxiety, factors the test would identify.”
Bachman has found that for many patients, her discussion creates a new self-awareness. “I can see it on their faces,” she says. “Many of them will say something like, ‘Wow, things have been kind of tough—do you think the pain is doing that to me?’”
Addressing psychological issues leads to improved outcomes
These nurses have learned that psychological testing can reveal issues that may affect patient outcomes. “We can help our patients take their healing a step further through referrals,”
says Bachman. “The psychological tests provide us objective data
we need because sometimes ‘gut feeling’ is not enough.”
† Dr. Boutacoff is scheduled to speak on the use of the MMPI-2 and MBMD tests in assessing bariatric surgery candidates at the American Society of Bariatric Surgeons conference in June.
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The MBMD™ Test in Practice:
MBMD Test: The Preferred Choice for Health Psychologist
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Health Psychologist Ron Carbaugh, PsyD, has nearly 20 years experience working with chronic pain patients. After working in a pain clinic as a Masters-level psychologist for several years, he earned his PsyD from the University of Denver and now operates a solo private practice in Denver. Carbaugh dedicates his time almost exclusively to chronic pain patients.
Carbaugh’s clients are referred by other physicians, primarily physiatrists, and fall into three categories:
- patients requiring presurgical psychological screening mandated by the Colorado Workers’ Compensation Act or insurance providers;
- patients undergoing medical treatments for their pain and whose physicians request a psychological evaluation for medical management or a suspected pre-existing psychological problem;
- patients who have not experienced successful outcomes from previous treatment or surgery for their chronic pain and were referred for pain management.
Carbaugh administers the MBMD (Millon™ Behavioral Medicine Diagnostic) test to all his chronic pain patients, along with
the P-3® (Pain Patient Profile) and PPI (Pain Presentation Inventory) tests.
The importance of understanding personality
Carbaugh looks to the MBMD test results to learn how the medical problem affects the patient’s functioning, and, more importantly, to learn about the patient’s personality style.
“My belief is that personality style dictates how we respond to everything,” says Carbaugh. “That’s the reason we assess these patients: to help determine how they will respond to their doctors and how they will cope, and how to prepare the doctor for the personality type and likely behavior of this person.”
Carbaugh finds the MBMD interpretive report narrative helpful—particularly the coping styles segment—to identify the positive and negative indicators of the individual’s likely response to treatment. He uses this information to help determine whether or not to recommend to the physician that the patient needs psychological treatment. He also uses the report to help advise the physician on patient management, i.e., how to address the patient in terms of his or her personality style, and how the patient is likely to respond to the treatment. “I think the MBMD test does that much better than the previous behavioral medicine inventories and much better than the more psychiatric inventories,” says Carbaugh.
Relevant and time-saving
Carbaugh has found that, for medical patients, the MBMD test is preferable over the more psychiatrically-oriented tests because its questions are less offensive to the patient. Carbaugh reports that he experiences a “higher rate of compliance from patients” since he began using the MBMD test shortly after its release in 2001.
Carbaugh also says the questions that ask how the patient is handling the medical problem are more relevant and valid to medical patients, so the report provides clinical information more germane to physicians.
For his chronic pain patients, Carbaugh appreciates the MBMD test for its ability to help determine probable need for psychological treatment, for the information it provides regarding personality style, for its design and utility specifically for medical settings, and for its time-saving features.
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Visit Our Website!
http://www.pearsonassessments.com/medical/index.htm
Tradeshows
Visit Us at American Society for Bariatric Surgery (ASBS),
June 12–18 in San Diego, CA
Learn how empirically based psychological assessments can help tailor psychological evaluations to meet the specific needs of medical professionals in bariatrics at the 21st Annual Meeting of the American Society for Bariatric Surgery (ASBS) June 12–18, 2004, in San Diego.
Pearson Assessments invites you to a pre-conference workshop, “Effective and Responsible Use of the MMPI-2 (Minnesota Multiphasic Personality Inventory-2™) and the MBMD (Millon™ Behavioral Medicine Diagnostic) tests in the Assessment of Bariatric Surgery Candidates” at no charge to ASBS conference attendees. The workshop will be held 7:00–10:00 pm Saturday, June 12 at the San Diego Marriott Hotel.
The presenters, Paul A. Arbisi, PhD, Susan F. Franks, PhD, and Lana Boutacoff, PhD bring significant expertise, knowledge of the tests, and experience using these tests for presurgical bariatric evaluations. They also are presenting in other courses at the ASBS conference.
Three CE credits are available from the American Psychological Association.
Call Kelly Robbins at 888.627.7271 for a brochure or to register for this workshop. Space is limited.
Find complete information and registration for the full ASBS conference at www.asbs.org.
Selected Course Offerings
Industry Educational Workshop
Saturday, June 12, 7–10 pm
Workshop I: “Effective and Responsible Use of the MMPI–2™ and the
MBMD™ Tests in the Assessment of Bariatric Surgery Candidates.”
Presented by: Paul A. Arbisi, PhD, Susan F. Franks, PhD, Lana Boutacoff, PhD
Allied Health Post-Graduate Courses
Sunday, June 13
Behavioral Health Course: Psychology and Bariatric
Pre-operative Assessments
11:15 am: “Psychological Testing”
Presented by: Lana Boutacoff, PhD, and Lisa Steres, PhD
Noon: “Talk to the Experts: Panel Discussion, Q & A”
Panelists include: Lana Boutacoff, PhD, and Lisa Steres, PhD
Research in Allied Health
1:40 pm: “The Study Design: Finding Answers to the Question”
Presented by: Susan Franks, PhD; Patricia Dittman, MS, RN; Mike Warthen, MDiv; Cynthia Buffington, PhD
Allied Health Science General Session
Monday, June 14, 4:00 pm
“Why Use the MMPI-2 in the Health and Behavioral Assessment of Bariatric Surgery Candidates?”
Presented by: Lana Boutacoff, PhD; Paul A. Arbisi, PhD; Joyce Thompson, RN; Peter Kelly, MD; William Rupp, MD
Also check us out at these upcoming tradeshows!
American Academy of Pain Medicine (AAPM)
March 3–7, 2004
Orlando, FL
www.painmed.org
American Society of Pain Management Nurses (ASPMN)
March 18–21, 2004
Myrtle Beach, SC
www.aspmn.org
American Society of Interventional Pain Physicians (ASIPP)
4th Semi-Annual Meeting
May 14–16, 2004
Phoenix, AZ
www.asipp.org
International Spinal Injection Society (ISIS)
September 9–11, 2004
Maui, Hawaii
www.spinalinjection.com
American Academy of Pain Management (AAPM)
September 9–12, 2004
San Antonio, TX
www.aapainmanage.org
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Winter 2004
