1. Doctor, Can I Work Despite My…. Heart Attack, Back Pain, Psychosis ???????? What Does Science Say ?? “ To all of the men and women around the world who remain productive despite significant emotional and physical pain.” Presley Reed.

2. Questions ? James B. Talmage MD, Occupational Health Center, 315 N. Washington Ave, Suite 165 Cookeville, TN 38501 Phone 931-526-1604 (Fax 526-7378) [email_address] [email_address]

3. The speaker is the current President of “ The premiere society for the prevention and management of disability” For more information, contact AADEP @ 1-800-456-6095 or visit our website @ www.aadep.org A Component of the SOCIETY FOR DISABILITY PREVENTION AND MANAGEMENT

8. AMA Publications

10. www.mdguidelines.com PAID CHAIR Musculoskeletal Advisory Committee 3 rd , 4 th , & 5 th Editions. Paid CHAIR of the Medical Advisory Board 6 th Edition.

12. ACOEM’s Practice Guidelines, 2 nd Edition NO ROLE

17. SSA 2008 Report to Congress

18. SSA 2008 Report to Congress

19. 1978 to 2006 US Population change 222.5 million to 300 million = 35% increase Disability change 2,879,000 to 6,806,000 = 136% increase

20. SSA 2008 Report to Congress

21. SSA 2008 Report to Congress

25. 6 Different “Recovery Curves” For 6 Different Types of Practioners Treating Low Back Pain

26. Am J Public Health 1994; 84: 190-196 Washington State Workers’ Comp experience with 28,473 claims “ Recovery Curve Has NOT changed since the 1950s when it was first published.

34. 1926 Article 19 2 6 is NOT a typo

36. Joe Jim Talmage MD

39. BOTH Patients and employers want “ Notes from the Doctor”

40. The “dreaded” form: What can Joe do ?? 9 % of all primary care visits require an opinion from the MD on work ability. - J Rainville, et al; The Physician as disability advisor for patients with musculoskeletal complaints. Spine 2005; 30 (22): 2579-2584

41. How many hours/day can he lift, sit, stand, walk, climb, kneel, bend, twist, pull, push, simple grasp, fine manipulation, reach above shoulder, drive a vehicle, operate machinery, temperature extremes, high humidity, fumes, noise, OTHER

42. http:// www.myexcusedabsence.com / Accessed November 01, 2007

43. www.myexcusedabsence.com www.junkbrosnews.com/Docnote.htm

46. Return to work formula My Fantasy: “To sit at the feet of Dr. Einstein and learn the formula for filling out Return to Work forms”

47. Joe Requesting Source Treating or IME DOC

49. Work Improves Life Expectancy

60. 2008 Revision

62. False Perceptions Are Common

63. Work Improves Life Expectancy

103. Social Science & Medicine 2011:72; 840-854

104. Social Science & Medicine 2011:72; 840-854

105. Social Science & Medicine 2011:72; 840-854

108. Some Jobs Are NOT Fun

111. http://www.workplacementalhealth.org/employer_resources/disabilityresources.aspx

116. Even if the patient doesn’t want to return to work, it is usually in his/her best interest to do so.

121. Risk

124. Temporal Correlation does NOT prove Causation

128. Risk : At work or at home, “Risk” is part of everyday life. “No Risk” is NOT an option !

129. Cohen JT, and Neumann PJ; What’s More Dangerous, Your Aspirin or Your Car? Thinking Rationally About Drug Risks (and Benefits) Health Affairs 2007; 26 (3): 636-646 FATALITY RISK: DRUGS Treatment Mortality Cause Fatality Rate per 100,000 person-years Smallpox vaccine Smallpox 0.07 First generation antihistamines, 4 months/year Increased deaths from NON-motor vehicle accident related injury 2.8 Prophylactic Aspirin in a 50 year old man CVA, GI bleed, etc. 10.4 Clozapine for schizophrenia Agranulocytosis 35. Natalizumab (Tysabri) for multiple sclerosis Progressive multifocal leukoencephalopathy 65. Rofecoxib (Vioxx) for arthritic pain Cardiovascular events 76.

130. Cohen JT, and Neumann PJ; What’s More Dangerous, Your Aspirin or Your Car? Thinking Rationally About Drug Risks (and Benefits) Health Affairs 2007; 26 (3): 636-646 OCCUPATIONAL FATALITY RISK Job Employees (thousands) Annual Fatalities (2004) Fatality rate per 100,000 person-years Office and Administrative 23,907 91 0.4 Total, ALL OCCUPATIONS 145,612 5,724 3.9 Firefighters 282 30 10.6 Transportation and material moving 10,098 1,511 15.0 Construction laborers 1,009 296 29.3 Taxi drivers and chauffeurs 188 68 36.1 Truck drivers 1,738 779 44.8 Logging workers 75 85 114.0 Tree Fallers 15 55 357.6

131. Cohen JT, and Neumann PJ; What’s More Dangerous, Your Aspirin or Your Car? Thinking Rationally About Drug Risks (and Benefits) Health Affairs 2007; 26 (3): 636-646 TRANSPORTATION FATALITY RISK Mode of transportation Fatality risk per 100 million miles Fatality risk per 100,000 person-years Train 0.03 0.11 Commercial air travel 0.03 0.15 Bus 0.05 0.19 Cell phone while driving 2.3 1.3 Passenger car or light truck 0.7 11 motorcycle 30 450

132. Cohen JT, and Neumann PJ; What’s More Dangerous, Your Aspirin or Your Car? Thinking Rationally About Drug Risks (and Benefits) Health Affairs 2007; 26 (3): 636-646 RECREATIONAL FATALITY RISK Activity Annual fatalities # of participants Annual risk per 100,000 person-years High school and college football 5 8,600,000 0.058 Downhill skiing 38 7,800,000 0.49 Swimming 412 47,000,000 0.88 Bicycling 762 36,000,000 2.1 Boating 703 24,000,000 2.9 Rock climbing 36 100,000 36 Climbing in the Himalayas - - 13,000

139. Risk : At work or at home, “Risk” is part of everyday life. “No Risk” is NOT an option !

144. NEJM 2006; 355 (20): 2064-2066 Data from Swanson: 1994 text edited by Monahan & Steadman Violence and mental disorders: Developments in risk assessment. University of Chicago Press, 1994: 101-136

145. Example of Psychological Risk: Suicide Rates JAMA 2003; 290 (11): 1515-1519 Condition Suicide Rate % per year Normal population 0.012 – 0.017 Bipolar, NO treatment 0.116 Bipolar, Lithium Rx 0.066 Bipolar, Anticonvulsant Rx 0.155

148. Capacity:

149. Ouch !

150. Capacity : Scientifically Measurable

153. Progressively tougher exercise builds capacity Return to Work with restrictions that progressively decrease Will Also Build Capacity

155. Work can be the progressive exercise that builds capacity.

156. Tolerance

158. Tolerance for symptoms while at work is the real issue

179. Choice #3

180. How then does the “Real World Doc” decide if Joe can work After his Heart Attack ? Despite his backache ? Gestält (Choice 3) “ Based on My Anecdotal Experience, Patients like Joe Usually Do … Or Usually Do Not… WORK, at this type Job”

183. “ Opinions are like Noses, Everyone has One, And We each Blow It Frequently” Old Tennessee Aphorism

186. Differing Opinions Based on Anecdotal Experience Plantiff’s Lawyer: “Joe, Go see Dr A” Defense Lawyer: “Joe, Go see Dr B”

189. J Gen Intern Med 1996; 11 (9): 525-532 MD perceptions on Visual Analog Scale Question RS NHC Confidence in ability to assess disability ( 0 = confident, 10 = not confident) 4.4 4.6 “ Burdened” by disability assessment (0 = more burdened, 10 = less burdened) 2.8 2.5

190. J Gen Intern Med 1996; 11 (9): 525-532 MD perceptions Question RS NHC Filling out disability form can compromise the physician patient relationship 82 % 86 % Filling out disability form is a conflict of interest for the physician 62 % 62 % “ Better” if an independent physician determines disability 80 % 80 %

193. Would Doctors LIE ?????

199. Ann Intern Med 2005; 142: 560-582

200. Page 566

201. Explains “Why Judges, Attorneys, Insurance Companies, etc. think Doctors Opinions and Testimony are for Sale” ($$)

206. Conclusions “ Can I Work Despite My …?” Heart Attack ? Back Pain ? (Fill in any medical problem)

208. Return to work formula My Fantasy: “To sit at the feet of Dr. Einstein and learn the formula for filling out Return to Work forms”

209. How then does the “Real World Doc” decide if Joe Can Work After his Heart Attack ? Or Despite His Back Pain ? Or Despite ___________ ? Gestält Or Secretary method Or by FCE FTE NOT by Science

210. Some day We Will Know More About Back Disability

211. The End Thank You