CONFLICTS IN MANAGEMENT
part 5 of 5

Patients who receive workers' compensation benefits for chronic back pain disability are often in conflict with the insurance company that pays the bills. They may see the insurance company as being only concerned with money and quotas, rather than their injury which they feel was caused by the employment. They feel pain and frustration with their limitations, and face adjustors who appear to doubt the sincerity of their suffering. Often, the workers' compensation payments are the only source of income for an injured patient and his family, so when an adjustor stops payment, the personal consequences are devastating. Not invariably, but frequently, animosity between the patient and the insurance company or employer grows and becomes an additional source of stress that complicates recovery. The patient may feel unrealistic pressure to return to work in a capacity that even his physician may not yet allow. If an adjustor is incredulous of the patient's claim, even medical care may not be reimbursed without a legal battle at an industrial board hearing.

From an insurance company's standpoint, chronic back pain that does not show clear organic pathology is often regarded as bogus. Adjustors do become incredulous of a patient's complaints and the lack of progress in treatment, and may fight the claim through hearings. They see redundant treatment by various practitioners leading to no greater results. When the tremendous cost of chronic low back pain is taken into account with such poor results, it is not surprising that this type of reaction would occur on the part of the insurance company. Too many clinicians offer me too solutions that use endless resources with little gain. Sometimes, expensive treatments such as surgical procedures even complicate the course of recovery with untoward effects that lead to longer and more expensive treatment. Insurance companies hire investigators who can document greater functional ability than the patients' claim, and adjustors lose faith in clinicians who blindly support such workers and knowingly or unknowingly foster continued disability.

Physicians are also caught in a conflict because of more than one role that they are asked to play. The first, of course, is that of clinician to the injured patient who comes to them in distress. When physicians, because of cynicism or frustration, lose that perspective they are rarely effective and perpetuate the frustration of their chronic patient. Yet, paradoxically, in chronic back pain the healer is really the patient himself who must take ownership of the problem and actively participate in the rehabilitation. A paternal stance by the physician that allows patients to maintain invalidism inadvertently reinforces disability. It is a fine line that physicians must walk between empathic caring and mobilizing the patient to greater functional activity.

The other role of the physician is that of an expert who determines impairment and gives opinions about disability. For the treating physician this is particularly conflictual since he must decide whose agent he actually is, i.e. the patient's or the insurance company's. In either case, objectivity can easily be lost. Where the physician is an independent medical evaluator and not treating the patient, objectivity may also be impaired through bias or over-involvement with an insurance company which pays for service. At times opinions are sought on causality that are beyond medical determination and best left to the legal arena. The ideal position is for the physician to remain a facilitator who sees the patient's and society's interests as similar, and who tries to promote those interests through comprehensive understanding of the patients within their milieu. No matter which side is correct, the hostility that develops between all of these conflictual interests has a negative effect on the recovery and rehabilitation of the patient. Unknowingly the various parties can reinforce the conflict that already exists. As a consequence, there is significant waste of resources within the workers' compensation system. Unnecessary treatment may be repeated, or necessary care may be withheld for the sake of cost containment. Knowledge of the nature of potential conflicts can help decrease artificial polarization and destructive fragmentation in therapeutic rehabilitation

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