Like many surgeons, my clinic fields many enquiries from workcover patients. I am one of the surgeons that does not turn them away but I have to be frank and tell you that I often get exasperated by certain aspects of looking after workcover patients, especially those who reside in regional Victoria. Among the reasons doctors usually cite for refusing to treat workcover patients is the red tape, the paperwork that workcover insurers demand and the disputes that often arise between the treating doctors and workcover insurers.
I continue to treat workcover patients because I know that negotiating the workcover system is not a walk in the park for workcover patients either and that there are many workers with genuine injuries who need the help of a good specialist. Apart from the stigma and prejudice that injured workers may face at their workplaces, I know that one of the other enormous problems is that workcover patients may have pain that neither they nor their treating doctors understand very well. As a result, workcover patients are often miserable, depressed and stressed, which in turn can make their experience of pain even greater.
Before we go much further, let me stress that not every workcover patient who comes to me with a “spinal injury” can be “fixed” with surgery. Interestingly when people see me for the first time they often describe their pain as “nerve pain” without knowing what is actually causing the pain. When you think about it, all pain boils down to “nerve pain” because without nerves we could not feel anything- we would be totally numb. What these people usually mean is that they think that their pain is caused by a pinched nerve somewhere. However there are actually many causes for feeling pain and sometimes it is actually coming from a disturbed joint in the spine or from a damaged disc in the spine, rather than from a pinched nerve. Sometimes the pain actually comes from “sick” nerves that have gone haywire and keep sending signals to the brain that you are in danger even when there is actually nothing that is pinching or irritating the nerve ending. Unfortunately there is no test for pain. The experience of pain is a very personal one and no-one can measure it like you could a length of string. You also cannot do an MRI and see where the pain is coming from, any more than you can take a great photograph of a telephone and tell if it is ringing! Like a car or any machine, our bodies will wear out with age and everyone will develop disc bulges or arthritic joints as they age. So just seeing something like a disc bulge on a scan does NOT necessarily mean that is causing pain. It is often possible to make an educated guess at where the pain is coming from but many general practitioners just make wild guesses and in my experience they get it wrong a lot of the time. This is one big reason why so many workcover patients with so-called back injuries have fuzzy or vague diagnoses and no-one is quite sure how to treat them.If you think that you may have a spinal problem, the best way to make sure that you get the right diagnosis is to see a spinal specialist.
From talking to workcover patients, many who have been injured for a long time start to feel that they are being accused of faking pain, or that they are insane or just imagining their pain. I am a very empathetic person and I believe that most workcover patients are really expeeriencing pain- they are not simply putting it on. It is totally possible for someone who is perfectly sane to be in a lot of pain even though a hundred and one tests seem to show that nothing is wrong with the part of the body where the pain is felt. On the other hand, it is possible for an MRI to show some disc bulges but for none of the disc bulges to be causing the pain. I don’t want to go into great detail for now but there are recognised conditions in medicine where the nervous system has become altered by pain even though the body part that was injured has already healed, causing abnormal pain sensations. This is why people who have had a leg amputated can suffer from phantom pain that seems to come from the leg that no longer exists. Unfortunately not all doctors are good at explaining this type of abnormal pain to patients.
Workcover patients need to have treating doctors and allied health practitioners that can help injured workers to help themselves. Workcover patients with possible spinal injuries deserve to have at least one consultation with a spinal specialist. If that specialist says that they should not have surgery, then the worker should have access to the best alternative treatment, especially pain education and expert physiotherapy. In my experience, this can be a real struggle with patients from regional Victoria, as the fact is that there are more and better quality healthcare practitioners like musculosketal physiotherapists and pain management specialists in the metropolitan or city areas.
I also want to emphasize that surgery is usually not some magical wand. The results of surgery can never be guaranteed and there are risks to every operation. If I believe that someone can make a full recovery without surgery, then I won’t recommend surgery but there are some conditions that I believe won’t get better without an operation. If I feel that someone needs a spinal operation to get better, I will say so and I will back that up with evidence. However I always inform the person that surgery is rarely going to be the be all and end all. There will usually be physiotherapy or a gym-based strengtheing program that the person needs to do after surgery to get the best result and the right attitude goes a long way towards that. Sometimes I am faced with someone who I think would benefit from surgery but the person does not have the right attitude or mindset to accept that they also need to do their part to get better after the surgery is over.
It is not always going to be easy to get the surgery approved, even with the support of a medical specialist. Consider the following letter I recently received about a Worksafe medical advisor’s reasons for rejecting a request for surgery:
“It is a fundamental requirement and right for patients to have comprehensive information and understanding of pain complexity prior to any potentially harmful surgery, but especially spinal surgery. This should include being advised of the limitations in basing intervention decisions on scan findings, which is rarely advised properly. It should also include a realistic appraisal of the statistical results from interventions in the relevant context and not just the overall results (which include most in a more favourable context). It should also include a science based explanation as to how the contextual factors (including well-intentioned information provided by clinicians) are the most influential factors in chronic pain outcomes and that such outcomes are paradoxically increasing despite advances in technical expertise and therapeutic options.”
What the medical advisor is effectively saying is that even if you have the best surgery in the world, you may not do well because there is more to pain than even doctors can understand. However I do think that workcover doctors sometimes get it wrong. I am pleased to say that I have many workcover patients who have made an excellent recovery after I have operated and gone back to work. Such successes gave me a lot of joy and go some way to making up for all the red tape and paperwork that I have to push through to get that surgery approved.