Defense Medical Expert Dr. John Townsend Weighs In on Delaware Practice Guidelines

Defense Medical Expert Dr. John Townsend Weighs In on Delaware Practice Guidelines

This week I am pleased introduce as my guest blogger Dr. John Townsend, who was featured in my last posting as the "expert victorious" in the Rodney Nesmith v. ServiceMaster case. Dr. Townsend, a Board-certified neurologist, is well-recognized at the Delaware Industrial Accident Board, most frequently offering testimony on behalf of the insurance industry. Dr. Townsend's observations regarding the current role of the Delaware Health Care Practice Guidelines is the first in a series of postings that will appear from physicians in 2010.

And now for Dr. Townsend's comments:

Re: Nesmith vs. Servicemaster

The case discussed on your recent blog is of interest in that it provides a litmus test for the Delaware Workers Compensation Treatment Guidelines that have been developed over the past two years. In previous cases in front of the Industrial Accident Board when there was a disagreement regarding a patient's treatment whether it was prolonged PT/manipulation or repetitive injections without obvious gains on the patient's part, a defense expert was generally limited to quoting the most up-to-date literature regarding said procedures. Unfortunately, the treating physician would generally prevail in these cases of overuse of services by citing that the patient had improved symptoms following some of the treatments.

What sets the Treatment Guidelines apart from business as usual is that they take more of a “show me the outcome" approach to treatment of the injured worker. They demand that the treating clinician document a patient’s functional improvement rather than merely implying that there is an improvement in the patient's subjective complaints. The overall goal of treatment, based on the Guidelines, is to improve the patient’s physical ailment enough to return the worker to some form of employment. So, rather than 3 times per week physical therapy or manipulative treatment for many months, the guidelines suggest up to 12 visits to demonstrate a functional gain. If there is no demonstrative functional gain the patient should engage in another form of treatment. This is of benefit to the injured worker in that if their current treatment is not producing results after a month of treatment then they should be directed to a treatment that may be more efficacious.

Likewise, rather than the boilerplate assertions that all injections of the epidural space or facet joints should come in sets of 3, there should be documentation of substantial improvement between injections before additional injections are considered. This forces the treating physician to actually re-evaluate the patient between injections and document the areas of improvement in their symptoms, activities at home, and activities at work. The increased doctor-patient dialogue will also hopefully allow patients to feel like they are having a say in their treatment process and will hopefully encourage them to be more active in their own recovery rather than feeling dependent on treatments or procedures that have been dictated to them without their input. While the Guidelines may save some money in some circumstances, and also provide a basis for discussing treatment modalities, the bottom line is that hopefully the injured worker in Delaware will get care that is ultimately helpful for improving their complaints and that is also focused on producing lasting functional gains rather than a modicum of symptomatic relief.

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