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Physiatrist and pain medicine specialist Steven Feinberg, MD, focuses exclusively on evaluating and treating complex workers’ compensation cases. Located in Palo Alto, California, Feinberg conducts “agreed evaluations,” in which both the patient’s lawyer and the claims examiner or defense attorney for the insurance carrier have requested an assessment. “The primary objective in the workers’ compensation system is to help people become medically stabilized so that they can get on with their lives and return to work,” he says. “We want to ensure patients receive care that is appropriate, direct, efficient, and cost-effective.” In working with complex cases, Feinberg recognized the need to assess psychosocial factors. “I see patients who typically have tried many treatment options with little or no success,” he says. “When people fail treatment, it’s often because of underlying issues that have gone undetected. The way people experience pain is not based solely on their medical condition; it can be affected by many other aspects of their lives. Gaining a well-rounded perspective on the patient is critical to successful outcomes.” To help him meet this goal, Feinberg turned to his daughter, Monica Feinberg-Gizzo, PhD, a clinical psychologist practicing in San Diego. He asked her to select a psychosocial test battery and help him incorporate the assessments into his protocol. Separated by 480 miles, the two entered a long-distance collaboration that has proven to be very productive.
Feinberg-Gizzo conducted extensive research and identified a battery of tests well-suited to Feinberg’s needs. Overall, she was looking for highly validated psychosocial instruments that would provide a wide range of information in a short amount of time. The battery she chose consists of three tests, including the P-3® (Pain Patient Profile), an assessment of depression, somatization and anxiety, which are the factors most frequently associated with chronic pain. Feinberg-Gizzo liked the fact that the P-3 test was normed on pain patients as well as a community sample. In addition, she was impressed with the Patient Summary, a one-page synopsis written in everyday language that makes it easy for the physician to share results with the patient. “And, the P-3 is quick and easy to administer,” says Feinberg-Gizzo. She also selected the MBMD™ (Millon™ Behavioral Medicine Diagnostic) test, which helps measure psychosocial factors that may support or interfere with a patient’s treatment. “This instrument was a good fit for our needs because, like the P-3, it’s normed on patients with chronic medical conditions,” says Feinberg-Gizzo. “And, this brief tool yields information on a broad spectrum of issues such as the patient’s coping styles, stress moderators, and treatment prognostics, which can help the physician better understand what’s going well for the patient and what’s not — and how the person will respond to treatment. Plus, the MBMD test assesses negative health habits, such as drug and alcohol issues, which is especially relevant if high dosages of a medication such as morphine are currently being used or are under consideration, as is often the case with chronic pain patients.” The third component of Feinberg-Gizzo’s battery is the VIP® (Validity Indicator Profile), which helps assess malingering. “One of the best aspects of the VIP test is that the verbal section is quite clear and concise, unlike that of other response-style assessments I reviewed,” she says. To evaluate Spanish speakers, Feinberg-Gizzo decided upon the BBHI™ 2 (Brief Battery for Health Improvement 2) test instead of the VIP measure. “I was attracted to the BBHI 2 not only because it offers materials in Spanish, but also because it has features that make it appropriate for complex pain cases,” she says. “It’s normed on a sample of physical rehabilitation and chronic pain patients as well as a community sample. In addition, it includes a standardized pain complaint scale that shows how patients view their pain and their level of disability. The BBHI 2 also allows you to compare the patient’s report to reference groups for pain in the same body area. And, it provides pre- and post-op test versions to help clinicians monitor progress.”
Several elements influence Feinberg’s determination about which patients should take the battery. “I don’t give the tests to individuals who already have received in-depth psychological assessment,” he says. “However, many of the injured workers I evaluate have never seen a psychologist or psychiatrist, or if they have seen one, have never taken standardized measures. I administer the tests to patients who are considering invasive procedures such as back surgery, those who may be at risk for medication misuse or abuse, those in emotional distress, and those who exhibit pain behavior. And, I often give the battery to a patient just because I sense that I am not quite getting the full picture through what the injured worker is sharing with me in our interview.” The instruments are administered by qualified staff members in Feinberg’s office. Feinberg-Gizzo has conducted training for the staff that covers the purpose of the measures, testing protocol, rules of confidentiality and how to respond to patient questions. Once the patient has completed the tests, Feinberg’s staff sends the results by fax or overnight mail to Feinberg-Gizzo. “To remain objective, I intentionally never see the patient and therefore I don’t know their history,” she says. “In addition, I rarely discuss a case with Dr. Feinberg until after I have reviewed the assessment results. I base my analysis purely on the results, which can reveal a different view than the physician might have had during the clinical visit. For example, a patient might come across in person as being quite sincere, but then the evaluation might show that the patient may be trying to influence the testing outcome by magnifying his or her symptoms. The tests provide another piece of information for the physician to take into account.” Drawing from the test reports, which she finds to be very straight-forward for all of these instruments, Feinberg-Gizzo drafts a narrative summary. Her write-up briefly explains what each tool is designed to measure, which is helpful background for attorneys, claims examiners and other non-healthcare professionals who may be reviewing the case. The report then presents her clinical impressions and treatment recommendations. At Feinberg’s request, she also includes her evaluation, on a 0-5 scale, of the likelihood that the patient will experience successful outcomes with traditional medical treatments for pain. She sends her report to Feinberg by secure E-mail, fax or overnight mail — the last step in a quick turn-around process that helps him keep pace with a busy workload.
“Part of my job,” says Feinberg, “is to make intelligent recommendations. I’m a seasoned pain specialist and yet sometimes the psychosocial test results surprise me. These instruments allow me to hone in on what’s really going on with the patient.” “When the patient’s scores are at the low end of the scales, my recommendation is usually to stay away from invasive procedures or narcotics and to schedule a formal psychological assessment,” he says. With other patients, the measures help confirm for Feinberg that there are no significant psychosocial factors to be addressed. Feinberg notes that he usually does not have difficulty receiving reimbursement for the tests from insurance companies. “Insurers are very hesitant to start a separate psychiatric claim; they do not want to open up that Pandora’s box,” he says. “But for me, it’s easier to get insurance authorization for testing because it’s part of my protocol for evaluating chronic pain syndrome, not part of a formal psychological evaluation.”
Feinberg-Gizzo is pleased to be part of a professional relationship with her father that’s focused on achieving better outcomes with medical patients. “Insight on psychosocial issues is a piece of the puzzle that is often missing in physicians’ evaluations of people with chronic pain,” she says. “These tests can help fill in the blanks.” For Feinberg, the instruments have become indispensable. “These tests from Pearson are a fairly inexpensive way for medical practitioners in the workers’ compensation arena to gain a wealth of useful data. They assist us in developing effective treatment plans, moving cases closer to resolution, and avoiding acute care. They have enhanced my reputation by helping me to be a better doctor.”
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