The Difficult 10 Percent

By Maja Jurisic, MD, VP, Medical Director National Accounts | 07/30/2015

Who are these difficult ten percent?

Employers rightfully have concerns about the cost of medical care for injured workers. Yet, based on our experience at Concentra, we know that most of the injured workers we see are treated and discharged from care in less than three weeks, and have fewer than four physician visits.

Studies have shown it is actually only 10% of the Workers’ Compensation cases that account for almost 90% of the cost. So, it’s dealing with the difficult ten percent more effectively that could really result in substantial cost savings.

Who are these difficult ten percent? When clinicians first start practicing occupational medicine, it often surprises them that they are generally not the people with the most severe injuries. Rather, this small but significant population consists of people who continue to feel pain after their tissues have healed. In the U.S., 550 million sick days are lost annually due to dysfunctional pain syndromes among the working population.

Changing the usual approach, and using a model of disease management that recognizes psychosocial issues, even during the initial evaluation of injured workers, can greatly improve outcome and satisfaction with care in these cases.

Like many people in the Workers’ Compensation system, when I first started seeing patients who had subjective complaints out of proportion to objective findings, I suspected them of malingering. After all, my prior 11 years of experience in the emergency department had taught me that some patients are sometimes less than truthful. Yet, I was wrong to harbor this suspicion.

It is more appropriate and more useful to view these persistent complaints as a maladaptive reaction to what has happened to the particular person in question, in which that individual patient uses an injury as a solution to a problem.

All disease and injury are disruptions not only on a physical or cellular level, but also on a personal and social one. The purely biological model of disease that is typically used has not served us well.

For many years, low back pain has been treated as a predominantly physical problem caused by the physical demands of the job such as heavy lifting and repetitive bending. Industry has responded by introducing ergonomic improvements and educating employees about proper lifting techniques. Despite this, low back disability has increased at a higher rate than other disabling conditions. This suggests that low back disability is not due solely to the physical factors in the workplace, but is instead a more complex problem that is influenced by job satisfaction, economic factors, psychosocial reasons, and labor/management issues.

How is it that some people develop a dysfunctional way of dealing with injury and pain? There is evidence that they are pre-wired for it. Our past experiences influence how we see and feel things in the present in a very concrete way.

When we are born, the connections (synapses) between the neurons in our brain are not fixed. The density of synaptic connections increases during infancy, and reaches its maximum by the age of two. At that point, it is 50% higher than in adults. Between the ages of five and sixteen, synaptic activity declines. The connections that persist are the ones that are activated and stimulated by our experiences.

So, people who have a lot of painful experiences at an early age develop very entrenched pain pathways. Later on in life, they actually feel more pain with a given stimulus than someone who does not have as many entrenched pain pathways. They are not wimps or malingerers-- they really do feel pain out of proportion to what those of us who don’t have such entrenched pain pathways would feel with the same injury.

How all the players in the Workers’ Compensation system treat these patients has a great impact on prognosis. The physician has a major influence on how patients understand their problem. Being aware of that, the physician should intervene when a patient starts to show dysfunctional ways of dealing with an injury. With a change in management strategies, the physician can help the patient move forward instead of heading down the slippery slope to chronic pain.

To do this, the physician has to give up the role of “healer” and become a “rehabilitator.” The doctor has to accept the fact that he or she is not going to “fix” the patient. It is that person’s way of dealing with pain and not tissue injury that is the problem.

So, the physician has to focus on function and not on pain, focus on what and how much the patient is doing and not how much an injury is hurting. It is also important for employers, supervisors, and insurance adjusters not to look on this patient’s pain as a moral failing. It only makes the situation worse to compare the injured worker who is not getting better as quickly as anticipated with others who got better faster following a similar injury. It is tremendously helpful for the employer and the treating physician to communicate, and to work together so as to get these workers to a healing plateau as expeditiously as possible.

As frustrating as this difficult 10 percent can be for physicians, employers, and insurance carriers, they just happen to be the group where appropriate management strategies can have the greatest impact on decreasing the costs of Workers’ Compensation injuries. If we meet the challenge of handling these problematical cases well, it can be a win-win-win situation for everyone.

It was Freud who said that love and work give meaning to life. For me as a physician, knowing that I made a positive difference in someone’s life by helping restore my patient to meaningful work is tremendously fulfilling. It’s also good for the patient who felt pain out of proportion to the severity of the injury to be encouraged to focus on function, not pain, and to take some control over his or her own recovery.

Not least, it can be satisfying for an employer to have an injured employee return to work in a timely fashion, knowing that enlightened attitudes and return-to-work policies in the workplace facilitated the process and helped keep the costs down.


Talmage, J. (2011). AMA guides to the evaluation of work ability and return to work (2nd ed.). Chicago, Ill.: American Medical Association.

Kasdan, M. (1998). Occupational hand & upper extremity injuries & diseases (2nd ed.). Philadelphia: Hanley & Belfus.

Chaplin MD, E. (n.d.). Chronic Pain and the Injured Worker: A Sociobiological Problem. In M. Kasdan, MD (Ed.), Occupational Hand and Upper Extremity Injuries and Diseases.