Tag Archives: medical case review

The Dependency Curve – Guest Post from Dr. David B. Adams

This Week’s Topic: “It’s Curvilenear”

Question: “He clings to me, then resents me, then begs me and then rages against me.”

Dr. Adams replies: ”We enter life entirely dependent aside from vegetative functions. We cannot exist on our own, and this characterizes most living species.

We oft-times terminate our existence by returning to that same position, reliant upon others for the same functions that we had learned to perform independently so many decades ago. It is the curvilinear shape of dependence.

We learn to ambulate, communicate and negotiate our world in stages and steps that enable us to function as separate beings, and, in turn, we then rear our offspring to do the same. This is how society exists and advances.

There are obstacles and trauma that require us to briefly regress to deal with illness and injury, loss and disappointment, but in all cases we return to that path of autonomy.

We marry and become interdependent. We allow others to manage most of our lives and become passive-dependent. We become addicted and co-dependent. We resent those upon whom we must rely and become hostile-dependent.

An injury may require an acute period of return to dependency. We call upon emergency medical services, rely upon primary care, must defer to hospital policies, and for the most part we become conditioned, helpless to the point that we cannot even remove our own sutures (sidebar: Unless you are married to a nurse, but that’s likely off-topic).

Injury becomes a struggle between the inherent need to be independent and the concurrent and often pressing requirement that we temporarily accept our dependent role. This will include passively accepting our providers, their schedules, their treatment approach, as well as the consistency/inconsistency of receipt of benefits. Since this most often is in sharp contrast to how we existed only seconds prior to injury, this is arguably the greatest trauma of all.

For some patients, dependency is a characterological flaw. It is a personality defect awaiting expression. It may have presented multiple times during the patient’s history, times to which we are not privy. But the chronically emotionally dependent patient becomes a challenge in case management.

Those assisting the chronically dependent patient become the target of neediness, resentment and fear. The role must remain clinical and, to some degree, sterile in order to address objective damages. The dependency may be emotionally catastrophic for some patients, but it is not often addressed during the course of injury care.

It is essential to recognize that the dependency arising after injury is either something that the patient finds aversive or something to which the patient too readily acclimates.

An injury can be catastrophic to the point of complete and permanent inability to attend to the Activities of Daily Living. In all other instances, the goal from the outset must be a return to whatever level of independence can be achieved. Thus, the inpatient healthcare team includes discharge planning and goals in their initial assessment upon admission.

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Words Matter

Recently, a nurse was sharing her angst that attorneys to whom she marketed via email were not responding to her. I have been giving this some thought because it is a situation that many new LNCs experience.

Everyone finds their comfort level in marketing, and chances are, if you are too comfortable, it might be time to change things up a little. This is particularly true if you are comfortable, but your efforts are not producing results.  Although LNCs can market to a variety of settings, let’s focus on marketing to attorneys, and begin by looking at ourselves.

What makes you buy a product that has no entertainment value? Need. You might watch a Bare Minerals commercial and be amazed that makeup can completely cover scarring, but if your skin is perfect, you don’t need to buy the product (and it is costly).  If you suffer from acne scarring or other blemishes, the cost may be irrelevant to the benefit you will gain from having the appearance of smooth skin.

Attorneys are the same way. If you call or visit and they do not see a need for you right then and there, they are going to say things like “I’ll keep your information on file”, or they may be “busy” when you call to schedule an appointment. This is not personal; they are concentrating their time and attention where they perceive a need, and right now, you are not it.

What do you do at this point? Do you simply move on to the next target and never look back? Or do you send them a partial work sample and CV, thank them for taking the time to look at or save your materials, and promise to keep in touch? Do you send them a relevant article a few weeks later and then maybe monthly? Because sooner or later, your name will come across their desk when they need your service, and if they like what they have seen of you, you might land a case.

During all this “down” time that no one needs you, what if they are curious enough to look you up online? What will they find?

If you are on LinkedIn, they should find a complete profile, with picture, your education and work history, hopefully a recommendation or two, and a respectable number of connections. They will look for a link to your website and a clear description of your services. They can only see what you have written.

Here is the crux of my rambling (which is another no-no). How many nurses have your medical knowledge and experience? Thousands.

What sets you apart and makes you special; what will convince the attorney that he needs you and not the others? Presentation, and the ability to communicate are critical to being a successful LNC. If your profile is not complete, if your description of yourself is not well-written, if your writing has errors in grammar or punctuation, or flips between first and third person, or past, present and future tense, you may not find work. To an attorney, words are everything.

Words reflect knowledge and experience, and how you put those words together in a sentence indicates the work product you can provide to an attorney. This is such an important issue that attorneys are constantly learning about the best way to write a brief, develop a line of questioning for depositions, or structure interrogatories to opposing counsel.  They will attack each other’s writing style and word choice, and are chastised by judges for using unnecessarily complex terminology.

Words matter. Attorneys work for their client, whether plaintiff or defense; they can be removed from a case if their work is subpar. This is always foremost in their minds. If your writing is poor, how can they trust you to analyze their case, present data in a clear and logical fashion, and not miss relevant data? How can they be comfortable that you will not represent them poorly to their client?

You cannot make a new client call you, but while you are waiting for the phone to ring, use that time to review your marketing materials – brochures, business cards, CV, sample work product and online profiles. Make sure these items have a common theme, represent your expertise, and do not misrepresent your ability to communicate. Look for webinars or courses that teach you how to write for attorneys.  (There’s probably one right now at www.patiyer.com/mcc, or www.lnctips.com).

There are many ways to write a report or chronology, but none of them include nursing shorthand, medical abbreviations, incomplete sentences and grammatical errors. Find a peer to critique your work and return the favor. If verbal communication is quicksand for you, focus on email and snail mail. Attend law seminars or sit in court and listen to trials, read about affidavits and other legal documents that you may never write but need to understand.  You will feel more confident, be more competent, and have no trouble letting that attorney know that s/he does indeed need you.