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Researchers at the University Of Texas Health Sciences Center at Houston, Rice University, and Shriners Hospital for Children-Houston recently published findings in the Journal of Bone and Joint Surgery (subscription required) regarding use of antibiotic-containing microspheres that could lead to their use in joint replacement surgeries. Researchers found that antibiotic-containing microspheres could significantly reduce the rate of infection in joint replacement surgery:

Porous metal implants that were coated with the microspheres prevented infection in 100 percent of the 11 specimens. In the tissue and bone surrounding implants that were not coated with the antibiotic delivery system, infection occurred at a rate of 64 percent. (Emphasis added).

According to a press release announcing the findings, the infection rate in joint replacement surgery is between 1% and 3%. While this is a low figure, one million persons per year undergo hip and knee replacements alone. This means that between 10,000 and 30,000 patients develop an infection after joint replacement surgery. As anyone who has been involved with a claim in which a joint replacement became infected knows, the costs of infection can be staggering. Often the original prosthesis will have to be removed to treat the infection. Sometimes patients end up effectively undergoing three joint replacements because an antibiotic-impregnated temporary prosthesis is used to treat the infection, which will then be taken out when the infection is cleared and replaced with a second permanent prosthesis. The lead researcher, Catherine Ambrose, Ph.D., noted:

[m]ade of biodegradable polymers, the antibiotics are gradually released over a period of weeks and eventually the microspheres dissolve, allowing sufficient time to prevent or treat an infection while reducing the likelihood of additional surgeries.

Better preventing and controlling infections in joint replacement surgeries would greatly decrease both costs and human suffering.The use of microspheres is exciting for reasons other than simply reducing the rate of infection. When persons develop an infection after a joint replacement, they are typically given systemic antibiotics. Microspheres offer a significant advantage when it comes to side effects because they are administered directly at the surgical site. According Ambrose, "[t]he microspheres could be administered directly at the surgical site, eliminating the need for systemic antibiotics that impact the entire body." Systemic antibiotics are hard on the body. They often cause gastrointestinal problems (and in extreme cases can lead to the development of infection with clostridium difficile, or c diff). Systemic antibiotics can also cause fever, rash, and potentially more extreme, though rare, side effects.It will be interesting to follow the use of antibiotic-containing microspheres in joint replacement surgery. If they prove as effective in practice as they have in the preliminary, preclinical trial, they will eliminate much suffering while reducing costs and improving outcomes in joint replacement surgeries.

Then [David] reaches into his shepherd's bag for a stone, and at that point no one watching from the ridges on either side of the valley would have considered David's victory improbable. David was a slinger and slingers beat infantry, hands down. 'Goliath had as much chance against David,' the historian Robert Dohrenwend writes, 'as any Bronze Age warrior with a sword would have had against an [opponent] armed with a .45 automatic pistol.'

Gladwell, Malcolm (2013). David and Goliath, p.12. New York: Little, Brown & Co.Goliath had no chance? The counter-intuitive is not necessarily unusual. Everyone in a contest involving more than pure chance should understand that each party has comparative advantages and disadvantages, even when the parties are unevenly matched. Using this information, the parties should seek to use their comparative advantages and exploit their opponents' comparative disadvantages even if doing so involves seemingly counter-intuitive strategy.In the liability and worker's compensation worlds outcomes are uncertain in most cases. This does not mean that the outcomes are not predictable, simply that the exact result cannot be known with certainty beforehand. While this presents certain challenges from an actuarial perspective, it creates opportunities for the parties even if power seems to be distributed unevenly.A perfect example of this is the 1980 U.S. Olympic hockey team. Going in to the tournament, any sane person would have bet against the U.S. team. Given the respective skill level of the teams involved in the Olympic hockey tournament, the U.S. would not even have been considered the second best team. In contrast, the Soviets fielded the equivalent of a "dream team." Just weeks before the Olympics, the Soviet team had beaten an NHL all-star team 6-0. Just as it would have been folly to bet against the 1992 U.S. Olympic men's basketball team, so it would have been folly to bet against the Soviets. Nevertheless, the contest involved two teams and, despite the unlikelihood, the outcome was not predetermined or guaranteed.What is truly interesting about the 1980 U.S. Olympic hockey team is that the team was not merely lucky. Instead, they were blessed with a deeper pool of talent than most observers realized and possessed of a cerebral genius in the cantankerous and foul-mouthed coach Herb Brooks:

The romantic notion that a bunch of college scrubs felled the world's greatest team through sheer pluck and determination is misguided. Brooks spent a year-and-a-half nurturing the team. He held numerous tryout camps, which included psychological testing, before selecting a roster from several hundred prospects. The team then spent four months playing a grinding schedule of exhibition games across Europe and North America. The players included Neal Broten, Dave Christian, Mark Johnson, Ken Morrow and Mike Ramsey, who would go on to impressive NHL careers.

In a testament to his coaching savvy, Brooks realized:

There was no matching the Europeans in skill. So [he] emphasized speed, conditioning and discipline. Knowing how luck plays a large role in short tournaments, he wanted a team that could grab whatever opportunities came its way.

In the game against the Soviets (not the gold medal game, by the way), Brooks' strategy worked to a T.

In the final 20 minutes, a pillar of the Brooks strategy – speed – came to the fore. Tikhonov relied heavily on veterans like Kharlamov and Mikhailov, players the Americans could catch… Brooks rolled four lines in quick shifts, taking advantage of tired Soviet legs. "It was the first time I ever saw the Soviets panic," said [goaltender Jim] Craig. "They were just throwing the puck forward, hoping somebody would be there."

By all rights, the Soviets should have crushed the American team; however, while Brooks used his comparative advantages effectively, the Soviet coach, Viktor Tikhonov, not only did not use his comparative advantages effectively, he ended up leaving open his comparative disadvantages to exploitation. As the Soviet team tired and the Americans surged, Tikhonov did not play his younger, less experienced players, the ones who could actually keep up with the Americans. Instead, "Tikhonov relied heavily on veterans like Kharlamov and Mikhailov, players the Americans could catch." Brooks' strategy is a textbook example of using comparative advantage to achieve an improbable (but not impossible) result.In the claims and legal world, finding your comparative advantage can turn weakness into strength. The key is to examine the claim or case by examining the assumptions based on conventional wisdom. Are the assumptions valid? How might things be done differently? And if done differently, how might that affect the relative strengths and weaknesses of both sides? If I act differently, how can I exploit my opponent's weakness and magnify my strengths?I once had occasion to observe this method in what appeared to be a problematic case. At the time my employer represented a plaintiff in a car accident case. The case was the low speed, low impact collision with little or no visible damage to the cars and soft tissue only injuries. The defense's main strategy was to use an engineer to extrapolate the forces involved in the accident based on the damage to the vehicles and then compare the estimated forces involved in the accident to forces involved in activities of daily living such as stepping off a curb or sneezing. The expert cited to an article published in Spine Magazine ("Acceleration perturbations of daily living. A comparison to 'whiplash'") to establish the magnitude of forces involved in activities of daily living. The theory was that the forces involved in the accident were small, comparable to such activities as stepping off a curb or sneezing; hence, injury could not have occurred in the accident.The question became not how to attack the engineering expert, but how to use him to support our claim. On cross examination, we established a couple of things before getting to the activities of daily living defense. First, we got the expert to admit that the lack of physical damage could result in increased force being transmitted through the plaintiff's body because damage to the vehicle would actually absorb force while a lack of damage would mean that virtually all the force in the accident would be transmitted through the plaintiff's body. Second, we got the expert to admit that he was not an expert in the biomechanical properties of human tissue. Specifically, we obtained his admission that he had no idea of what forces would be necessary to cause tissue yielding in the human neck (or any other part of the body for that matter). Once establishing these admissions, we walked the engineer through the activities listed in the article and had him compare those forces to the force he estimated to be present in the accident. Following this, we asked the engineer a series of questions about injuries that commonly resulted from the listed daily activities, including a fractured ankle from stepping off a curb wrong and a herniated disk resulting from a sneeze.The expert's admissions presented him with a conundrum: if he refused to answer on the grounds that he was not a medical expert, then his opinion regarding the injury causing potential of the accident would not be credible (and could possibly be excluded). If he answered the questions about the injury-causing potential of the forces involved in daily activities in the affirmative, then he would be admitting that the forces he was attempting to describe as benign could actually cause significant injury. Ultimately the engineer admitted that the activities of daily living could cause significant injury and that he could not determine if the forces involved in the accident, however benign-seeming, would have no effect, some effect, or an injurious effect on the soft tissue structures in the plaintiff's neck. In essence, the engineer helped make our case by demonstrating that what appeared to be a questionable claim was in fact entirely normal and comparable to injuries we all suffer from such common things as twisting an ankle while stepping off a curb. What seemed to be an advantage to the defense turned out to be a comparative advantage for the plaintiff. Needless to say, the jury found our client's favor with respect to medical causation and the nature and extent of the injury.Not every case will be amenable to using counter-intuitive strategies to exploit your comparative advantage and your opponent's comparative disadvantages. One thing that can be done, though, is to investigate claims with an open mind so that the assumptions we bring to our claims do not obscure potential strategies that seem, at first glance, to be counter-intuitive or unusual. Sometimes the best strategy is one that is unexpected and will keep the other side off balance.[Full Disclosure:  the genesis for this post was Malcolm Gladwell's David and Goliath, which is a quick, interesting read for those so inclined.


In a soon to be published study in the journal Organizational Behavior and Human Decision Processes, Michigan State University researchers found that "[u]sing a smartphone to cram in more work at night results in less work the next day." While this is not altogether surprising, some of their findings were. For example, it makes sense that smart phones inhibit sleep because they keep people mentally engaged late at night; however, smart phones also "emit 'blue light'" which is "known to hinder melatonin, a chemical in the body that promotes sleep" and so are physiologically (as well as psychologically) disruptive to sleep. Another surprising finding was that "smartphones had a larger negative effect than watching television and using laptop and tablet computers."Regardless of the precise reasons why, using a smartphone late into the night is likely to disrupt sleep and reduce your productivity the next day. On some nights, sleep disruptions will be unavoidable, but on other nights it might be more productive overall to turn off the smartphone and get a good night's rest. As Management Professor Russell Johnson, lead author of the upcoming study put it,

There may be times in which putting off work until the next day would have disastrous consequences and using your smartphone is well worth the negative effects on less important tasks the next day … But on many other nights, more sleep may be your best bet.

The bottom line is that persons who use their cell phones late into the evening will not perform as well the next day. This could have important consequences not only for mental acuity on the job but also for workplace safety. So unless it is absolutely necessary to burn the midnight oil, it is probably a good idea to turn off the smart phone when it is time to turn in.

1/16/2014 in Medical Conditions, News

Wouldn't it be nice if there was something we could do to improve our health that does not require leaving the office or really moving at all? Turns out there is: standing. A study published in the journal BMC Public Health found that sitting less is independently "associated with excellent health and excellent quality of life." While the study found that physical activity had a stronger effect on health and quality of life, simply sitting less played an important role as well. As the authors put it:

High volumes of time spent sitting are associated with an increased risk of all-cause mortality, cardiovascular disease mortality, type 2 diabetes mellitus, and other diseases or conditions when adjusting for participation in moderate-to-vigorous intensity physical activity. Therefore, insufficient moderate-to-vigorous physical activity and sitting time may be distinct influences on poor health.

Of importance to those of us dealing with disability in the medicolegal context is the authors' hypothesis that prolonged sitting leads to a slippery slope of disabling conditions.

Spending long periods in occupational sitting is associated with overall fatigue, musculoskeletal pain, and poor health in data from interviews with office workers. In the ergonomics literature, sitting is linked to one of the most prevalent chronic conditions, low back pain, frequently associated with disability. Thus, prolonged bouts of sitting daily may potentially feature prominently in a downward spiral of decreased mobility, physical function, physical fitness, engagement with life, physical activity, and eventually greater risk of chronic disease...

The authors note that this is a working hypothesis and that more work is needed to determine the precise sequence of events in this downward spiral. Nevertheless, it seems clear that excessive sitting plays a discernable role in poor health which increases the likelihood developing and the severity of disabling conditions such as chronic low back pain. This is useful information for employers who may wish to implement work space modifications that would allow employees to stand while working. In addition, the amount of sedentary time in a worker's shift could become a useful component of physical job demand analyses, reflecting a risk factor that has hitherto not often been considered.Medical News Today also reported on the study and raised some interesting aspects of the study and its implications. The article notes that breaking up our sedentary time changes our metabolism:

Sitting for a long time means there is little muscular contraction going on. This shuts down a molecule called lipoprotein lipase, or LPL, that helps take in fat and use it for energy.

As Sara Rozenkranz, one of the study's authors, explains to Medical News Today:

We're basically telling our bodies to shut down the processes that help to stimulate metabolism throughout the day and that is not good. Just by breaking up your sedentary time, we can actually upregulate that process in the body.

In addition, the article suggests that if work spaces are modified to allow more standing the health benefits would be significant. For example, there is evidence that increasing standing time by three hours per day without doing more causes the body to burn and additional 144 calories per day. This is "equivalent to shedding 8 pounds of human fat over a year." Good news for anyone who would like to lose some weight but has not interest in going to the gym. It may be better news for employers who can take a small step toward a healthier workforce and the cost and efficiency benefits that a healthier workforce brings.

1/13/2014 in News

Medical News Today reports on an article in Pscyhological Science (subscription required) that found how we practice new tasks is more important than the frequency with which we practice new tasks to master them. Specifically, researchers found that persons who took risks or took more time between practices mastered a new video game faster than their peers who were more conservative and frequent in their approach to practice. The researchers concluded that, "individuals who were able to learn faster had spaced out their practices or registered fluctuating results during early game performances, indicating that these participants were analyzing how the game works, leading them to perform better." Tom Stafford, one of the authors, stated "inconsistency doesn't necessarily reflect flakiness, it reflects a willingness to explore the parameters of the game… [B]eing unafraid to fail early on, you gain the knowledge needed to support superior performance later on."The findings may prove important in developing training and education strategies in multiple settings, including the workplace. According to Stafford:

If we can work out how to learn more efficiently we can learn more things, or the same things in less time. In an economy where we're all working for longer and longer, the ability to learn across the lifespan is increasingly important… This kind of data affords us to look in an unprecedented way at the shape of the learning curve, allowing us to explore how the way we practice helps or hinders learning.

This should give anyone who is an educator, whether in a school, the office, on the athletic field, etc., pause to consider how to foster creative risk-taking. Novel approaches to problems should be embraced rather than criticized when the approach is creative and well-thought out as it appears that the seeds of mastery are sown in the fields of creative failure.

With enough time, anything would be possible. We could solve every problem. No deadline would be impossible to meet. No obligation would get neglected.The reality is that time is often at a premium. This is particularly true at certain times: when a deadline is looming, when you return to the office after time away, when your workload increases unexpectedly, etc. Everyone struggles to varying degrees when time is scarce. What most people don't know is that the scarcity of time actually affects how our brain performs.In an influential Science Magazine article about scarcity, authors Anuj Shah, Sendhil Mullainthan, and Eldar Shafir note that "the busy (facing time scarcity) respond to deadlines with greater focus on the task at hand. Across many contexts, we see a similar psychology. People focus on problems where scarcity is most salient." As a result, busy persons tend to "borrow" time by requesting extensions to assuage the effects of time scarcity. Unfortunately, this frequently leads busy person to "neglect important tasks that seem less pressing." In psychological terms, "cognitive load arises because people are more engaged with problems where scarcity is salient. This consumes attentional resources and leaves less for elsewhere." Which has the perverse effect of causing persons "to use their resources less efficiently or make riskier … decisions." Thus, exceedingly busy persons are prone to triage their workload inefficiently, yielding a mixed bag of results in which some tasks are completed with focus and attention while others slide into neglect and often have to be completed frenetically at the last minute (if they are completed on time at all).So what is the solution to scarcity of time? One key is to better manage our mental bandwidth. The idea being that we only have so much brainpower and pressing matters can take over all of our mental attention. We can "put in place systems that minimize the temptations and costs that can come with [reduced mental bandwidth]." This is why, "setting long deadlines … is 'a recipe for trouble" and setting "shorter deadlines or a series of deadlines can make the best use of the brain's inherent deficiencies." Strategies that limit the amount of mental attention being devoted to a single task will have the effect of allowing for mental attention to be devoted to numerous smaller tasks, reducing the risk that important tasks will be neglected.Your IME vendor should help you increase your mental bandwidth by taking over the job of keeping you informed, responding to your questions promptly, and meeting your IME deadlines. While no one has enough time, at Medical Systems we help you get some back.

We have all heard IME's referred to pejoratively as "insurance medical exams" or "defense medical exams." Given that many triers of fact are cynical about the independence of IME's, how can you defend against a charge of bias in an IME? First, you can choose an IME company that is independent – that is not beholden to shareholders or larger corporate interests. Second, you can choose a doctor that is independent - that has no contractual relationship or exclusivity agreement with the IME vendor. Third, you can choose an IME vendor that will work with you to find the doctor that is right for your claim or case.Why should you care about who owns the IME vendor you use? Quite simply because you value independence. While everyone who schedules an IME, whether plaintiff or defense, employer or employee, hopes the report will come back favorable to their position, the most important thing about an IME is that it is credible with the trier of fact. When an IME vendor is beholden to shareholders or larger corporate interests, the vendor's first responsibility is to their shareholders or corporate owners. While every IME vendor is attempting to be profitable, you want a vendor whose only responsibility is to the client: to deliver credible, independent reports in a timely fashion. Then the vendor is not beholden to any third party.Why should you care about the doctors' affiliations with an IME vendor? Once again, because you value independence. You want an IME vendor that is beholden only to being objective, the only true form of independence.  Physicians that have contractual or exclusive relationships with IME vendors may compromise their independence because they take on an obligation to fulfilling the terms of an agreement with the vendor; they may become beholden to something other than absolute objectivity.  This, at a minimum, compromises the appearance of impartiality. A physician that has no formal relationship with an IME vendor has the primary (and sole) obligation to prepare an objective report. Hence, no formal relationship between the IME vendor and the medical expert can taint the appearance or fact of the expert's independence.You also want an IME vendor that will work with you to find the medical expert that is right for your case. Perhaps it is important that your IME doctor be in active practice or that the doctor testifies for both plaintiff and defense. You want your IME vendor to meet your requirements. You want your vendor to have a well-developed network of physicians and contacts that can be mined for the right expert. You want an IME vendor that understands your needs and can recommend the doctor that is the best fit for you. You can't take a "one size fits all" approach when managing your files. Your IME vendor shouldn't take a "one size fits all" approach in finding an expert for you. An IME vendor with a network of truly independent physicians guarantees that your IME vendor will put your interests first.At Medical Systems we are beholden to no corporate overseers. We refuse to establish exclusivity or other contractual relationships with the physicians on our panel (in fact we require that our doctors are not exclusive to us or anyone else). We have the network and the staff to be responsive to your needs so that you get a medical expert that is unbiased and right for your case. In short, Medical Systems is independent so your expert will be too.

12/30/2013 in Medical Conditions, News

Although this report has been all over the news for the last few days, it bears repeating. In Finland a group of 146 candidates for partial  arthroscopic meniscectomy agreed to participate in a trial in which half would receive a meniscectomy and half would receive sham surgery, in which arthroscopic portals would be incised but no procedure performed. The candidates all had degenerative meniscus tears and no evidence of osteoarthritis. The study, which was published in the New England Journal of Medicine, found that,

In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.

Although the study did not determine who might actually benefit from meniscectomy, it "included patients with mechanical symptoms such as catching or locking of the knee," according to a physician that NPR interviewed regarding the results.  As The Wall Street Journal noted, the study estimated that the annual cost of arthroscopic meniscectomy in the U.S. is $4 Billion.While the study size is small, "[t]he implications are fairly profound," according to Jeffrey Katz, a professor of medicine at Brigham and Women's Hospital in Boston who wasn't involved in the Finnish study.  It will be interesting to see how the study affects worker's compensation claims as work-related knee injuries in which a meniscus tear is alleged are relatively common.  One of the authors of the study was not optimistic that it would change clinical practice, noting that a prior study which found physical therapy was as effective as surgery for patients with osteoarthritis and a meniscus tear did not.  Regardless, I expect that the best medical experts will raise this issue when addressing the reasonableness of treatment in the context of meniscus tears, which should give additional weight to their opinions.

One of the trickiest areas for employers to negotiate is the intersection of worker's compensation and disability laws. Frequently, issues under a state worker's compensation act, the Americans with Disabilities Act ("ADA"), state fair employment laws, and family and medical leave laws overlap. Unfortunately, there is no specific guide for how to navigate the laws when they overlap. Employers are left on their own to wade through the morass.One area of overlap that employers can get a leg up on is using a worker's compensation IME to address fitness for duty issues. Under the ADA and most state fair employment compensation laws, employers are entitled to have an employee undergo a fitness for duty examination if the employer has a legitimate concern about the employee's ability to perform the job safely. In a straight fitness for duty situation, employers are only entitled to know if the employee can safely perform the job without restrictions and without risk to other employees.Under state worker's compensation laws, employers are entitled to a broader range of medical information regarding the employee making the worker's compensation claim. One reason is that the employee who makes worker's compensation claim waives the doctor-patient privilege. Hence, employers are entitled to obtain all medical records reasonably related to the injury alleged without the employee's authorization. In addition, employers, in most states, suspend benefits if an employee refuses to attend and IME. This provides a significant incentive for an injured worker to attend the IME.When obtaining an IME in the worker's compensation setting, employers may wish to consider asking questions targeted at the employee's ability to perform the job safely. Often the IME physician will have the benefit of records going back many years that relate to the employee's condition. In addition, employers frequently provide the IME physician with a detailed job description to be reviewed as part of the IME process. This puts the IME physician in an excellent position to judge whether the employee can safely return to employment.Not every IME will lend itself to a fitness for duty evaluation. In some cases worker's compensation and disability laws do not overlap. Sometimes there will be no imminent return to work so a fitness for duty examination would be premature. Nevertheless, in the right case employers can use worker's compensation IME's to their advantage by having the expert address the injured worker's fitness for duty. Not only will it kill two birds with one stone, it will have the added benefit of ensuring that the worker's compensation and fitness for duty opinions are consistent.


Are you an employer who wants to cut costs?  An employee who doesn't want to have to deal with co-pays, out-of-pockets, and other health insurance related costs?  Are you just a person who wants to live a longer, healthier life?  Good news, there is something that will make you all happy!  What is this miracle drug?  Exercise.I can hear the air escaping from your deflated expectations.  The truth is, though, that exercise has proven to be a remarkable means of improving health, speeding recovery from injury, and ameliorating the natural effects of aging.  Studies across medical fields, even including psychiatry, demonstrate that exercise typically works as well as or better than pharmaceutical or other medical interventions to treat chronic conditions.  In a New York Times blog, Gretchen Reynolds describes the findings from a recently released report:

The results consistently showed that drugs and exercise produced almost exactly the same results. People with heart disease, for instance, who exercised but did not use commonly prescribed medications, including statins, angiotensin-converting-enzyme inhibitors or antiplatelet drugs, had the same risk of dying from — or surviving — heart disease as patients taking those drugs. Similarly, people with diabetes who exercised had the same relative risk of dying from the condition as those taking the most commonly prescribed drugs.

Amazingly, exercise is rarely studied and appears to be infrequently prescribed by physicians, as one of the lead researchers noted.

The results also underscore how infrequently exercise is considered or studied as a medical intervention, Dr. Ioannidis said. “Only 5 percent” of the available and relevant experiments in his new analysis involved exercise.

Equally amazing is the fact that this knowledge is old news.  In 1996, the American Heart Association journal Circulation carried a long article titled, "Statement on Exercise."  The article notes that exercise:

  • favorably changes the way the body metabolizes carbohydrates and fats;
  • enhances the positive effects of a healthy diet;
  •  redistributes body fat in a way that likely lowers cardiovascular risk;
  • has positive effects on insulin sensitivity;
  • can help prevent and alleviate osteoporosis;
  • reduces cardiovascular response to stress;
  • increases performance on tests of cognitive functioning;
  • protects against the development of certain cancers;
  • improves overall adjustment and reduces depression and anxiety; and
  • reduces the risk of developing cardiovascular disease.

So how do we get from merely knowing what the benefits of exercising are to reaping the benefits from actually exercising?  On an individual level, exercise requires dedication, planning, and opportunity.  There is not much more to it.  On a broader level, the necessity of exercising needs to become a societal priority and expectation among the medical community, the employment community, and the school community.  And really, this is not about marathon running or competing in triathlons.  We just need to expect and demand that people be more active, whether they are patients, employees, or students.Take the medical community as an example:  when a person goes to the doctor for type II diabetes, the doctor prescribes medication, monitors A1C levels with regular blood tests, etc.  The doctor asks the patient to diet and to exercise and probably tells the patient how important it is; however, the manner in which the doctor discusses diet and exercise suggests it is a more of a recommendation than a necessity.  Instead, the doctor should require the patient to change her diet and to exercise.  The patient can be told that exercise is at least as important as medication, if not more so.  The patient should be expected to monitor her exercise the way she monitors her blood sugar.  A simple reorientation from recommending exercise to demanding it would change exercise from an aspiration to an actual habit for many persons.What can employers do?  From the outset, it must be noted that the line between occupational health conditions and non-occupational health conditions has been blurring recently.  A NIOSH report (p. 178) noted that as the incidence of acute occupational injuries has declined, focus has increasingly shifted to chronic conditions such as low back pain for which it is"considerably more difficult to determine the workplace causality."  The report goes on to note that,

As the distinction between occupational and nonoccupational health fades, it becomes natural to think about the impact of workplace and employer interventions on all health conditions and to think about the employer costs for all mandated or employer-sponsored health programs.

The common response among employers has been to implement wellness programs, with which employers have had varying degrees of success.  However, most research finds wellness programs to be cost-effective within three years of implementation.  Even without a formal wellness program, employers can take simple steps to encourage their employees to be active. Employers can offer on-site exercise classes or install showers for persons who would like to commute by bike or run at lunch. Creating the conditions in which the opportunity to exercise is readily available and expected* will increase the number of employees exercising.  Which means healthier employees and lower costs for both occupational and nonoccupational conditions.

*It must be noted that employees sometimes resist these efforts because they do not think an employer has the right to tell them how to live their lives; however, as long as employers are paying group health insurance and worker's compensation premiums, nothing could be further from the truth.  We accept drug and alcohol policies in the workplace because of the potential costs of intoxication to the employer.  For employers who bear responsibility for a significant portions of their employees' health-related costs, the demand for healthy employees should be no less vociferous than is the demand for a drug-free workplace (since the costs are certainly no less and are likely considerably more).

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