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A Case for Evidence-Based Medicine in Workers’ Compensation

Long before Tiger King clawed out his fifteen minutes of fame, there was Clark Stanley, a.k.a. the “Rattlesnake King.” Stanley, a silver-tongued Texan born in 1854, found fame and fortune in the late 1800s with “Clark Stanley’s Snake Oil Liniment.” He sold his salve across the country as a cure for “pain, lameness, rheumatism, neuralgia, contracted cords, frostbite, animal bites, and everything a liniment ought to be good for,” until federal authorities finally put him out of business. It just goes to show, whether it is 19th-century snake oil or 21st-century
cleanses to “detoxify” your colon, there is never a shortage of unscrupulous marketers ready, willing, and able to come between uninformed healthcare consumers and their hard-earned money.1

Unfortunately, bad medicine is not limited to snake oil salesmen and occasionally finds its way into the mainstream. In their book, Quackery: A Brief History Of The Worst Ways To Cure Everything, Lydia Kang, MD, and Nate Pedersen explore the long history of accepted medical practices eventually proven to be useless and oftentimes worse than the disease.

For instance, centuries before the dangers of mercury toxicity were recognized, physicians prescribed vaporized mercury as a remedy for syphilis. Therapeutic dosage was reached when the patient started salivating uncontrollably, coincidentally, also a sign of mercury poisoning. 18th-century doctors used tobacco enemas to treat drowning victims, literally blowing smoke up the patient’s rectum in hopes of warming them back to life. As the son of an ear, nose, and throat surgeon, I’d be remiss if I failed to acknowledge practitioners who, once upon a time, threaded leaches and dangled them onto tonsils to suck out infection. In the 1990s, American doctors operating “fen-phen mills” prescribed millions of “miracle” weight loss pills before discovering they also caused serious heart valve defects. History and hindsight show accepted medical practices are not always good medicine. Still, if you want to liven up a Friday night workers’ comp party, just bring up the subject of evidence-based medical treatment guidelines for injured workers. However, be prepared for the apocalyptic opposition chorus:

“Let the doctors practice medicine and not the insurance companies!”
“The only thing the [insurers/lawyers/doctors… take your pick] care about is money!”
“Only doctors from [insert your state here] can decide what’s right for patients from [repeat your state here].”

Same arguments, same misunderstanding of the process and purpose of guidelines. At the heart of Workers’ Compensation is a promise to provide reasonable and necessary medical treatment that expedites recovery and return-to-work. Why would anyone be opposed to treatment guidelines based on scientific studies distinguishing care that has proven to be helpful from that which has not? Why would stakeholders oppose a drug formulary designed to reduce opioid abuse in favor of better treatment options? Doesn’t the art of medicine go hand-in-hand with science? Still… some do, notwithstanding voluminous information supporting evidence-based medicine.

Evidence-Based Medicine in Workers' CompIn ODG’s case, decades of data show states adopting ODG treatment guidelines and formulary have substantially better outcomes relative to their sister states. Look first to 17 years of positive experience in Ohio, which adopted ODG treatment guidelines in 2003. Treatment delays decreased by seventy-seven percent (77%), accompanied by a sixty percent (60%) reduction in medical costs and a sixty-six percent (66%) decrease in lost days per claim.

Look to North Dakota, which adopted ODG guidelines in 2005. Already a high-performing system, the use of ODG rules resulted in “one of the largest direct cash infusions into North Dakota’s economy” according to the state’s House Majority Leader, Rick Berg. Since Texas adopted ODG guidelines in 2007 and the formulary in 2011, Lone Star stakeholders have seen premiums, medical costs, and lost time decrease by sixty-three percent (63%), thirty percent (30%), and thirty-four percent (34%), respectively. Other states implementing ODG since then saw similar results, prompting more recent adoptions in Indiana, Kentucky, and Montana. Independent research by both WCRI and NCCI confirms the positive impact of ODG’s evidence-based treatment guidelines and formulary. A list of states that have implemented ODG’s evidence-based treatment guidelines and formulary is available here.

So, in the age of COVID-19, what is the responsibility of state policymakers in ensuring injured workers are not subjected to snake oil, tobacco enemas, or their modern-day equivalents? Do we leave it to device-makers and drug manufacturers to lobby the bureaucracy? Do we shift the burden to practicing physicians and demand they analyze the countless studies produced each year, perhaps between Mr. Thibodeaux’s lumbago and Mrs. Leblanc’s torn rotator cuff? Do we gather a group of doctors in a smokeless room until they reach a consensus? But, of course, “consensus” is not the same as “evidence-based.” Rather, as Margaret Thatcher once said, it is “something in which no one believes and to which no one objects.”2

The better answer, of course, is medical treatment guidelines should be crafted by dedicated physician editors and supported by trained methodologists and data analysts. They should be created by unbiased medical experts with experience reviewing and analyzing complex scientific medical studies, doctors, and support staff who understand what makes one study more or less valuable than the next. Because employees and employers deserve medicine that is properly grounded in science, treatment guidelines should be created by experts like those at ODG.

And, as for Clark Stanley? After an investigation found no benefit from (and no snake in) his product, Mr. Stanley was charged in 1917 under the Pure Food and Drug Act for “misbranding” his product. He was fined twenty dollars, a whopping four hundred dollars in today’s money. Still, evidence-based analysis killed the demand for his product and ruined his business, protecting the public and leaving the Rattlesnake King to fade into obscurity.

Anybody know the CPT code for snake oil?

– Patrick F. Robinson, VP of Government Markets, ODG by MCG

This article was previously published in the October 2020 edition of Workplace Health Magazine.

Photo courtesy Shutterstock/Likoper


  1. Wanjek, C. (2011, September 6). Study Dumps Colon Cleansing as Useless and Dangerous. Retrieved from: https://www.livescience.com/15912-colon-cleansing-useless-dangerous.
  2. Colon, D., Workers Compensation and Prescription Drugs: 2016 Update, https://www.casact.org/education/annual/2016/presentations/C-34.pdf; Thumula, V., Liu, T., Impact of a Texas-Like Formulary in Other States, June 1, 2014, https://www.wcrinet.org/reports/impact-of-a-texas-like-formulary-in-other-states/

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