Case Scenario

One of my patients has been on disability for three years, but I wonder if she is well enough to work again. When I started working at this clinic site, I saw a then–37-year-old woman with a history of multiple symptoms including headache, fatigue, aching joints, dizziness and chest pain. Because of bouts of sinus tachycardia, she previously had an extensive cardiac work-up, including Holter monitoring, echocardiography and tilt test. The only positive finding was orthostasis on the tilt test; a mineralocorticoid had been prescribed. Her symptoms seemed temporarily improved. Another physician had prescribed a beta blocker for the tachycardia, which worsened her fatigue. The patient was placed on disability for sinus tachycardia and orthostasis; her physicians continued to fill out the forms. This task now falls on me.

The patient is alert and pleasant, has a healthy appearance and seems amenable to treatment suggestions. Although some of her problems correlate with physical evidence, many of them—such as sudden bilateral vision loss, which resolved with no objective findings—seem related to anxiety. I have discussed the psychiatric overlay of her symptoms, and she seems willing to accept my explanation even though she has taken antidepressants in the past without any discernible change. She continues to bring her disability forms to me and presents with new, often drastic symptoms, many of which are unrelated to the original diagnosis on her disability form.

Commentary

The frustration of the physician who wrote this case scenario is real, and many physicians experience this frustration in their practices. Physicians receive forms from various disability-granting agencies requesting information regarding the initiation or perpetuation of disability claims. The frustration is easily understood when put into proper context. Why should physicians feel comfortable making decisions about disability claims if they have neither the training nor the experience to determine level of disability for their patients?

To approach problems like this, it is important to understand the limitations of the role of a primary care physician. We typically find ourselves at the top of the decision-making chain in clinical medicine. Information flows to us so that we can make appropriate decisions about our patients. We use this information to make recommendations for therapy, future investigation or referral.

In the disability arena, a major shift occurs in the physician's role in the decision-making process. To be sure, all information flows to the top so that appropriate recommendations can be made and conclusions drawn. But in this instance, it is not the primary care physician who assumes the decision-making role but an administrator. The administrator may be an insurance agent, an administrative law judge or a member of a workers' compensation board. In this process, physicians contribute to decision-making only insofar as they provide data to the administrators. Thus, the physician functions in the same role as the radiologist, pathologist, subspecialist, social worker, nurse or other medical provider who usually gives information to the primary care physician so that recommendations can be made to the patient.

In disability cases, physicians must understand that they are in a position of providing information to a nameless person within a bureaucracy. Physicians have no other role or responsibility in the matter. Therefore, they should complete the forms honestly and assume no other role. When physicians understand that they are no longer at the top making final decisions, they should feel much more comfortable with their role in this process.

What can physicians do if they feel that disability is granted inappropriately, or that disability is denied when it should be granted? Unfortunately, there is little that they can do, because their role is merely one of providing information. Once the forms are filled out appropriately and honestly, it is up to the plaintiff, defense attorneys or patient-industry advocates to challenge the results within the system.

There are times when a physician may feel pressured, by a patient or a third party (such as an attorney), to complete forms showing a bias toward one party. This step should be avoided at all costs. First, it is dishonest. Second, it is unethical. Third, the physician may be held liable in court for providing deliberate misinformation. And, finally, someone always pays.

Let us say that an employee walking into work slips on ice in the parking lot and twists his back. The employee reports off work and sees his physician, who prescribes activity, heat, analgesics and a muscle relaxer. The patient is instructed to return for a follow-up visit in one week. At that appointment, the employee reports that the pain is only slightly better and that he is experiencing stiffness. The physician recommends continued activity and medication, and a return visit in another week. At that appointment, the patient's symptoms are similar. Continued time off work and physical therapy are ordered, and the injured worker files a workers' compensation claim. The employee returns two weeks later and states that he is feeling better but is still experiencing discomfort. Nevertheless, the physician advises him that he can return to work. Because it is a Wednesday, he requests to return to work the following Monday. The physician agrees just to keep him happy, but someone in the office where he works will have to cover for him. Remember, that could be your office and your money lost. Somebody always pays.

There is a tremendous amount of financial interest in the disability arena. An opposing attorney will likely question the results of any medical report. Matters may be opened or reinvestigated, and decisions changed based on the information provided by the physician. Once a decision is made, the physician can challenge it by writing a supplemental letter to the granting agency. Sometimes these letters are ignored, but sometimes they are taken into consideration. Nevertheless, there is really nothing more that the physician, as an interested or a disinterested party, can do. Again, the important message here is that the physician is part of the process but is not the decision maker.

This type of problem comes up frequently when physicians are asked to complete Social Security disability forms. Most claims are disposed of by a bureaucrat (favorably or unfavorably for the patient) based solely on information provided by the physician on a medical evidence of record. This record consists of the report and documents that the treating physician supplies to the Social Security Administration (SSA). Once these results are received by the SSA, the patient may challenge them, which will require further documentation or examination. This may take the form of an independent medical examination performed by a physician hired by the SSA to provide additional information.

Again, proper training is necessary for a physician to feel comfortable in this role. Training is now being provided within the disability arena by several organizations, including the American Academy of Disability Evaluating Physicians; SEAK, Inc., Legal and Medical Information Systems; the American College of Occupational and Environmental Medicine, and various committees within medical and surgical subspecialties. Training should be considered if a physician continues to feel uncomfortable in the process. Training is necessary for physicians who have a particular interest in the disability arena and wish to participate in the decision-making process as an independent medical evaluator. In fact, several states now mandate training for physicians who evaluate workers' compensation claims.