Disability Request on Initial Visit

[prominence]

How do attending psychiatrists out there in SDN land handle the patient who requests an excuse note from work for a few days/weeks or disability paperwork on the very first visit (without access to previous psychiatric treatment/hospital records or other collateral information readily available)?

I'd love to hear some opinions on others' policy on this matter.

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[michaelrack]

How do attending psychiatrists out there in SDN land handle the patient who requests an excuse note from work for a few days/weeks or disability paperwork on the very first visit (without access to previous psychiatric treatment/hospital records or other collateral information readily available)?

I'd love to hear some opinions on others' policy on this matter.

disability paperwork: "No."

brief note excusing from work: might do this, especially if patient or public safety involved (suicidal truck driver having thoughts of running truck of road; cop with bipolar becoming increasingly reckless, etc). Even if safety not involved, it's probably reasonable to right a note for a few days while you further evaluate the patient.

 

[whopper]

Another issue I was taught in fellowship that was barely touched in residency.
Disability evaluations from treating physicians are a sticky issue.

If you advocate for something against the patient's wishes, it can seriously hurt the therapeutic relationship. For that reason, several are of the opinion that treating physicians shouldn't be doing disability evaluations because of the apparent conflict of interest.

In many situations, you really can't assess a person's ability to work or not in an office setting. Think about it. For example, let's say you have someone who says he has panic disorder, and you never saw the person have an actual panic attack while he was ever in your presence. How can you tell with certainty if this person really has that disorder? You can't. The nature of the office visit does not allow for the level of assessment where you can put the level of observation needed into a "real" disability evaluation.

Then there's the other type of evaluation where they ask if you believe the person can do their job. In most of those cases, you don't know what the job entails. For example, if the person was a truck driver, you have no expertise to evaluate their ability to drive. If someone's a surgeon, do you have the ability to gauge their skill as a surgeon?

If you do a disability evaluation, it should be to the degree where it meets reasonable medical certainty, that is the likelihood is more than not. In some cases, despite the lack of expertise, you will have enough to make a statement. In other cases, you will not.

Freely state your limitations.

e.g. in the panic disorder case, if it were going to Court, you should clearly state the conflict of interest, tell the Court that the evaluation may be better handled by a neutral physician that does not have a doctor/patient relationship, and that you can only go on what the patient told you. Also state that malingering testing is not a usual part of treatment.

In a letter to the workplace, do a similar route. Clearly state that you could only go on what the person told you. If the person gave you a presentation that is consistent with panic disorder, then state so, but also state your limitations, and that it is beyond your scope of practice to tail your patient 24/7 to witness an actual panic attack.

 

[prominence]

If you do a disability evaluation, it should be to the degree where it meets reasonable medical certainty, that is the likelihood is more than not. In some cases, despite the lack of expertise, you will have enough to make a statement. In other cases, you will not.

thanks for the replies guys.

whopper, i don't know if this is semantics, but i was referring more specifically to the 1 or 2 page temporary short-term disability paperwork forms (which sometimes feel subjective to me) that a pt's employer requires for short-term disability/medical leave of absence, which asks for the outpatient attending psychiatrist's professional opinion/judgment on specific questions regarding the limitations of the psychiatric dx rather than a more thorough disability evaluation.

whopper, how do you handle these forms when an outpatient requests you complete them on the first visit? do you defer or do you cite in all you answers on the form, "as per pt's self report"?

 

[OldPsychDoc]

Where I (all too) often find this getting sticky is when the patient claims symptoms which are triggered by a "hostile work environment". Of course, said hostility of co-workers and supervisors is often exacerbated by the patient's obsessive, or negativistic, or passive-aggressive, or outright antisocial presentation in the workplace...and nine times out of ten, it is a company or governmental department facing major economic stressors which further sap employee morale.

I can't tell the patient "stay home until the economy improves or you find a new job", but that seems to be what they want.

 

[Suedehead]

this is an excellent topic. we receive so little training on such practicals.

I'm curious about different approaches to the question of approving disability generally, not just on the first visit.

more often than not, I'm getting this on the 3rd or 4th visit. i still don't feel i know the pt enough to make this sort of call.....

 

[jettavr6]

First visit -- no way. Very difficult, if not impossible to fully evaluate a patient.

 

[prominence]

I have heard of private practice psychiatrists explicitly stating to patients before the first visit that they will not complete any disability paperwork, though they will glad comply with forwarding the pt's psychiatric records to the appropriate employer or other bureau.

Can psychiatrists legally do that in outpatient practice?

 

[whopper]

I can't tell the patient "stay home until the economy improves or you find a new job", but that seems to be what they want.

That could be outright malingering, or a misinterpretation by the patient of what is vs what is not allowed or within our capabilities or the rule of law.

Several have a misinterpretation that just because they may have a condition, that gives them free reign to get days off from work.

As for hostile work environments, they exist, but a psychiatrist in typical clinical practice can't evaluate for it. What's he going to do? Go to the workplace and be there 9-5 for 1 week to assess the hostility? Get real. No way.

Some forensic psychiatrists do this. It involves more than just the person claiming the workplace is hostile. It also involves expertise and training on just what is a hostile workplace. In several of these cases a forensic psychologist may be better suited because the industrial behavioral sciences are often not taught AT ALL in a psychiatric curriculum. They are taught in psychological curriculum, but often only on an elective basis, though some psychologists specialize in this area.

I also have the problem of seeing several doctors write for disability when in fact they did not do a "real" assessment. I've seen cases where one person gets it from a doctor, then tells all his friends about this doctor that'll give anyone disability.

The few times I've written and advocated for disability when it was my own patient (and not a case where I was a neutral evaluating doctor) were cases where the person had a case manager that was able to meet with the person several times a week. In several of those situations, the case manager witnessed the person having the actual signs that might prevent them from working. Either that or they were in inpatient or group home and there were very good records showing what was going on with that patient from round the clock observation.

Otherwise, I typically tell a patient that I cannot give such a letter, write to the Court that the Court needs to appoint a neutral doctor to evaluate, and I will only do such an evaluation if Court-ordered. Otherwise I'll have to write a letter that is chock full of limitations as I've written above.

There's more I'll write about this but I got to go to work!

 

[Suedehead]

Otherwise, I typically tell a patient that I cannot give such a letter, write to the Court that the Court needs to appoint a neutral doctor to evaluate, and I will only do such an evaluation if Court-ordered. Otherwise I'll have to write a letter that is chock full of limitations as I've written above.

!

Is this a viable option? is this an avenue the pts can take, that the court an appoint a neutral doctor to assess for disability, etc?

I was under the impression that it was my responsibility to determine disability for a mental disorder, that without my signature, the pt was un-disableable.

I'd love this off my back. I'd love a strong and informed position regarding disability, I just don't really know the system well enough.... yet....

 

[whopper]

Is this a viable option? is this an avenue the pts can take, that the court an appoint a neutral doctor to assess for disability, etc?

Yes it is but not in all areas. It actually is standard care in many areas that have evolved to the point where the Courts are educated on this issue.

I was under the impression that it was my responsibility to determine disability for a mental disorder, that without my signature, the pt was un-disableable.

At the most, you can only assess what you can assess. As I mentioned above, there are several avenues where you CANNOT give an assessment/opinion/evaluation such as determining one's ability to drive. Inability to drive is something that would be a factor in disability.

If you are in a situation where you absolutely must do the disability evaluation such as being court ordered, then fine, do it, but also mention that you have several limitations, and that other professionals may have to determine what you could not.

I'd love this off my back. I'd love a strong and informed position regarding disability, I just don't really know the system well enough.... yet....

That's why some people go into forensic fellowship. I'm not saying you should do that, but at least be buddies with one who is that can guide you.

Here's a sample letter...
(Mind you these would be rough drafts. In real life I would triple check them, and the final product would be much more concise and without spelling errors.)

To whom it may concern,

You requested that I give my medical opinion concerning Mr. X's ability to work. He is a bus driver, so most of my opinion would have to be based on his ability to drive a bus.

I regret to inform you that I have no expertise in evaluating Mr. X's ability to drive. There is no education in any known medical school or residency curriculum where a medical doctor is educated on the assessing one's ability to drive a vehicle. My ability to ascertain his fitness to drive a vehicle is no better than a layman's and therefore I cannot render an expert opinion on this area.

I am a member of the American Psychiatric Association (APA) and that organization plays a large and highly respected role in defining the standards of care within my profession. The APA has stated that it is not within the role of a psychiatrist to be able to determine one's safety to drive a car. Further, if a person is being treated with a psychotropic medication, it is not a psychiatrist's role to determine how that medicaiton may adversely affect that person's ability to drive. We are recommended to inform our patients of the side effects of the medications including ones that may affect the ability to drive, but from there, it is up to the patient to determine for themselves if they can drive.

If you need further assistance in determining Mr. X's ability to drive, I respectfully and humbly recommend you have him assessed by a professional qualified to do so such as someone from the department of motor vehicles.

Respectfully,

Here's another sample letter...

To whom it may concern,

The Court requested that I render a medical opinion regarding if Ms. X's panic disorder renders her eligible for disability. I regret to inform you that while I can offer an opinion, it is severely limited by several factors.

I am Ms. X's treating physician. I have a bias to advocate for her. This may have at the very least unconciously affected my opinion. It would be better for a doctor without a doctor-patient relationship to evaluate her and render an opinion.

My opinion is limited to only what Ms. X has told me and what I see in interviews that usually last only up to 30 minutes. During those interviews, I have never actually witnessed signs of the mental disorder I believe Ms. X. has. Several patients with her disorder often times only present with panic attacks at random times that likely would not be during a visit with their treating psychiatrist.

Ms. X's stated symptoms are consistent with someone with panic disorder. She told me they are to the degree where they do cause disability because she cannot focus at work out of fear of her next panic attack. While my opinion is within a reasonable degree of medical certainty, I remind the Court that my opinion is merely more likely than not true. It is more likely than not that people would not fake symptoms to their doctor and ask for treatment. I cannot verify with any higher degree of certainty if she indeed meets the requirements for disability, and this would be outside the scope of my practice. It is not within my responsibility or practice scope to forensically evaluate my patients.

In a typical forensic evaluation of someone with Ms. X's disorder, a doctor would typically interview coworkers, friends, and family of Ms. X. If possible the forensic evaluator may also follow her at work to see her symptoms in a community setting.

I respectfully recommend that a forensic psychiatric or psychological evaluator may be better suited to for the task of determining Ms. X's eligibility for disability.

Respecfully

 

[michaelrack]

I regret to inform you that I have no expertise in evaluating Mr. X's ability to drive. There is no education in any known medical school or residency curriculum where a medical doctor is educated on the assessing one's ability to drive a vehicle. My ability to ascertain his fitness to drive a vehicle is no better than a layman's and therefore I cannot render an expert opinion on this area.

I am a member of the American Psychiatric Association (APA) and that organization plays a large and highly respected role in defining the standards of care within my profession. The APA has stated that it is not within the role of a psychiatrist to be able to determine one's safety to drive a car. Further, if a person is being treated with a psychotropic medication, it is not a psychiatrist's role to determine how that medicaiton may adversely affect that person's ability to drive. We are recommended to inform our patients of the side effects of the medications including ones that may affect the ability to drive, but from there, it is up to the patient to determine for themselves if they can drive.

I didn't know that the APA states that it is not the role of a psychiatrist to determine safety to drive a car. I disagree with you that "There is no education in any known medical school or residency curriculum where a medical doctor is educated on the assessing one's ability to drive a vehicle." There is some medical literature on dementia and driving, including assessing dementia patient's ability to drive. Driving ability decreases along with cognitive decline. I am not sure of the details of the assessment, but I am confident that some primary care and psychiatry residents learn how to use mental status testing as well as historical information (asking the family about the patient's functioning) to assess the dementia patient's ability to drive.

Of course, this assessment usually is not part of a formal legal proceding

 

[michaelrack]

A further note about driving: Doctors of various specialties are expected to assess commercial drivers and give or deny clearance for medical problems within their specialty area.

 

[whopper]

My statement was based on a few cases a few years ago where I was specifically asked to assess a patient's ability to drive.

I went to the APA website and found the APA's policy on assessing one's ability to drive in those cases. I printed out the APA's stance and mailed it to those who made the requests. My post above reflected what the APA's statement.

Now that said, this was a few years ago, and memory can play tricks on you. So I went to the APA website again to look for the statement. I can't find it right now, and I am looking for it.

In my search, however, I did find this which is from the APA and in tune with my previous statements....

http://www.psychiatryonline.com/content.aspx?aID=152357&searchStr=automobile+driving#152357

In an office or hospital setting, accurate assessment of functional abilities such as driving is not possible (55). Furthermore, the influence of neuropsychiatric impairments or behavioral symptoms on driving performance is neither clear-cut nor predictive (56, 57). However, risks of driving should be discussed with all patients with dementia and their families, and these discussions should be carefully documented.

Further, the AMA has it's own guidelines on assessing one's ability to drive. The AMA's guidelines are outside the scope of usual psychiatric practice and involve assessing one's vision among other functions that are not within the expertise of the psychiatrist.

Jeff Metzner, M.D. is one of the nations leading if not top experts on psychiatric disorders and fitness to drive. Based on a presentation he gave in 2009, much of our knowledge of psychiatry and driving is limited at best. One of the only real findings made was that benzos could significantly impair one's ability to drive which is not surprising given that works in the brain in a similar manner to alcohol.

http://www.fmcsa.dot.gov/rules-regu...el-Psychiatric-Psychiatric-MEP-Panel-Opin.pdf

 

[whopper]

Aha....

Found it...

http://www.psych.org/Departments/ED...entsandRelated/PositionStatements/199304.aspx

The Role of the Psychiatrist in Assessing Driving Ability
POSITION STATEMENT

Approved by the Board of Trustees, December 1993
Approved by the Assembly, November 1993

"Policy documents are approved by the APA Assembly and Board of Trustees… These are …position statements that define APA official policy on specific subjects…" -- APA Operations Manual.
The presence of a mental disorder per se does not imply impaired driving capacity. Nonetheless, persons suffering from mental disorders may experience symptoms that can interfere with their ability to operate motor vehicles safely. Accurate assessment of the impact of symptoms on functional abilities usually is not possible in an office or hospital setting because such an assessment typically requires specialized equipment or observation of actual driving, which goes well beyond the scope of ordinary psychiatric care. Moreover, psychiatrists have no special expertise in assessing the ability of their patients to drive. Thus, psychiatrists should not be expected to make such assessments in the usual course of clinical practice.

Psychiatrists do, however, have a role to play in advising patients about the potential impact of their illnesses and treatments on driving ability:

1. When appropriate, psychiatrists should discuss with their patients symptoms of their mental disorders that may be serious enough to substantially impair their driving ability.

2. Psychiatrists should warn their patients about the possible effects of prescribed psychotropic medications on alertness and coordination and about the possibility that such medications could potentiate the effects of alcohol.

3. When clinically appropriate, medication with a low potential to impair driving ability should be chosen preferentially, depending on the patient's driving requirements and habits.

Given the importance of maintaining confidentiality in psychiatrist-patient relationships, psychiatrists should not be required to report information on patients' driving ability to state departments of motor vehicles (DMVs). However, a statute that allows, but does not require, reporting when there is clear-cut evidence of substantial driving impairment (e.g., a family's statement that a moderately demented patient has had several recent minor accidents) is socially desirable and can be clinically useful. Ultimate responsibility for assessment of patients' driving ability should lie with DMVs. Reports made in good faith should be accompanied by immunity for psychiatrists from subsequent liability.
__________
This statement was drafted by the Council on Aging whose members are: Burton V. Reifler, M.D. (chairperson), Gabe Joseph Maletta, M.D., Ph.D. (vice-chairperson), Dilip V. Jeste, M.D., Marion Zucker Goldstein, M.D., Gene David Cohen, M.D.*, Rena Magno Nora, M.D., F.M. Baker, M.D., M.P.H. (observer-consultant), Christopher C. Colenda III, M.D.*, Jeffrey R. Foster, M.D.*, Gary J. Kennedy, M.D.*, Donald Peter Hay, M.D.*, Judith H.W. Crossett, M.D.*, Kenneth Mark Sakauye, M.D.*, Yeates Conwell, Jr., M.D.*, Jean Pierre Loebel, M.D. (consultant), Thomas Elliot Oxman, M.D. (consultant), Ian R. Cameron, M.D.*, Barry W. Rovner, M.D.*, Robert J. McDevitt, M.D. (Board liaison), Joesph Esra V. Rubin, M.D. (Assembly liaison), Eric D. Caine, M.D. (consultant), and Gary Lloyd Gottlieb, M.D. (consultant and liaison to the American Association of Geriatric Psychiatry).
(*=corresponding member.)

Just a snippet from the above...


Ultimate responsibility for assessment of patients' driving ability should lie with DMVs.

That said, in Canada, their medical associations have more clear cut guidelines that put the doctor with more responsibility.

I, however, do not live in Canada. Given that driving and a mental disorder is a medicolegal issue, I will follow the American law and guidelines, not the Canadian ones.

 

[whopper]

There is some medical literature on dementia and driving, including assessing dementia patient's ability to drive. Driving ability decreases along with cognitive decline. I am not sure of the details of the assessment, but I am confident that some primary care and psychiatry residents learn how to use mental status testing as well as historical information (asking the family about the patient's functioning) to assess the dementia patient's ability to drive.

Yes there is.

The problem, however, is that this is a medical/legal issue and the legal complexities are enormous.

The specific details of how to assess one's ability to drive given certain medical conditions were made by the AMA. Again, as I mentioned above, much of it is outside the scope of a psychiatrist in usual clinical practice, and the APA does not advise us to be the final decider.

Another issue with dementia is, assume we actually did have a responsibility and the law clearly stated we have expertise to do a driving assessment. Fine.

The person's fine to drive now. How about 3 weeks later? 3 months later? We don't know. When you stamped on your letter that the person was fine at that moment, it's not going to have much relevance in the immediate and near future.

Due to that conundrum, I am more than happy that the APA states I'm not where the buck stops.

I have heard several lecturers declaring that if you're a psychiatrist in this situation, a neurologist should be the one in charge and you should refer to the neurologist.. That IMHO is more appropriate with the AMAs guidelines on assessing driving. That said, however, I don't see any official documentation that backs the claims I heard.

 

[Shikima]

Why not punt it back to primary care and have them consult you back if there is something psychiatric needed?

Just watch your documenting....

 

[Therapist4Chnge]

There is some medical literature on dementia and driving, including assessing dementia patient's ability to drive. Driving ability decreases along with cognitive decline. I am not sure of the details of the assessment, but I am confident that some primary care and psychiatry residents learn how to use mental status testing as well as historical information (asking the family about the patient's functioning) to assess the dementia patient's ability to drive.

Of course, this assessment usually is not part of a formal legal proceding

Neuropsychologists often get referred these cases for evaluation. I've done them for driving, financial decision making, capacity, etc. Assessments for disability can be a bit dicier, though I've had more than my share of, "I can't work and need disability" folks who were trying to work the system. Malingering assessments are always an entertaining experience with the ICWaND folks.

 

[kugel]

Neuropsychologists often get referred these cases for evaluation. I've done them for driving, financial decision making, capacity, etc. Assessments for disability can be a bit dicier, though I've had more than my share of, "I can't work and need disability" folks who were trying to work the system. Malingering assessments are always an entertaining experience with the ICWaND folks.

Any thoughts on one can get a neuropsych consult for a patient on Medicaid? I haven't found any avenue for this. I'm certainly not suggesting neuropsychologists should be doing this for free, I really just don't know how to get the ball rolling. There must be some way, huh?

For inpatients, I can sometimes get Physical Therapy / Occupational Therapy to evaluate specific functions related to job performance or driving.

For students/residents, if you have not already done so, ask the PT and OT depts to each give a lecture on what their therapists can do, how best to utilize them, and how to properly consult them on some of the less-well-known aspects of their professions. Fascinating stuff, and enormously useful.

 

[Psychiatrypd]

If they are too sick to go to work, then they are too sick to stay home and do nothing. They will just get worse. If they are too sick to go to work, then they need to be in a day treatment program , also known as partial hospitalization. I give them a day off and then refer them to day treatment and tell them that the day treatment facility will fill out further work notes. In general, being sick is not a free pass to stay home and do nothing. People who are really seriously symptomatic will get worse and worse if they stay home and ruminate. If day treatment is not available in your area, then make up a treatment plan with the patient that involves part time work, daily exercise, seeing a therapist weekly, attending support groups, going to the public library to use their computers to access information about their condition, etc. If the person has severe schizophrenia, then it is a different matter. If they hear the voice of God talking to them through a transmitter in their teeth, then just put them on disability. I do not write people off work for more than two weeks at a time. They have to keep appointments and really work at their recovery.

 

[Therapist4Chnge]

Any thoughts on one can get a neuropsych consult for a patient on Medicaid? I haven't found any avenue for this. I'm certainly not suggesting neuropsychologists should be doing this for free, I really just don't know how to get the ball rolling. There must be some way, huh?

For inpatients, I can sometimes get Physical Therapy / Occupational Therapy to evaluate specific functions related to job performance or driving.

My neuro work has been limited to the VA system and private pay, so I haven't looked much into Medicaid billing. I do know that it is a pretty prevalent problem because many/most boarded neuropsychologists won't take Medicaid and many don't take insurance.

For students/residents, if you have not already done so, ask the PT and OT depts to each give a lecture on what their therapists can do, how best to utilize them, and how to properly consult them on some of the less-well-known aspects of their professions. Fascinating stuff, and enormously useful.

OT and PT people are definitely great resources, though I admittedly didn't know much of what they did until I had a random conversation with a social worker about their scope of work. We were somewhat limited in what kind of consults we could submit because of limited resources, but they definitely helped out a number of my patients.

*cut for length*

I do not write people off work for more than two weeks at a time. They have to keep appointments and really work at their recovery.

I wish more providers took your approach. I can't tell you how many consults I've had where it is very evident that they can still work doing *something*.

 

[whopper]

Any thoughts on one can get a neuropsych consult for a patient on Medicaid?

Neuropsychologists are hard to find. At the state forensic hospital, we have several cases that should be seen by such a doctor, and there is none we have a hold of to provide such services.

We actually did have one here 2 years ago, and IMHO a not so wise decision the hospital did was to flood her with work outside her usual field. She left in a hurry after that. IMHO what they should've done was not give her any work except for the neuropsychology stuff becuase that alone had her swamped.

Hey, if you got a golden goose, you buttkiss it, not haze it. But hey, that's just my opinion.

Getting to the original question....
---> My advice is look for neuropsychologists at the VA first. The VA has a need for them because several soldiers experience traumatic brain injury and these days survive. Decades ago, such soldiers were often dead, but thanks to the advancements in medical technology and battlefield medicine, these soldiers can now live. Unfortunately, they're now in a situation where they need extensive neuropsychological and psychiatric treatment and not getting any because there is hardly any available.

If they are too sick to go to work, then they are too sick to stay home and do nothing. They will just get worse.

Agree. If you've studied disability psychiatry, a large percentage that are on disability for just a few months never get off. That figure skyrockets highly elevated after 1 year. Unfortunately, my notes from forensic fellowship are in a different office, but the rates are horrendously high. A large number of those on disability from my own anectdotal experience can work but refuse to do so because they feel they've reached a type of privelidge club being on disability. The problem though is not working for too long, when you are capable of doing so is not mentally healthy and it can actually worsen depression.

So you got a person who is depressed becaues they are not working, but they refuse to work when you bring it up. This is not every disability person, and I have had a fair share of people on disbality that I knew truly needed to be on it.

It's funny because despite what I wrote above, that doctors should clearly state their limitations, I know plenty that blatantly and quite incorrectly state patients need disability. Unfortunately, market several incentives actually promote such behavior. Then the judge, not having any medical training completely believes the doctor. Then you have a situation where dozens if not even hundreds in the community get it that do not need it.

Then you got a situation just a few blocks away where someone truly needs to be on it, but they can't get it because they don't know the right doctor that'll write for it.

 

[nancysinatra]

As for hostile work environments, they exist, but a psychiatrist in typical clinical practice can't evaluate for it.

Ob/Gyn clerkship, anyone??

 

[nancysinatra]

I didn't know that the APA states that it is not the role of a psychiatrist to determine safety to drive a car. I disagree with you that "There is no education in any known medical school or residency curriculum where a medical doctor is educated on the assessing one's ability to drive a vehicle." There is some medical literature on dementia and driving, including assessing dementia patient's ability to drive. Driving ability decreases along with cognitive decline. I am not sure of the details of the assessment, but I am confident that some primary care and psychiatry residents learn how to use mental status testing as well as historical information (asking the family about the patient's functioning) to assess the dementia patient's ability to drive.

Of course, this assessment usually is not part of a formal legal proceding

People with seizures can't drive--not until they are seizure free for six months. And come on, people can't drive if they are drunk or blind or completely paralyzed. Plus we TELL people they can't drive home right after surgeries. So it's NOT true that there is "no known medical school" that doesn't assess driving ability in any way whatsoEVER. The real thing here is not driving--it is malingering disability. (Whereas I bet if a patient were saying, "my auditory hallucinations tell me to run the car off the road"--you wouldn't hesitate for a second to say that person shouldn't be driving.)

Now here is a question: Should people with pseudoseizures be prevented from driving???

 

[whopper]

People with seizures can't drive--not until they are seizure free for six months. And come on, people can't drive if they are drunk or blind or completely paralyzed.

True, but I'm talking about this from a legal definiton of the word "expert" point of view. The things you mentioned with the exception of the seizres are in a "reasonable man" standard, not an "expert" standard. A seizure and one's ability to drive is outside psychiatry's legal scope and should be handled by a neurologist. Driving laws concerning seizures also vary by state.

Anyone can tell a blind person he cannot drive. You don't need a medical doctor for that. Nor is there a course requirement in medical school for that.

If you state something to your patient as a medical doctor using your medical expertise, then you can be held liable for that statement. In the area of one's ability to drive, this is very serious because of several factors including 1) Driving is not a right, it is a priviledge that can be taken away by the government 2) As a medical expert, you can be held liable if you tell your patient he can drive and then he crashes into someone. Whatever negative outcomes from that accident can be on you. Given that the AMA criteria for assessing one's ability to drive is outside the scope of psychiatry, and given that the APA does not recommend we assessment's one one's ability to drive....
Do so at your own peril. I don't recommend it. I'd have a cake walk convincing a judge and jury (rightfully so IMHO given that the guidelines are clearly laid out in print from the APA and AMA) about what our place is in assessing one's ability to drive....and our place is clearly laid out as not being being able to perform this assessment.

Now here is a question: Should people with pseudoseizures be prevented from driving???

The more PC term for pseudoseizures is psychogenic nonepileptic seizures. Personally, I find that definition a load of bull. Why? It's not because of PC. I do think on occasion the PC term more correctly describes a subject. No, it's because in a pseudoseizure, the person is not having a seizure. So to call it a nonepileptic seizure, when in fact it's not even a seizure to begin with is misleading.

So the critics of the term pseudoseizure complain that the root "pseudo" implies the person is lying, so therefore it's a bad term. Let's use the new term that by the way calls the phenomenon a seizure when it is not a seizure, but just happens to look like one?

From the merriam webster's dictionary

Main Entry: sei·zure
Pronunciation: \ˈsē-zhər\
Function: noun
1 : a sudden attack (as of disease) ; especially : the physical manifestations (as convulsions, sensory disturbances, or loss of consciousness) resulting from abnormal electrical discharges in the brain (as in epilepsy)
2 : an abnormal electrical discharge in the brain

A seizure is an abnormal electrical discharge in the brain. In pseudoseizures, the person is not having an abnormal electrical discharge. So to call it a nonepileptic "abnormal electrical discharge" when there is none...WTF?

Hmm, I think I'm going to start calling fake Rolex watches...."Inexpensive Rolex watches." Or perhaps a wedding ring encrusted with a cubic zirconium a "non carbon formed diamond wedding ring."

Sorry for the digression. I'm going to call it pseudoseizure because no matter what I call it, I can't pick a term that people will accept. I apologize to those that find it rude and barbaric to call it such, but IMHO calling it the other creates it's own set of PC problems too.

Pseudoseizures have not been ruled in or out as being intentional. Some theorize it's a form of conversion disorder or another disorder with several parallels to conversion disorder. Others believe it is completely and intentionally fabricated by the patient.

The jury's still out. No one has been able to figure this one out yet. So it's hard to decide whether or not someone with the disorder should drive.

 

[billypilgrim37]

A seizure and one's ability to drive is outside psychiatry's legal scope and should be handled by a neurologist. Driving laws concerning seizures also vary by state.

I'm pretty sure in the states I've been in that the above was mandatory for all physicians, not just neurologists. And in one of those states, any unexplained LOC, not just a seizure, was grounds for six months of no driving. In one state, this required the physician to send a letter to the DMV, the other not.

 

[erg923]

I didn't know that the APA states that it is not the role of a psychiatrist to determine safety to drive a car. I disagree with you that "There is no education in any known medical school or residency curriculum where a medical doctor is educated on the assessing one's ability to drive a vehicle." There is some medical literature on dementia and driving, including assessing dementia patient's ability to drive. Driving ability decreases along with cognitive decline. I am not sure of the details of the assessment, but I am confident that some primary care and psychiatry residents learn how to use mental status testing as well as historical information (asking the family about the patient's functioning) to assess the dementia patient's ability to drive. v

I know I am late here, but a mental status exam to determine driving safety/ability...get real! Sure, if your MMSE is 10 you should def NOT be driving, but what about 21, 22, 23? What studies exist on the (ecological) validity of a MMSE (or similar mental status exam) to driving? I know that the Trail Making Test has been found to correlate with driving ability, but as far as I am aware, most other tests are not correlated with it all. The ones that are are usually complex attention tests, such as trail making. Thus, if most of our more robust npsych tests and batteries have poor ecological validity for this ability, I cant imagine that mental status screening test would...

Unless grossly impaired, I would not feel comfortable taking this privledge away from a patient unless I was able to utilize tools expresed designed for making that determination in cognitively compromised patients such as the Useful Field of View Test; SMCTests; or the NorSDSA.

Some degree of cognitive decline does not automatically equate to bad driving, as strange at they may sound I know.

 

[whopper]

I'm pretty sure in the states I've been in that the above was mandatory for all physicians, not just neurologists.

Be very very careful. This is not a criticism of you, this is a criticism of any doctor that may have mislead you. Of course since I haven't read all the laws concerning this issue in the state's you've been in, you and those doctors could have been right.

Several doctors talk of what is and what is not legal as if they literally mean it when in fact it is anectdotal and wrong.

If someone told you a state wants to make a law specifically stating that a psychiatrist can assess one's ability to drive in clear and utter defiance with what the leading and most highly respected professional society who has more experience and expertise in the matter than the state legislature, that seriously begs the question that someone's claim of the law is not accurate.

While I was in residency, doctors often made comments, "Yeah James, Neurontin treats bipolar disorder." Does it? No double blinded placebo controlled study says is does. As we all know, several doctors do not practice evidenced-based medicine. Psychiatrists that give out Neurontin to treat bipolar disorder are a dime a dozen. As we all know, several doctors make anectdotal claims that are not true when you actually check them out.

The good ones are the ones that specifically state if their claims are evidenced-based or not, vs. if it's anectdotal

During my own journey to understanding the law and psychiatry, I never really felt I got the proper training until I received training in fellowship. Several times doctors I've worked with never actually read the laws, but commented on the legal specifics of several psychiatric issues. As I learned more and more, I figured out they never even really read the laws, and had they actually read them, their own notions would've been different.

Even if that law is true, you do not have to follow the law. I'm not advocating breaking it, I'm advocating you do not have to practice something the state law says you can do. The law says I can wear a pink bra in public, but I choose to not do something the law allows me to do. Again, do not break the law, but do not simply do something because the law says you can do it. I can hardly imagine any laws spefically demanding that YOU HAVE TO DO A DRIVING ASSESSMENT. If such a law actually existed saying doctors can do a driving assessment, it is likely saying only that, that you can do it, not that you have to do it.

A doctor can refuse to perform a procedure if he/she believes it is unethical but under the context that he/she explain what is going on to the patient and what alternatives the patient has.

If such a law actually existed that said psychiatrists could do a driving assessment, even though several professional sources state otherwise, I'd simply decline the assessment saying that operating on merely the premise that the law said I could do it, without considering the evidenced based data and professional standards would be to perform care which would be considered below the standard.

I personally wouldn't believe it until I saw it in writing. As I posted above, I provided in writing the APA's position on a psychiatrist's ability do assess someone to drive.

In one state, this required the physician to send a letter to the DMV, the other not.

This is something I've seen as well, in fact I've even seen it as a USMLE question. In this type of case, you are merely following the law--alerting the DMV who according to the APA are supposed to have the final say on assessing one's ability to drive. If the state says you have to report someone for losing consciousness, so be it. It is not asking you to assess their ability to drive.

I know I am late here, but a mental status exam to determine driving safety/ability...get real!

I provided a link above from someone who is arguable the country's leading psychiatric expert on driving and psychiatric disorder, and he said clearly that we psychiatrists don't know much in terms of assessing one's ability to drive.

If you feel that you can assess one's ability to drive, kindly leave me your business card, and I'll have someone hand out flyers outside your office telling your patients that if they get into a car accident after they were told by a psychiatrist they were fit to drive to give me a call!

I hate to sound like an ambulance chaser, but I have no ethical problems making someone practicing in clear violation of professional standards and the standard of care to the degree where someone was harmed known to the public.

 

[kugel]

Be very very careful. This is not a criticism of you, this is a criticism of any doctor that may have mislead you. Of course since I haven't read all the laws concerning this issue in the state's you've been in, you and those doctors could have been right.

Several doctors talk of what is and what is not legal as if they literally mean it when in fact it is anectdotal and wrong.

In California, "Every physician and surgeon shall report immediately to the local health officer in writing, the name, date of birth, and
address of every patient at least 14 years of age or older whom the physician and surgeon has diagnosed as having a case of a disorder characterized by lapses of consciousness."

That IS the law here. (details below, so you can read it for yourself)
Check with your facility (or malpractice company) Risk Management Lawyer for what the laws are where you practice and how you are expected to comply with those laws.
I'm calling our Risk Management lawyer in the morning.




HEALTH AND SAFETY CODE
SECTION 103900

103900. (a) Every physician and surgeon shall report immediately to
the local health officer in writing, the name, date of birth, and
address of every patient at least 14 years of age or older whom the
physician and surgeon has diagnosed as having a case of a disorder
characterized by lapses of consciousness. However, if a physician and
surgeon reasonably and in good faith believes that the reporting of
a patient will serve the public interest, he or she may report a
patient's condition even if it may not be required under the
department's definition of disorders characterized by lapses of
consciousness pursuant to subdivision (d).
(b) The local health officer shall report in writing to the
Department of Motor Vehicles the name, age, and address, of every
person reported to it as a case of a disorder characterized by lapses
of consciousness.
(c) These reports shall be for the information of the Department
of Motor Vehicles in enforcing the Vehicle Code, and shall be kept
confidential and used solely for the purpose of determining the
eligibility of any person to operate a motor vehicle on the highways
of this state.
(d) The department, in cooperation with the Department of Motor
Vehicles, shall define disorders characterized by lapses of
consciousness based upon existing clinical standards for that
definition for purposes of this section and shall include Alzheimer's
disease and those related disorders that are severe enough to be
likely to impair a person's ability to operate a motor vehicle in the
definition. The department, in cooperation with the Department of
Motor Vehicles, shall list those circumstances that shall not require
reporting pursuant to subdivision (a) because the patient is unable
to ever operate a motor vehicle or is otherwise unlikely to represent
a danger that requires reporting. The department shall consult with
professional medical organizations whose members have specific
expertise in the diagnosis and treatment of those disorders in the
development of the definition of what constitutes a disorder
characterized by lapses of consciousness as well as definitions of
functional severity to guide reporting so that diagnosed cases
reported pursuant to this section are only those where there is
reason to believe that the patients' conditions are likely to impair
their ability to operate a motor vehicle. The department shall
complete the definition on or before January 1, 1992.
(e) The Department of Motor Vehicles shall, in consultation with
the professional medical organizations specified in subdivision (d),
develop guidelines designed to enhance the monitoring of patients
affected with disorders specified in this section in order to assist
with the patients' compliance with restrictions imposed by the
Department of Motor Vehicles on the patients' licenses to operate a
motor vehicle. The guidelines shall be completed on or before January
1, 1992.
(f) A physician and surgeon who reports a patient diagnosed as a
case of a disorder characterized by lapses of consciousness pursuant
to this section shall not be civilly or criminally liable to any
patient for making any report required or authorized by this section.




Title 17 CCR § 2806. Disorders Characterized by Lapses of Consciousness.


(a) “Disorders characterized by lapses of consciousness” means those medical conditions that involve:

(1) a loss of consciousness or a marked reduction of alertness or responsiveness to external stimuli; and

(2) the inability to perform one or more activities of daily living; and

(3) the impairment of the sensory motor functions used to operate a motor vehicle.

(b) Examples of medical conditions that do not always, but may progress to the level of functional severity described in subsection (a) of this section include Alzheimer's disease and related disorders, seizure disorders, brain tumors, narcolepsy, sleep apnea, and abnormal metabolic states, including hypo- and hyperglycemia associated with diabetes.

Note: Authority cited: Sections 100275 and 103900, Health and Safety Code. Reference: Section 103900, Health and Safety Code.

Title 17 CCR 2808. Sensory Motor Functions.


“Sensory motor functions” means the ability to integrate seeing, hearing, smelling, feeling, and reacting with physical movement, such as depressing the brake pedal of the car to stop the car from entering an intersection with a green traffic light to avoid hitting a pedestrian crossing the street.


Title 17 2810. Reporting Requirements.


(a) Except as provided in Section 2812, a physician and surgeon shall notify the local health officer within seven (7) calendar days of every patient 14 years of age or older, when a physician and surgeon has diagnosed a disorder characterized by lapses of consciousness (as defined in Section 2806) in a patient.

(b) The report prepared pursuant to subsection (a) of this section shall include:

(1) The name, address, date of birth, and diagnosis of the patient; and

(2) The name, address, and phone number of the physician and surgeon making the report.

 

[heyjack70]

As an aside to this topic: are physicians bound by insurance company agreements to provide "disability evals", or social service evals, etc? Can you tell your patients that you choose not to perform such work because it takes time and can get you sucked into legal proceedings that you won't get paid for?

 

[whopper]

In California, "Every physician and surgeon shall report immediately to the local health officer in writing, the name, date of birth, and
address of every patient at least 14 years of age or older whom the physician and surgeon has diagnosed as having a case of a disorder characterized by lapses of consciousness."

That IS the law here. (details below, so you can read it for yourself)
Check with your facility (or malpractice company) Risk Management Lawyer for what the laws are where you practice and how you are expected to comply with those laws.
I'm calling our Risk Management lawyer in the morning.

Fair enough. The above though does not force a doctor to assess the patient's ability to drive. It merely forces a doctor to report the patient who has a lapse in consciousness. The two are different issues. That was my point. If you report someone in the above context, you are not assessing their ability to drive.

Assessing one's ability to drive is the no-no. Reporting to the state, under the state's owns laws mandating you do so is not a no-no. It's required.

As an aside to this topic: are physicians bound by insurance company agreements to provide "disability evals", or social service evals, etc? Can you tell your patients that you choose not to perform such work because it takes time and can get you sucked into legal proceedings that you won't get paid for?

No. Show me where on the physician billing form where you are reimbused for a disability eval. All the reimbursement guides are for clinical treatment, not disability evaluations.

If an insurance company hires you to do a disability eval, that's different. I would recommend that if you are the treating physician, you clearly state your potential conflicts of interest in this regard. E.g. most doctors treating their patients do not do malingering assessments. That should be considered in a disability evaluation. IMHO, the best doctors do to disability evaluations should be neutral doctors who have not established a doctor/patient relationship.

The entire point of a disability evaluation is for a doctor to state to an authority such as the Court, state agency, or employer that the person really has the problem, and as a result they deserve compensation. The authority wants to make sure the person is not malingering. For that reason malingering must be considered and ruled out to the best of the doctor's ability. Doctors with a patient/doctor relationship rarely do that with their own patients, and in fact some experts in the field state that doctors shouldn't not push the malingering issue too strongly unless there's specific reason to do so because we are not supposed to do harm. A malingering diagnosis can cause harm to the patient.

What I'm finding ironic is I've been taught that pretty much never should clinical doctors do such evaluations on their patients in the usual clinical setting, yet doctors all the time are doing that. I've noticed several doctors are writing notes for their patients without a real evaluation that meets the professional standards. As a result, when I tell my patients I will not write a disability evaluation for them or another such evaluation, I keep getting the "well doctor X said he'd do it." It's quite frustrating.

Can you tell your patients that you choose not to perform such work because it takes time and can get you sucked into legal proceedings that you won't get paid for?

Exactly. You write a note for disability, you may get ordered to give testimony by the Judge. If you are ordered, to ignore the subpoena could land you in jail on the charge of contempt of court.

If you do a disability evaluation--that you were hired to do, any court time you could bill. You write the disability and state in your agreement that if you have to give testimony in court you will bill for it. If you leave it for a judge to order you there, without such a contract, now you HAVE TO SHOW UP whether you are paid for it or not.

Usually judges will not do this because they know they are forcing a professional to give testimony for free that they would usually bill in the thousands for. That said, it can happen, and it almost happened to me though not in a disability case.

(In that case, there was a patient who was on 15 meds at the maximum dosage and I was trying to wean her off the meds. Her previous psychiatrist put her on that regimen. She had factitious disorder. I spent months trying to get her on-board with fact that the risk of the meds outweighed the benefits. After 6 months with no success, I told her that I would start weaning her off the meds whether she liked it or not because some of those meds were actually contraindicated with each other.

The patient started faking symptoms to get the meds, and since she was not bright, she did not know what to fake. E.g. she wanted Elavil. I asked her why she needed it. She said the pill made her feel like someone was hugging her. I told her "Elavil is not to be given to allow people to feel as if they are being hugged."

The patient was under community supervision where judge occasionally reviewed the case. The judge, not having me available, nor my notes available, was not aware that I was trying to get the patient off of meds, and was puzzled why the patient was on several meds when she did not have a condition that warranted them.

The judge darned almost ordered me in--which would've forced me to drive 1 hour to court, then wait about 2-3 hours before the judge actually saw me, then I'd have to spend 1 hour driving back to work. Thankfully she didn't.

All about 4-6 hours, none of it paid, and at that time I was working crazy hours in fellowship. That would've really ticked me off.