Job Accommodations while in Clinical Role

[romanticscience]

As a clinical and forensic psychiatrist, I'm aware of the ethical implications of the two contrasting roles. Some of my patients look to me, often influenced by other people (e.g., primary psychotherapists), to weigh in on workplace accommodations. Am I being overly strict to hesitate about these, considering them as amounting to opinions about disability? I usually inform them that they can request the accommodations themselves without my input and refer them to JAN - Job Accommodation Network

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[Bartelby]

Some employers seem to demand a physician fill out the form. I do so when I think it seems appropriate. I am more eager to fill out paperwork that lets my patient stay gainfully employed than paperwork that certifies they cannot work and thus may perpetuate inactivity and illness.

My usual approach, though, is to be pretty conservative about my recommended accomodations. I write for pretty simple and easily defended ones (for example, time off for appointments). If a patient pushes for more (and they do) I tell them that I have not performed a forensic assessment of fitness for duty and that they would need to arrange for one to get that level of detail in their requested accomodations. For example, they might say they need a particular computer system at work and I will not sign off on that because it is really getting into the weeds and requires more extensive understanding of their role and functional limitations.

I find this approach works pretty well. My patients get some recommended reasonable accommodations without turning it into a wishlist situation.

 

[splik]

As a clinical and forensic psychiatrist, I'm aware of the ethical implications of the two contrasting roles. Some of my patients look to me, often influenced by other people (e.g., primary psychotherapists), to weigh in on workplace accommodations. Am I being overly strict to hesitate about these, considering them as amounting to opinions about disability? I usually inform them that they can request the accommodations themselves without my input and refer them to JAN - Job Accommodation Network

I wouldn't consider this a forensic evaluation except in specific circumstances. Some people get overly and unnecessarily rigid about this and patients are not usually in a position to retain a lawyer who retains a forensic psychologist or psychiatrist for this sort of thing at great expense. Things like workplace accommodations, FMLA, short term disability, ESAs, N648 forms can and usually should be best done by the treating psychiatrist. Of course, one does not have to do any of the above. Just make sure you are comfortable with it. If the patient is requesting something and you have no clue about accommodations or don't understand their job, then don't get involved. In addition, if they are in particular lines of work (e.g. high security clearance w/ government, law enforcement, impaired physician etc) and you feel more extensive evaluation is warranted, then a FFDE by a forensic expert may be appropriate.

Do you do school accommodations forms? Those are definitely supposed to be completed by the treating doctor, would be totally ridiculous to have it as a forensic eval. I don't want patients to abuse the system, but we can be helpful in supporting legitimate requests for college students etc. I don't really see any difference in workplace accommodations unless it's a more high risk/liability position.

Typically the only workplace accommodations I've supported for patients reduced hours, time off to attend appointments with me, or remote work.

To me, the important questions are:
1. Does the request seem reasonable?
2. Does the request support your overall treatment goals?
If the answer to both is YES, then support the request. If it is no, then don't.

I want my pts working or in school so I support their (reasonable) requests and don't charge for it. I charge for other sorts of things (e.g. ESAs, N648s, disability paperwork).

 

[romanticscience]

Thanks, this was really helpful! I'm usually stuck when the patient asks me to determine their accommodations. I, too, am usually OK with affirming basic stuff. I like @Bartelby advice about having a limit before referring for an IME.

 

[Sushirolls]

I recently had some one ask me to tell their work they could work from home.
Essentially they traveling out of state to be with a sick family member, unsure if they were care taking or not.
I said no.
Encouraged to discuss with PCP, and reviewed that FMLA exists for people be care takers for sick family, and to consider that avenue.
But to blanket write to 'work from home' because of anxiety. Which last visit pastient was stable for XYZ diagnosis, and there was no anxiety spectrum diagnosis at all. Nor had the patient presented to the office to discuss 'anxiety' symptoms but expected this form to be filled out.
Offered very near appointments to discuss symptoms - patient didn't schedule to do so.

No forms from me.

 

[romanticscience]

Don't get me started on the stress-sensitive patient who has workplace conflict, loved working from home due to avoidance, and now wants me to write a letter to allow full remote to accommodate *cough* enable her AGORAPHOBIA.

Yea, a discussion about behavior, contingency, and reinforcement with this patient didn't work. I'll have some 100% remote and another xanax prescription! Please and Thanks!!

In fairness to the patient, they did *admit* to wanting to escape. Now, what do I, as a clinician, do? Discharge them? Rogerianly--Ericksonianly trust that the patient knows best (why this stuff doesn't work all the time in psychiatry) or Skinnarianly accept nothing less than exposure--habituation! Safety signals be damned.

Within reasonably safe interventions, I usually give in, but the price is I bug them about it again and again. Similar to how Gunderson would passively submit to the borderlines by admitting them to the hospital by saying, "I don't think you need it but if you insist..."

 

[Merovinge]

Don't get me started on the stress-sensitive patient who has workplace conflict, loved working from home due to avoidance, and now wants me to write a letter to allow full remote to accommodate *cough* enable her AGORAPHOBIA.

Yea, a discussion about behavior, contingency, and reinforcement with this patient didn't work. I'll have some 100% remote and another xanax prescription! Please and Thanks!!

In fairness to the patient, they did *admit* to wanting to escape. Now, what do I, as a clinician, do? Discharge them? Rogerianly--Ericksonianly trust that the patient knows best (why this stuff doesn't work all the time in psychiatry) or Skinnarianly accept nothing less than exposure--habituation! Safety signals be damned.

Within reasonably safe interventions, I usually give in, but the price is I bug them about it again and again. Similar to how Gunderson would passively submit to the borderlines by admitting them to the hospital by saying, "I don't think you need it but if you insist..."

WFH is no more accommodating the agoraphobia than QID Xanax for alcohol use disorder .

The options are: 1) go to work and get consistent CBT 2) take a medical leave to do RTC or PHP. If you are at the point that you cannot leave your house to work I don't really see what else in on the table. If they want to find a different doc, find a different WFH job, live in avoidanceland with poor quality of life, they can certainly choose to do so, but I wouldn't for a second even tacitly make that seem like a reasonable option.

This is exactly analogous to social anxiety in kids where the family thinks doing online school (where their grades are shockingly much better) is going to lead anywhere positive. In fact, such kids just turn into your patient once the can has been kicked down the road. COVID allowing for remote work, things like the online Khan Academy school, that stuff is amazing. Using it to promote avoidance is such a headpalm.

 

[comp1]

Ugh, outpatient sounds just as horrible as it was in residency. Ultimately, what's good for the patient? I really like the idea of helping the patient self-advocate.

 

[FlowRate]

Thanks, this was really helpful! I'm usually stuck when the patient asks me to determine their accommodations. I, too, am usually OK with affirming basic stuff. I like @Bartelby advice about having a limit before referring for an IME.

IMO legitimate accommodations are usually pretty self evident. A starting off point might be just asking the patients what part of their job they're struggling with.

But yes there are also a lot of inappropriate requests for enabling avoidance that are couched as "accommodation."

I think school accommodation requests are almost more tricky than workplace requests. The goal with workplace is just to keep people employed and to suggest accommodations that are reasonable. Generally workplace requests present a very mild hassle for the employer, if at all. With school it's often requests for extra time on tests which gives a competitive advantage in a setting that is sometimes zero sum when you consider all of the other students (curved courses, standardized tests.)

 

[Crayola227]

Ugh, outpatient sounds just as horrible as it was in residency. Ultimately, what's good for the patient? I really like the idea of helping the patient self-advocate.

Some posters seem aware, and others do not, that the concept of "self advocating" when it comes to disability accommodations and employers/schools is COMPLETELY ridiculous.

The self advocating, is reaching out to ombudsman and the Title IX office, or HR, and then being given a form that you go to your doctor with and ask for help.

People seem to misunderstand that there is an ENTIRE medicolegal landscape that the patient MUST navigate. The patients don't make the rules. Physicians don't make the rules. The rules are made either by federal or state law, and workplace laws and employers. Employer policies may or may not actually follow the law, keep in mind.

Do no be naive to the extent that employers will resist even the most minor "hassle." Or that they can and will discriminate and even fire employees over this stuff, despite it being highly illegal, and the patient having little recourse. Having a signed form from a physician is often the only paper-thin defense the patient has from this kind of thing.

I've personally worked with more than one Title IX director and others involved in this system. The overarching theme is how unbelievably unaccommodating employers will be unless someone seen with authority sends in the right paperwork.

I have seen employers balk at patients with lower extremity injuries having a wheelchair or cane at work, even when the nature of the work made that entirely possible and not much of an issue otherwise! Even because, the employer was concerned what "people would think" to see the employee with one!

Is this discrimination with a capital D? Of course it is. But you would be completely shocked what employers will do or try to get away with.

Now, let's not say something like, "well if your employer is that bad, find another job."

And, you might say, if the employer is this awful, why would a form from a physician make any difference? Won't they just find another way to screw the patient?

Well, yes and no. Some employers if faced with paperwork, rather than just the typical bullying that might happen when there is no 3rd party (like a physician or lawyer), and it's just between the patient and their employer or HR, some of them will decide it isn't worth it and "give in" and stop hassling the patient.

Or, say they do go ahead and fire the patient anyway. Now, when the patient files for unemployment, the employer may not fight the claim and just let it go, because they don't want to get into the whole thing, not when the patient has some paperwork about disability on their side.

You know, some of the times when patients ask us to intervene on their behalf with a school or employer, you aren't always "enabling" dysfunctional behavior. You aren't always being asked to give an opinion that you can't reasonably give. You aren't doing something the patient can do themselves. Lawyers can't actually help a lot of these situations without a sympathetic physician, actually.

Keep in mind, the patient's insurance will often cover the visit to see you and ask your help. Help only you can give, a lawyer can't. But it won't cover a lawyer.

I know this is a little sideways from some of the examples given in this thread where it sounds like patients may want something unreasonable or counterproductive for them.

But we need to correct the notion that patients do not get backed into a corner where only a physician's letter can help them avoid unfair treatment, or help them maintain employment in a reasonable fashion, or allow them FMLA.

(Also not everyone qualifies for FMLA depending on the particulars of their job. And last I checked, the employee can be asked to get information corroborating the situation, like from a physician).

I can't for the life of me understand why physicians are under the impression that this is not something patients need help with, frequently not something the patient or their lawyer can do for them, or that it wouldn't be something that would be under a treating provider's job.

Use your best judgement, but don't assume it's someone else's job or the patient needs to see a damn forensic whatever or other special eval. Most of the time it isn't rocket science and people aren't asking for the moon. Be a god damn human being.

 

[annoyedpsychiatrist]

Some employers seem to demand a physician fill out the form. I do so when I think it seems appropriate. I am more eager to fill out paperwork that lets my patient stay gainfully employed than paperwork that certifies they cannot work and thus may perpetuate inactivity and illness.

bingo. Im also careful with wording. "While I can not objectively prove that the Ms X would benefit from an enclosed cubicle, I think its reasonable to assume this may give her a more positive workplace enviroment which could in turn benefit the employee/employer".

disability paperwork i pretty much never do, unless I believe the patient is so severe (uncontrolled psychosis/bipolar) that working would pose a threat to them or others. I do not do disability paperwork for depression/anxiety/PTSD.

 

[Celexa]

Some posters seem aware, and others do not, that the concept of "self advocating" when it comes to disability accommodations and employers/schools is COMPLETELY ridiculous.

The self advocating, is reaching out to ombudsman and the Title IX office, or HR, and then being given a form that you go to your doctor with and ask for help.

People seem to misunderstand that there is an ENTIRE medicolegal landscape that the patient MUST navigate. The patients don't make the rules. Physicians don't make the rules. The rules are made either by federal or state law, and workplace laws and employers. Employer policies may or may not actually follow the law, keep in mind.

Do no be naive to the extent that employers will resist even the most minor "hassle." Or that they can and will discriminate and even fire employees over this stuff, despite it being highly illegal, and the patient having little recourse. Having a signed form from a physician is often the only paper-thin defense the patient has from this kind of thing.

I've personally worked with more than one Title IX director and others involved in this system. The overarching theme is how unbelievably unaccommodating employers will be unless someone seen with authority sends in the right paperwork.

I have seen employers balk at patients with lower extremity injuries having a wheelchair or cane at work, even when the nature of the work made that entirely possible and not much of an issue otherwise! Even because, the employer was concerned what "people would think" to see the employee with one!

Is this discrimination with a capital D? Of course it is. But you would be completely shocked what employers will do or try to get away with.

Now, let's not say something like, "well if your employer is that bad, find another job."

And, you might say, if the employer is this awful, why would a form from a physician make any difference? Won't they just find another way to screw the patient?

Well, yes and no. Some employers if faced with paperwork, rather than just the typical bullying that might happen when there is no 3rd party (like a physician or lawyer), and it's just between the patient and their employer or HR, some of them will decide it isn't worth it and "give in" and stop hassling the patient.

Or, say they do go ahead and fire the patient anyway. Now, when the patient files for unemployment, the employer may not fight the claim and just let it go, because they don't want to get into the whole thing, not when the patient has some paperwork about disability on their side.

You know, some of the times when patients ask us to intervene on their behalf with a school or employer, you aren't always "enabling" dysfunctional behavior. You aren't always being asked to give an opinion that you can't reasonably give. You aren't doing something the patient can do themselves. Lawyers can't actually help a lot of these situations without a sympathetic physician, actually.

Keep in mind, the patient's insurance will often cover the visit to see you and ask your help. Help only you can give, a lawyer can't. But it won't cover a lawyer.

I know this is a little sideways from some of the examples given in this thread where it sounds like patients may want something unreasonable or counterproductive for them.

But we need to correct the notion that patients do not get backed into a corner where only a physician's letter can help them avoid unfair treatment, or help them maintain employment in a reasonable fashion, or allow them FMLA.

(Also not everyone qualifies for FMLA depending on the particulars of their job. And last I checked, the employee can be asked to get information corroborating the situation, like from a physician).

I can't for the life of me understand why physicians are under the impression that this is not something patients need help with, frequently not something the patient or their lawyer can do for them, or that it wouldn't be something that would be under a treating provider's job.

Use your best judgement, but don't assume it's someone else's job or the patient needs to see a damn forensic whatever or other special eval. Most of the time it isn't rocket science and people aren't asking for the moon. Be a god damn human being.

I agree with you, but also, by nature as psychiatrists, we ARE going to get a lot of maladaptive requests like the 'I don't want to leave my house' requests above. It calls for an individualized, nuanced discussion with each patient.

I had an interaction recently that shines some interesting light on these dynamics. I was doing an off service rotation in outpatient neurology. The docs I worked with were dedicated, kind, very knowledgeable, and utterly clueless about psychological dynamics. Which lead to this interaction--

A lovely middle aged gentlemen with a disabling neurological illness came in. Despite his very real physical limitations, he remained employed at a job with moderate physical demands. He was dispirited that his physical limitations made him feel he was a failure and wouldn't be able to realize his dreams of opening up his own business with his sons. He was sensitive to how he was perceived by others in his business and concealed his illness.

The very well meaning neurologist immediate leapt to offering him an accomidations letter. I saw the poor man deflate on the spot. I gently intervened and asked the man a few targeted questions--had his physical limitations caused any specific problems with his bosses or clients? Was taking slightly longer, and needing more breaks than he did before, causing any objecting issues or was he comparing himself in his head to what he would be able to do without his illness?

He conceded that he was probably comparing himself to an ideal, and that so far his physical limitations hadn't lead to any problems. I encouraged him to be kinder in his self-judgment and think objectively about the physical performance required in his line of work. He left the visit without an accomadations letter (although aware it was an option should he need it) and more optimistic than he would have been with one. Ironically, the very caring neurologist would have made him worse by immediately assuming his illness made him unable to work without accomidations.

Ultimately we should be striving to do what is best for the patient--sometimes that will be endorsing accomadations, and sometimes it won't be.