Disability Evaluations

[Psychferlyfe3000]

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I had a law firm reach out to me and ask if I could eval a patient and fill out a form describing their level of functionality. I'm curious to know what the risks are if I do this.

 

[comp1]

So there are much better questions than risks here, but this forum sure does get obsessed about liability, so okay. You can get sued if the patient dislikes your report. You can get sued if the disability carrier doesn't like your report. You get sued for anything at any time. You can get sued if you say the person isn't disabled and then goes on to do something in their job that harms someone else. You can also get sued if you refuse to do it at all for an established patient! Is any of this likely, no, it definitely is not. Liability is a question for whoever will be responsible for defending you in court, eg your malpractice carrier. Now onto better questions. Is this sort of thing within your training? Did you do these in residency? I know you didn't do FAA or commercial driving exams in residency. You probably did do SSDI exams and some states require you to do them if you have an established relationship and it is within your scope of knowledge. What kind of functionality are they asking? Are you familiar with that job requirements? How would you actually assess it if you were? There are so many questions here.

 

[Fan_of_Meehl]

"I had a law firm reach out to me and ask if I could eval a patient and fill out a form describing their level of functionality. I'm curious to know what the risks are if I do this."

Are we talking about a 'form' (questionnaire?) that was constructed by people working at a law office? In my one instance of having such a 'form' (along with a request that I fill it out) mailed to me by a lawyer, I was impressed by how biased / potentially misleading the form was and refused to fill it out.

The PCL-5 (filled out by patients) is bad enough. Being asked to complete a 'form' (with ratings/scales slapped down by lawyers (not psychometricians)) strikes me as kind of dubious, I dunno. I guess it depends on the structure/nature of the form.

Liability may be a concern but, for me, the central concern would be with respect to the validity/integrity of my responses and how they were to be used.

 

[PsyDr]

That is an IME and you should bill in a level consistent with that kind of service.

The risks:
1) You, doing something you don't know how to do, and....
a. getting shredded by an opposing expert who points out that you don't know the usual methods and terms (Very very likely)
b. getting shredded in cross examination, for the same reasons if it goes to deposition (less likely)
c. getting a board complaint after its over by someone who says you didn't know the standards (even less likely)
d. getting a lawsuit without E&O insurance for the same, and losing your personal assets (very unlikely)
2) You charge a rate that is far below the market rate, and get screwed financially (very likely).
3) You charge a rate that is far below the market rate, it goes well, cruddy attorneys flood with referrals for this kind of work, and it limits your actual business until your opinion gets challenged and you lose this line of work (likely).
4) You try your best, make mistakes because you don't know the terms and methods, it backfires on the "patient" (hint, it's never "patient"), and they come to your office all pissed off because they think you're to blame for the failure of their life plan, and it is an unpleasant afternoon.

 

[comp1]

All of the above, of course, but also thinking about it last night, disability evaluations are not good for just the clinical interaction, in general. It's very much a conflict of interest. Your goal is to get the patient as functional as possible. Very, very rarely is supporting a disability claim going to further this sort of goal. When I filled out SSDI applications for patients in residency it was pretty uniformly forms that parents of children with schizophrenia brought in. In terms of work disability, I would write for short term leave to do PHP/IOP, but that was it. Anything else was generally much more harmful than helpful. Of course declining the disability evaluation will upset the patient.

 

[Bartelby]

I think PsyDr nailed it.

The odds of getting sued are very low. Occasionally an evaluee sues an expert for something like Intentional Infliction of Emotional Distress (IIED), but this is very rare. The main person who has standing (authority) to sue you is the attorney who retained you, and for a variety of reasons this is very unlikely to happen. Still, as PsyDr pointed out your malpractice insurance probably does not cover such suits unless you have added forensic work to your policy in writing.

Much more likely is that your work will fall well below typical standards and criticism from the opposing expert and (if it goes to deposition) the defense attorney will be humiliating and stressful. This is unlikely to generate any formal professional sanction against you but can be really unpleasant.

If you are doing a disability evaluation for a disputed claim consider:

• Many exams can take 3-5 hours to complete and are far more thorough than a typical clinical intake.
• It is not unusual for the evaluating expert to consider a wide range of records including past medical records, employment records, depositions, and other case documents. Depending on record volume this can take anywhere from several hours to over 20 hours in the most record-intensive cases (though this would be rare for a pure disability claim).
• Psychological testing is becoming pretty much an expectation. The test should assess for malingering. If cognitive claims are involved, you may also find yourself up against neurocognitive testing. You should probably have neurocognitive testing done if it is likely to be an issue. Most psychiatrists don't have much training in test administration, so you have to proceed with caution.
• Writing a good forensic report is a skill that you hone with training and repetition. It sounds like they just want you do do a brief form, and I would be cautious agreeing to have that stand as a formal report.

If you do take the case, I think it is best to have someone with forensic experience serve as a paid mentor for the first few. That makes sure you do not miss the mark too badly in terms of methodology and opinion quality.

Keep in mind that the clinical role and the forensic role are very different, and you have to approach it that way when you accept forensic cases. See the famous "On Wearing Two Hats," free through JAAPL online On wearing two hats: role conflict in serving as both psychotherapist and expert witness - PubMed

 

[comp1]

I think we're all assuming that there is some sort of litigation going on. The OP isn't clear on that at all. This may be a SSDI request. Some people waste their money on retaining lawyers for that. That does not typically involve forensic level write-ups or assessments and I'd be very surprised if any of them have any psychometric testing behind them.

 

[Merovinge]

I think we're all assuming that there is some sort of litigation going on. The OP isn't clear on that at all. This may be a SSDI request. Some people waste their money on retaining lawyers for that. That does not typically involve forensic level write-ups or assessments and I'd be very surprised if any of them have any psychometric testing behind them.

I have completed a few of these for young adults (or late adolescents) with schizophrenia. It was actually pretty chill? I never got any pushback and don't have any forensic training. I felt it was the right thing to do and didn't charge for it, although I was salaried anyway at that job and not RVU based.

 

[splik]

If it’s not for your patient this is a forensic eval. It sounds like they are trying to get something on the cheap I would politely decline. Once an attorney screamed at me after I told her my rate. This is after she was going on about how these SSDI psychiatrists don’t get paid enough to do a decent eval. The most common evals are for SSI/SSDI (which usually don't involve a forensic eval or IME). After that is worker's comp (doesn't sound like that is the case here). Then there are the C&P evals for vets or for nexus letters. Finally, there are private disability evals. These are better paying but the disability companies usually want to do a flat fee for the IME.

If it is for an existing patient I would usually decline unless it’s important to their care and wellbeing. For example patients with dementia, severe TBI, schizophrenia etc Instead I offer to provide their notes. That usually contains sufficient information even though the disability question is not specifically addressed.

 

[docloufan]

I had a law firm reach out to me and ask if I could eval a patient and fill out a form describing their level of functionality. I'm curious to know what the risks are if I do this.

No. Asking for headaches. There are plenty of people that do this as their actual job and specialty.

 

[FatherPsychiatry]

Speaking of SSI evals, I haven't done them in years but did anyone actually get paid for them? I remember that standard government packet had a page where it said you can request some payment from the government for doing the evaluation. I sometimes tacked on a page requesting various amounts just for kicks (I wasn't expecting anything), anywhere from like $2 to $500, but nothing ever showed up.

 

[comp1]

No...I've never seen any payment from the state. That might be a state specific offering since this is mostly state administered? You can request payment from the patient in most states, however.

 

[Psychferlyfe3000]

Thank you for your responses everyone. I wanted to provide more info on the form they want me to fill out. It is summarized as: "The “Report of Physician” is used to provide the court with a medical evaluation of an individual (often called the respondent) in cases involving guardianship of a person who may be disabled or incapacitated. It helps the judge determine whether a guardian should be appointed." As someone who is not knowledgeable about forensics, it is risky for me to proceed without guidance?

 

[randomdoc1]

Thank you for your responses everyone. I wanted to provide more info on the form they want me to fill out. It is summarized as: "The “Report of Physician” is used to provide the court with a medical evaluation of an individual (often called the respondent) in cases involving guardianship of a person who may be disabled or incapacitated. It helps the judge determine whether a guardian should be appointed." As someone who is not knowledgeable about forensics, it is risky for me to proceed without guidance?

yes

 

[comp1]

Okay, so wow, we were way off. This is not a disability form at all. It's a conservatorship form. Depending on your general psychiatry residency, this certainly could have been a core part of your training. It sounds like it was very much not for you, which is challenging. You do in fact need guidance, but it's going to be completely state specific. Hopefully you work in a large system and can discuss this with other local physicians. Doesn't necessarily need to be a psychiatrist, could be a PCP or neurologist as they have likely received such requests. If there aren't any, call your malpractice carrier for advice. They can confirm that such an assessment would be covered under your policy and give you general advice. I suspect it likely would be covered. It would be very hard to practice inpatient psychiatry, for example, and not fill out a conservatorship request. If you somehow always did avoid them, you'd likely be practicing well below the community standard of care. I understand you're likely not inpatient, but this is not some way out in the weeds thing. I do fully get the poster's concern above that you could theoretically be drawn into some grand family conspiracy to take grandpa's money leading to non-stop subpoenas for the rest of your life. You could also be being asked to fill this out for son or daughter recently diagnosed with schizophrenia so that the family can consent for medications over their objection. States vary, hugely. Talk this over with other local providers.

 

[lol.psych]

Please don't do this. Not because I don't think you (random psychiatrist on the internet) would do a bad job (I don't know you), but because you are obviously in way over your head. I say this from the perspective as someone who had the bare minimum forensic exposure in residency, then went to work in a forensic setting (not in a forensic capacity, though -- just providing clinical care to pts under forensic commitment), and I had no idea how much I didn't know. It took me a solid year to feel like I had any idea what the heck was going on legally/forensically, what the different types of court testimony entailed, which types of hearings would be easier vs more difficult for me and why, etc. [edit: and I had a lot of supervisory and administrative support, a lot of people wanted me to have a good experience and stick around. Without this, it would have been a nightmare.]

Please ask yourself, do you really need this in your life? Do you want it in your life? If so, is there a less risky way to dip a toe in it, like starting with some CMEs, going to a conference, finding a mentor of some sort...

 

[comp1]

I'm genuinely ignorant of this, do forensic fellowships have any focus on civil conservatorships?

 

[Stagg737]

I'm genuinely ignorant of this, do forensic fellowships have any focus on civil conservatorships?

Absolutely should be. Exposure to civil cases and mentorship in those areas is something that sets a lot of the stronger forensics programs apart. Frankly, the basics of guardianship and/or conservatorship (if the state defines them differently) should be core for any decent general residency imo. Understanding what guardianship is and how it is established is essential when working with SPMI patients, that’s well within general psychiatry. I filled out a few of these in residency and several since. I’d actually argue that outpatient docs should be filling these out more often than inpatient as they’re the ones who treat patients longitudinally and can speak to their level of debility and actual need for ongoing, long-term lack of ability to care for themselves. Depending on the state this can be pretty straightforward in terms of what we actually fill out.

 

[Stagg737]

The above said, I would not fill this out if contacted by a law firm to fill it out for a patient I don’t know. Unless you’re forensically trained or have solid experience doing this type of eval, this is not the kind of thing to be done for a patient you don’t know. You’re potentially saying this individual should have civil rights taken away and the gravity of this type of assessment and the outcome is not something to ever take lightly.

 

[Psychferlyfe3000]

Well, it wasn't a close call I guess, haha. I turned it down citing lack of experience. Thank you for the collective wisdom.

 

[PsyDr]

Thank you for your responses everyone. I wanted to provide more info on the form they want me to fill out. It is summarized as: "The “Report of Physician” is used to provide the court with a medical evaluation of an individual (often called the respondent) in cases involving guardianship of a person who may be disabled or incapacitated. It helps the judge determine whether a guardian should be appointed." As someone who is not knowledgeable about forensics, it is risky for me to proceed without guidance?

Oh, that is way different. This is a guardianship evaluation. Your specific state will have a form about WHICH capacities are impaired, and to what degree. There are different types of capacities that you'll be asked to determine (e.g., capacity to consent to medical treatment, to consent to sexual relationships, enter into contracts, decide where to live, vote, "testamentary capacity, etc). There's multiple areas here, and each has a specific legal standard about what makes a "rational" decision. Most of what I said remains true, although your civil liability is probably lower.

Regardless, if you don't know the terms of art and standards, you should not do it. Just picture you asking me about how Fick's law interfaces with Laplace's. My response would be embarrassingly bad.

Daniel Marson is a good starting point for readings in these areas.

 

[FatherPsychiatry]

I'm genuinely ignorant of this, do forensic fellowships have any focus on civil conservatorships?

I wouldn't say focus, but it was a small part of my forensic fellowship. But all the fellows in my class did a ton more of basically the same thing during residency. I testified in court like 10 times during residency regarding conservatorship and/or contested involuntary holds, involuntary meds etc.