Extending disability

[medstudent234]

I'm a PGY-3 who has been getting a lot of postpartum patients recently whose ob/gyn placed them on disability for postpartum depression or anxiety, and then they come to me asking for their disability to be extended.

Some of them have therapists, but apparently only an MD can extend disability. I have very mixed feelings about this, specifically because while I don't think maternity leave in this country is long enough, and some of them are quite symptomatic, I don't think that not going to work is necessarily going to help them recover significantly faster or that it would be harmful for them to return to work.

Curious how others approach this.

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[Old&InTheWay]

If you dont think the pt is disabled, don't extend their disability. I don't have to deal with this issue because I have a blanket policy against doing any disability paperwork ("you can have treatment or you can have disability, not both"), but my colleagues will say that if pts need to be on short-term disability then they need to be in a higher level of care (e.g. IOP/PHP) and only complete paperwork for pts who engage in higher level of care.

Wait, I don’t think I understand what you mean. It kind of sounds like you are saying that you think people who are on disability shouldn’t get or don’t need treatment. ?

 

[splik]

Wait, I don’t think I understand what you mean. It kind of sounds like you are saying that you think people who are on disability shouldn’t get or don’t need treatment. ?

In my particular patient population (patients with FND and somatoform disorders, trauma-related disorders), they cannot get better with treatment if they are trying to get (or maintain) disability - and almost all of them are. This would obviously be different if you are talked about patients with SPMI in a community mental health setting but in general, patients cannot get better if they have to keep proving they are ill. So I do not treat patients who want disability because it is an exercise in futility. There are also a lot of patients who dont want treatment, they just want to see you for disability, and again - I am not the doctor for them. In my old FND clinic, the initial letter would specifically tell patients that I don't help with disability and almost every patient still came along wanting me to fill out forms for them.

 

[Armadillos]

I think when comes to disability it’s worth differentiating between applying for government disability and private short term disability insurance that patients have paid for which tends to just want some basic info from the treating doctor in my experience.

I personally would be super pissed if I’m ever sick enough or injured enough to not be able to work for a couple weeks and my doctor took some moral stand delaying getting insurance benefits that I’ve been paying for

 

[Sushirolls]

You need to talk to your attendings, and chief residents, etc and get guidance from your program how to handle these cases.

 

[NickNaylor]

I had many requests to fill out disability paperwork in our outpatient clinic. If I didn't feel that a patient was truly disabled, I would say as much to the patient. I told them that I would still be happy to fill the paperwork out for them but that it likely would not support their case. That would typically be the end of it.

You are under no obligation to fill out disability paperwork, and you do not have to fill out paperwork to "extend" their disability for the sole reason that they are currently receiving disability and otherwise do not have an income. If the patient doesn't like that answer, encourage them to get a disability lawyer who I'm sure would be happy to refer them to physicians who will happily support his/her bid for disability.

 

[hamstergang]

I don't think that not going to work is necessarily going to help them recover significantly faster or that it would be harmful for them to return to work.

Then there really isn't anything for you to debate.

 

[FlowRate]

The edge case I've run into is FMLA paperwork. They're still working but want to be able to take days off of work as an accommodation. I don't really have a reliable way to figure out what's "objectively" appropriate but if the patient is asking for something subjectively reasonable (1-2 days per month) I oblige.

 

[Trismegistus4]

The edge case I've run into is FMLA paperwork. They're still working but want to be able to take days off of work as an accommodation. I don't really have a reliable way to figure out what's "objectively" appropriate but if the patient is asking for something subjectively reasonable (1-2 days per month) I oblige.

In a way, it's good that the OP is having this experience now. When I was in residency, it seemed like all of our outpatient experiences involved either diagnosing and treating new problems, or (in community mental health clinic) taking over the care of the seriously mentally ill. I was unprepared for just how many new patient referrals in the private world would involve patients who are already getting some inappropriate thing they want to continue, and are just looking for a new doctor to continue it. I would never advise anyone to take a job working in outpatient for a large hospital system. As a psychiatrist, you are inevitably the dumping ground, existing primarily to give the PCPs (whom these patients present to first) someone to punt to. This scenario happens over and over: someone's been on chronic benzodiazepines for years but their old psychiatrist retires, or they've been on Adderall for years after a dubious diagnosis in a 5 minute PCP visit at age 35 with no childhood history of ADHD, or they have some ongoing FMLA accommodation but they have to change doctors because their insurance changed. They go to a new PCP in your system, who says "I'm going to need you to see a psychiatrist for that. I'll put in a referral, then continue that temporarily, only until you can see the psychiatrist!" Then the patient presents to you after a 2-3 month wait, having spent that time building you up in their mind as their only lifeline, believing there is only one acceptable outcome of the appointment, and that is to walk out the door with a continuation of whatever inappropriate thing they came in with, this thing they feel they absolutely need to survive.

FMLA can be especially egregious--I have one patient who somehow got a previous doctor to give him up to eight days a month for panic attacks! And I have a guy on my schedule tomorrow who was getting both a daily scheduled benzo and stimulant for years, and of course believes that combination is the infamous "only thing that works."

 

[tr]

I'm a PGY-3 who has been getting a lot of postpartum patients recently whose ob/gyn placed them on disability for postpartum depression or anxiety, and then they come to me asking for their disability to be extended.

Some of them have therapists, but apparently only an MD can extend disability. I have very mixed feelings about this, specifically because while I don't think maternity leave in this country is long enough, and some of them are quite symptomatic, I don't think that not going to work is necessarily going to help them recover significantly faster or that it would be harmful for them to return to work.

Curious how others approach this.

As someone with a focus on perinatal psychiatry, I think that it is pretty much always harmful for the mother of a young infant to be required to return to work before about 6 months postpartum, almost regardless of whether she has a mental illness. (Some women do feel better returning to work, but those aren't usually the ones asking for more time off.)

Disability as a perverse incentive against improvement doesn't really apply to this patient population.

I extend these disability requests as a matter of routine.

 

[Mass Effect]

As someone with a focus on perinatal psychiatry, I think that it is pretty much always harmful for the mother of a young infant to be required to return to work before about 6 months postpartum, almost regardless of whether she has a mental illness. (Some women do feel better returning to work, but those aren't usually the ones asking for more time off.)

Disability as a perverse incentive against improvement doesn't really apply to this patient population.

I extend these disability requests as a matter of routine.

I agree with your stance overall, but curious about why you say 6 months? Is there some literature suggesting that or is it just based on your experience?

 

[tr]

I agree with your stance overall, but curious about why you say 6 months? Is there some literature suggesting that or is it just based on your experience?

No, it's not a hard barrier, just a suggestion based on clinical experience and on the recommended age for starting solid foods (which reduces pressure on a mother who is pumping).

 

[Mass Effect]

No, it's not a hard barrier, just a suggestion based on clinical experience and on the recommended age for starting solid foods (which reduces pressure on a mother who is pumping).

Gotcha! Thanks for the explanation.

 

[Candidate2017]

In a way, it's good that the OP is having this experience now. When I was in residency, it seemed like all of our outpatient experiences involved either diagnosing and treating new problems, or (in community mental health clinic) taking over the care of the seriously mentally ill. I was unprepared for just how many new patient referrals in the private world would involve patients who are already getting some inappropriate thing they want to continue, and are just looking for a new doctor to continue it. I would never advise anyone to take a job working in outpatient for a large hospital system. As a psychiatrist, you are inevitably the dumping ground, existing primarily to give the PCPs (whom these patients present to first) someone to punt to. This scenario happens over and over: someone's been on chronic benzodiazepines for years but their old psychiatrist retires, or they've been on Adderall for years after a dubious diagnosis in a 5 minute PCP visit at age 35 with no childhood history of ADHD, or they have some ongoing FMLA accommodation but they have to change doctors because their insurance changed. They go to a new PCP in your system, who says "I'm going to need you to see a psychiatrist for that. I'll put in a referral, then continue that temporarily, only until you can see the psychiatrist!" Then the patient presents to you after a 2-3 month wait, having spent that time building you up in their mind as their only lifeline, believing there is only one acceptable outcome of the appointment, and that is to walk out the door with a continuation of whatever inappropriate thing they came in with, this thing they feel they absolutely need to survive.

How do you handle these patients? I have patients in residency in the exact scenario you describe where PCPs dump their problem patients (i.e., PCP is tired of shady patient and cutting them off from the controlled substance unless they "see psych"). I'm in a difficult spot because I have a find a way to turn them down without making them mad and file complaints which the clinic administration will always view as the resident's fault. Outwardly, admin takes a harsh stance on inappropriate prescribing but always caves to patient complaints.

 

[hamstergang]

How do you handle these patients? I have patients in residency in the exact scenario you describe where PCPs dump their problem patients (i.e., PCP is tired of shady patient and cutting them off from the controlled substance unless they "see psych"). I'm in a difficult spot because I have a find a way to turn them down without making them mad and file complaints which the clinic administration will always view as the resident's fault. Outwardly, admin takes a harsh stance on inappropriate prescribing but always caves to patient complaints.

It all depends on your attending who is the one really agreeing with your prescribing recommendations or not.